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Senate | May 20, 2013 | Committee Room | Appropriations

Full MP3 Audio File

Please take your seats and we will get our senate subcommittee on health and human services started. I have a couple of announcements to make before we get started. First of all, our senate sergeants at arms are here to help us. Steve Wilson Robert Young and Ken Kerbey and we thank the se gentlemen for their help on a daily basis when they’re up here and we appreciate it so much. Near the end of the hour we are going to devote 30 minutes to public comments and a list is being made and if you would like to offer comments those of you who are from the public we would be glad to hear from you. We will impose a 2-minute limit and if you stick to that limit, and I ask that you do, we’ll be able to hear from 10 different speakers. That will be toward the end of that time and we do intend to get out of here. This will be our sub committee meeting and we will end at 6:00 so that we can go to session at 7 tonight. Let me go over the ground rules that have been established for appropriations. There will be no amendments or votes taken in our sub committee this afternoon but tomorrow when the full appropriations base budget committee meets there will an opportunity for people to submit amendments and here are the rules that must be met in order to make the amendment met for consideration. Money can only be transferred only among items within the same sub committee section. Amendments where money is being transferred among items within a sub committee must clearly identify the items or programs that are being increased and decreased. Non-recurring reductions cannot be made to fund recurring renditions. Amendments that spend reversions are not allowed. Amendments that increase or create new management flexibility reserves are not allowed. Amendments that increase spending in the sub committee budgets are not allowed. Amendments are not allowed where funding for an item comes from statewide reserves. Since this is a meeting for full appropriations amendments that address finance portions of the bill will not be heard. Amendments must be in writing the originally signed with 75 copies for distribution. To be considered a proposed amendments must be logged in by the city clerk in room 643 by 10 am on Tuesday may 21st 2013. Now having said all that the proposed senate HHS budget should’ve been received by all the members of the committee and this time I would like to turn proceedings over to co chairman senator Ralph Hise. [Speaker Changes] Thank you MR chairman. Committee members to the public. I would be greatly amiss if I did not begin this process by thanking our staff. Susan Jacobs has put together an incredible team and they have done a great job to what I think has been a very difficult task in the Medicaid budget and in an ever changing and growing environments in Medicaid from me and the chairman and other committee e members I would like to say thanks. As I begin this overview and I will begin with the money report. And I’m gonna go through several items in this step by step and eventually we will go thru it more chronologically but I do want to begin for those on the money report page G13, I’m gonna begin with what was the April surprise of this year coming forward.

Along this thing they can replace number were seized from the Medicaid replace number that will increase to the Medicaid in the first year of $434,000,000 and $607,000,000 in second year again in the bets by the call settlements are $18,000,000 the woodworking affect the affordable care act which is $50,000,000 the first year 104 240040000000 dollars second year in the transfer cost of the war also included under the affordable care act on the move until that the from the insurance they currently receive Medicaid program under the 22,000,000 as represents display each represents an additional $1.33 billion to its latest in by $134,000,000 the first year $796 second of them sure all wear educators and, we don't control enrollment with national legal control realizations as a Federal program that we administer an event of Thomson you have gross of 2% in revenues you have to deal with the builder stuck with that it's a distracting everything in this study much as funds coming out of control and we do and they shouldn't only do with the waste transportation this is the message of this budget and you say it all rights to certain with full I would go through some things we've done some changes required to call suggests we bite from act one, (SPEAKER CHANGES) starting back don't you want that again with several of the level of the several these income from governor's budget and others hoping to single four some of the lots and the differences or the first area shall see something we've done throughout the entire budget by way of going through the portal budget and locate their historical transfers from their budget line items to make a film Medicaid gaps in two will looking at it for two and three years to transfer money from the department, we can fill and Medicaid budget only continued allocate that Europe are a movie four is not all) for each of the area we shall I am watching the funds rate commission transfer damage which will play in the consideration number four , (SPEAKER CHANGES) we fund the department of justice settlement agreement we entered into last year of this will increase to 150 slots on the first year and 700 MB Los the second year for funding are consistent and spins 3.80000009.3000000 second year going out to the next page I'm afraid we have done in this budget if you're into just a story of this committee goes somewhere fairly lengthy process of hearing about 3 minutes each from nonprofits all across a study them in making the decisions when we continue funding those nonprofits at those levels that one is denying that they provide incredible services will weed out that the legislature has the capability for the oversight that's necessary to become the funds were spent so we had transformed those existing funds to the secretary of HHS and created a competitive block grant process for nonprofits of this cynical a lot of slick slenderness that the wall would combine together to put it on its more expressly laid out the provision of specific areas of funding by (SPEAKER CHANGES) we've also in addition to this odd that half 1,000,000 we've also , from the water in funds on such services water and java block grant and mental block grants on the mother of five million dollars of which returning by a formal part of a liquor students to mistakes those programs are currently existing while secretary of the some funding levels consistent with ??.....

Areas that we were previously funding. Moving on, G3, number 10 and 11. We have transferred the funding for 2500 Pre-K slots in the first year and 5000 slots in the second year to the child care subsidy program, in which we will fund 2600 students the first year and 5200 students the second year. It is out belief that there is a stronger focus in the community looking at development birth through five than only looking at four year olds which is where the subsidies come into play. And we think we can do better things in our community by moving those funds accordingly. We also, I will say there is also some subsidy funds moving in that tends to come across in various block grants. So the total funds have also in overall net increase in the next item number 12, a 9.8 million. Moving on, G4. Federal funds for county child welfare services, the feds are cutting out, a significant amount of these funds they're actually changing the formulation as I understand it Typically the state covers 31% of those funds. we actually with this budget fund we cover 33% of those funds to continue providing for child welfare services. Line 17 also under child welfare, we provide funding to support an additional 100 form of foster care youth and adopted children after age 12 for scholarships, for their funding at the community college and university levels. G5, number 25, project care. This was a program started in a handful of counties all across the state as a pilot program. The governor sought to continue the pilot program as it moved forward we have maken [??] the decision to instead expand this program statewide. This is a program that provides respite services for families for caring for a person with dementia at home. So that individuals in that sense can have them stay at facilities for time periods to provide respites for the family. Number 27, we have decided to close four of the sixteen child development service agencies in the state. We are prioritizing those closures on the basis of services that are currently available in those communities outside of those service centers. So the department will make the decisions on closing those centers. The CSA's that have the highest case loads of children who reside in rural or medically under served areas of the state. We did this for a savings recurring of 10 million dollars in the second year and non-recurring savings of 8 million in the first year. G6, number 28, the adapt [??] drug purchasing program. The governor in his budget placed an 8 million dollar cut in these funds in both years because that is what the program had reverted in the previous year for unspent funds. There is a lot of confusion as to the amount of funding that program will need to continue to operate to provide the medications that are necessary. There is also a lot of change coming in the next year and we're beginning to assess what individuals will be able to receive those drugs when they're on an exchange in the state and have insurance on the exchange so have questions about how to continue to fund it. So while we have continued the 8 million dollar recurring cut for both years, we have put a 6 million dollar non-recurring funds back into that we think will keep the...

on hold for both years as we begin to make some of these assessments moving forward. Items 30 and 31, under Oral Health. We provided for 39 dental hygienists, 2 dental technicians and 7 other administrative positions in the state that can work with the school systems to identify dental problems but could not by their position and ?? provide services for those dental problems. We have instead taken the funding available for those dental hygienist positions and and moved it to the local health departments who have clinics so that they can actually provide services but in doing so we have eliminated much of the state oversight that was required and is listed in those positions that you see there for individuals who were identifying problems in the community. Now that will fall under the health department who already have dental clinics and will provide these funds for the provision of actual services within those areas. G7 36. The ?? Centers. The alcohol, drug abuse treatment centers. We are closing the three state operated ?? centers effective July 1. These centers, residential treatment programs, have shown no evidence that they provide better outcomes than community based treatments, however, their cost for operating these centers averages to $158,000 a bed for a year, 240 beds. We have instead taken a portion of those funds that would be roughly equivalent to serving those individuals, we rounded it up, roughly equivalent to serving those individuals in community settings what we pay for individuals in community settings, and have transferred a portion of those savings, $10,000,000 and $20,000,000 in those years to provide those services within their community. We have also made the decision in number 39 to close the ?? ?? which is a 24 bed residential school for children with mental health or behavior disorders. This service operates at $112,500 a bed and is not a full time program. These are students who are there for part of the week that is moving forward. We have a need, as with both of these, we have a need to provide these services, we just don't believe the centers in which are providing them do so in a cost effective manner. G8 Statewide Telepsychiatry Program. In order to reduce the issues that we have in hospitals all over this state with mental health patients and getting a diagnosis and getting them placed, we are establishing a statewide telepsychiatry program and are funding $2,000,000 in each year to get that program up and going as hospitals participate all over the state, individuals can be evaluated and diagnosed and assigned more quickly to treatment centers all across the state, ultimately something we believe will be a cost saving for the state and particularly for our hospitals and community centers. We also provide funding for opening the new ?? Hospital, 43. Compared to the Governor's budget we do adjust these figures to more accurately reflect when the anticipated opening of the hospital is but we provide $11.5 million and $16.5 million the second year to fund equipment purchases and prepare for the opening of that hospital. G9 Mental Health Drug Management. We are now beginning a process of pre-authorizing mental health drugs in this state. Our conversations that we've had with psychologists and psychiatrists all over the state tell us that we still have an issue

With these prescriptions being over prescribed and prescribed for off label use particularly not in conjunction with counseling and other treatments other exterias and particularly involve with the prescription of these drugs to children. We believe that this pre-authorization can address that issue in the State. Moving forward and we will save the State tremendous money and medications that we are providing for individuals that are not consistent with their plan of treatment. Item 48, the hospital provider says consistent with what was in originally in the transparency bill, we have increased the State's retention of that assessment by 7 million dollars from 43 to 50 million dollars. However, we have now changed that there is a percentage. So, 15.6% of assessments will be retained to the State rather than a flat fee amount that we've worked with for the last 2 years, this is a change that can reflects lot of different areas kinda, if we move through the budget but coming forward so you will see that in the second year that would increase, our estimate is 7.1 million additional fund returned. Items 49 and 50 we felt were for transparency purposes we want it to backyard at this point and show the State and State match expenditures for CCNC, what portion goes to its services and what portion goes to position payments. This is a part of the, there is a, you will see this slider under Child Health Insurance as well. so to get the overall picture there is some summing together of couple of areas but under medicated area, the budget this is how you see what we were spending on CCNC and what they spend on permitive ?? assessments. 51, now to play HT10 Hospital base rates. We are now creating a regional system for hospital base rates across the State. What you will see the effect of this is we look at hospital spend on medicate patients even considering for diagnosis of the individual that are going to the hospital will. There is no economies of stale in hospital care. The larger the hospital you go to, the more it will cost across the State. This services the fact and we also have an issue which are spoken by many times in which rural health care exists in the State because of the good will of urban areas which were the profits are and as they balance up, that's what they send funds back to padying ?? services. This begins to move the playing field to raise base rates to a more even level within our region so that larger hospitals are not holding a much higher base rate than the rural hospitals are. This is was in within each region. It is not a net money move, but it is a significant policy dredge. 52 Medicate co-payments. This one of the government, following the government recommendation this move medicate co-payments to the maximum amount allowed under Federal Law, I think it's a movement from 3 dollars and 3 dollars and 90 cent for the co-payment for individuals on medicate. Item 54 that was in the Governor's budget, we did reduce hospital out-patient payments from 80% to 70% of cost. Number 55, we have also began to implement a shared savings plan in which we will with-hold 4% of provider payments on medicate with the exception of primary care because under the Affordable Care Act, you can do that until 25th end. We are with-holding a portion of those payments and CCNC along with the department that will develop the measures that will show the cost reductions and efficiencies that exist and we can begin to pay those back to providers in performance based measures as we move forward. It is our hope that not only moving forward that we will send to see those payments will come back in addition to cost saving measures that come to the State as a result of rewarding those providers.

But to do the best of reducing their cost them the 56 we're changing significantly the manner in which we play from scrimmage and drops on wheels toy with over the years and blend all season moved of their rates for individuals prescribing ever goes back and four contracted with a madman are we saying that they share a former budget and Brian cost of com the huge impact on our budgets legalese all we have now moved to a situation which we will help pay the invoice to mail white or misuse of state pays for the ingredients and we will now ladies but dispensing lead to an average of $9.84 of the average consumer a $2.00 differential between generic bond name brand products that can be a most decisions about 80% of the average 29 dollars and four steals a formal play for each prescription by the students to seven women and are the notion we literally considered this is a 12 hour limit per day,(SPEAKER CHANGES) we're now, moving this too was the equivalent dollar amount $432 by offer services of this is a label and $12.00 and add or $132 that would be in excess of services we would pay for services for someone who was in a skilled nursing facility are others are can still receive a higher now we do put a cap on the ground are currently serves as to 11 significantly we have made a change to the hope is a change we can move forward with the other populations in the future and even expand coverage within the currently the supplies to a one area we can move pregnant females currently pregnant females are pregnant for that time. (SPEAKER CHANGES) The department had increased rate of 195% of Federal poverty we move them right back down to the Federal minimum 133% Federal poverty level four of the entire population undergo 183 a week now will fully pay their premiums on the stock so we will give a portable insurance policy of making continue with them after the pregnancy of four very limited calls on for most individuals slipping on 103 for just $125 a month , would be the maximum individual replace 2% of the rank of 100 m are calling for a family of solutions like corbel calls to the complaint with the pass command process of moving 47 on this to change this change along the second year will say was $20,000,000 estimate for a 61 would have to wait for a sense of furlough bank increases include inflationary and other mayors of moving four , number 62 with come across an interesting provision of state claiming that they came through on 2000 women are without the general assembly that whilst with a hospital acquires a another hospital or in some cases and other Physicians practice all that they can buy x-ray of the acquired facilities automatically moves to play straight of the larger facility to acquire the without any consideration of calls for regions areas of those within four of this is a process that we're all by a cross the study were asking to be a less like plan amendment also that larger facilities and others Enquirer facility and make it more profitable simply because they changed my employees on the final hospital and the ownership by the stomach forces across this weekend and we're rolling back onto the case after December 31, 2001 way to go back to the base rate they would ever say that they not been acquired up as we said were adjusting some of those anyway ??.....

Kind of moving forward, so. 64 we do allow additional personal care services for qualified individuals, this is particularly individuals with diagnosis of Alzheimer’s, or dementia. This was the result of the cutback last year to 80's on the comparability measure, we now are expanding that back to 130 hours for those individuals, but we are adjusting rates overall to accommodate for that, reducing rates overall to accommodate for that I mean. Make sure that words in. We have gone over G13, really extensively. We'll go to G14. We are doing a study of community care North Carolina. We're matching the 100,000 we're putting up with 100,000 that's available funding that is coming up to do an actuarial in a model of the money saved in improved healthcare, how it comes with CCNC. The remainder of these budgets are items that you have for the most part seen elsewhere in the budget, but these are how they apply to the health choice section instead of the Medicaid section as they're budget separately. You'll see again the mental health drug management, the rate freeze' for automatic increases, shared savings plan, prescription drug on invoice cost. Again you see the CCNC funds that are ?? under the health choice plan. An additional rebase that is necessary for health choice, and the changes to the hospital cost settlement. [SPEAKER CHANGES] Why don't we see if we have any questions on the money report before we go into the provisions? Members of the committee do you have any questions thus far? Senator Robinson. Senator McKissick. [SPEAKER CHANGES] Well I probably wanna be recognized for a series of questions. I'm not quite sure where to begin except early on in the report if that's appropriate Mr. Chair. [SPEAKER CHANGES] That'll be fine. [SPEAKER CHANGES] Thank you. Give me a minute to flip back to the early pages. We'll just kind of take em in the order in which you covered them in the money report. Let's start out with item number three here which talks about the funding which is for NC Fast. I noticed you got $864,000 in year two I did not see this appropriation in year one. And of course I'm sure this is only some partial appropriation coming into this particular segment of the budget, that there are other ways this efforts being financed. But could you speak to why there's nothing here under 13, 14. [SPEAKER CHANGES] This is a division over and above what's considered in a rebase. [SPEAKER CHANGES] OK. [SPEAKER CHANGES] Moving forward in the funds that are coming forward. This was a Governor's item in his budget as the department has said they will need to additional funds to match the federal funds moving forward in the year in which they need it, so. [SPEAKER CHANGES] OK. Now let me ask you this, let's move to item number six, the competitive program for the non-profits. I understand that we have quite a few non-profits that historically been funded under this particular section of the budget. But many of them are reliant upon funding that comes in from the state of North Carolina for the work that they do. It would seem to me that if we were establishing some type of a block grant program for a, considering applications that it would be quite a logistical pass to organize that to establish some type of merit based system for analyzing who the individual applicants are, and for doing this in an expedient matter that would ensure that those that are deserving meritorious non-profits would be able to get funds which they need in a timely way. With that said what's in vision about how this would operate? And what do we know about the department in terms of their capacity to take this task on? I don't see any kind of companion piece unless there's maybe a special provision that provides for additional staffing, and resources that we needed to carry out the task which would be contemplated and necessary through item number six.

On Saturday the CIA to respond to the page, and the provisions to move, go to this page 117 a provisions of lay out the specific areas in which the funds will be designated by which will no longer made to take your agency or others by we're talking about , funding going 21 ended under prevention in the slaying of that we currently had two million dollars it was well in the body of equally among regions of the lead bank system of voters another competitor out there and will be providing that on statewide, it would allow the parts like stability as they currently breaking down the equal funding between a finger six regions am not mistaken,(SPEAKER CHANGES) two balanced in ward 821 overarching of them on recent sales are soaring association and sales of two which uses you some of them some have delayed or to apply the party and eventually like to make decisions which way the earlier reflected equal funding of CT 16 moving four all we do think the secretary's office two on is to transfer these funds the measuring the funds and works in so many of these areas already on its probably have a better position to continue to live from the general assembly has historically been a war would be in the future of it, make those decisions were recalled on the addition to that, perhaps in this direction that one would contemplate holding it might be better to five fund and ourselves this year fell off a special provision in all of staff to develop a plan a condition for a planned for the planet's year until they will be in place they can get their applications in a timely way continue to be funded by 237. (SPEAKER CHANGES) One where we're looking right now we know in the 20th on the role of something that might allow for what corporation transition action to read with interest rate will be as for the other funds, which have savings were contemplated with Mr. Action and I assume that the goal was to be like servants savings in the process from a cartoon all from what we have here is one lamb always the case today and I don't know if saying that exactly what goals collected into each received last year there is an industry that's the first there is no savings in this state is the data for the mall was required for a reduced budget items or they were we continue to Walter funding would be this level (SPEAKER CHANGES) I we just played no savings by doing this to move funds and all but two department is solely an administrative arm decision when you went to a landfill the transition bridge might be a better idea for being there and is doing quite like this year will we get all were 210010 and number 11 be a great case looks to me it looks as if we're a limiting and 2500 slots in year 105, Sr. two understand that there's some are sincere but which could be a subsidy plan created but the actual number of individuals that will be surgeons and difficult for me to determine based on the way I see this Lions club in the budget so maybe you can provide further on our liberation of what is believed we could be lives in terms of an affectionate; see more people are aware of the Ottawa see less in the end of the deaths were weakening of the-ball to give these kids ready and being in a minute or call the school system so they can you open a hole to withdraw cash and futures is the highest risk is startling beyond calendar subsidiary is not a new program is currently existing program and slaying of corners and said Mr. Markets is currently boasts more short program five as a priority for individuals and 34 and that if the current mortgage division said in the 34 and five star facilities on there that could provide some services of come up with the slot allocations we took an average cost of crawls under the current a subsidy system and greet a system of the funniest and when you take a dollar man with the same amount over becomes about 2500 realized from about 26, a place under current spending levels are more they do there is some variations on as a??................

Now whether an individual ghostly five star so you're forced are selling off him and custom average across and as long as we work mostly somber sea surface is a conservative , increase of four we expect the suspect will be on quite a bit higher than 100 additional slots and 200 additional slots which saved one that's when we'll admit that the bill was insistent that we have a flashlight into the skill level allow for the additional students to be a part of this year is applet is contemplating a move by the films that a canister view special regime.(SPEAKER CHANGES) Michael Copeland bigger items: we currently have a waiting list, for the Solzhenitsyn exist on all over nothing to most counties are you'll find across a study of the week only individuals with beginners, shortage of individuals are looking into that program all that's the only four hits off a bed of filling them under the current standards exist for the subsidy programs and Bernice exists for installing IE: that when this evidence, in terms of moving them to some: the other: the same as string of these units that will be participating of the chapters of the program provides for children are studied five and some say the project provides only for four year olds to listen to gifford's shock for the population surges with an apple said it is the most women look into that although much of the early years of intervention are more important move and four are making four isn't all ages are used more mortgage will have to overcome officials and who would follow. Nationally known item number 24 don't need love your grants … (SPEAKER CHANGES) If we're willing it from 24 will begin to 25 you'll allow a little bit further along what is we're hoping to accomplish with this change the system commander of showing how we've bonded is coming from the on the commuter water and the someone else on the department spending spree one of the ones that really would come alive May 20 was as big as I assume we did the pilot programs will the sunset, $2500 thousand and the inland side of the music, counselor able to get some additional monies with a general fund appropriation but, as it was as two of them used almost a former staff to have a question considered sending to see the program I did find it with Federal grants to 500,000 SMS for expiring from the governor had requested a $500,000 expansion just replace terms expiring evergreen (SPEAKER CHANGES then the chance to propose to take appropriate state why I change from some of the general fund money that had been going into the much larger home and community can block grants to this program so they could be expanded from about 25 county school all went against a quick phone since we're taking it from the money that had been the no is the block grant funds into the 24,000,000 lives and then we will not be able to fund that we previously funded with no structure sources but SA, facsimile my family back home and communicate likely to stay out of noxious 25 percent difference lists of Federal funds and goes from those kinds of about 2 to 17 area agencies on aging and they have a lot of discretion still lack of local Bishops Services the like to find on occasion and some that would probably be the county's financial area on the team PDC to determine how two, I reduction and today would eventually to go back and use the role of management flexibility in passing that surely have become that's correct all of 27 shell development service agencies were limiting the same form and are EL and explain a little bit more, why are we doing and what becomes of ocean would ensure and would like to be we use to determine who will affect the delimited org: surgeons to end of a snow storm ??....................

Mrs. Thomas [SPEAKER CHANGES]. senator McKissick those, the child, those 16 agencies are operated under the early intervention branch in public heath and for the pass several years. That branch has been running a lot of vacancies in those divisions and that was the source of a lot of the money, as you can see 17 million each year. That have been transferred over to medication shot falls. So obviously those program were not operating currently at capacity. If it were left up to the department, this agencies would not have to close until July first 2014. And it would be left up to the department to determine which of those sixteen will close and they will report that to the LME in the interim. [SPEAKER CHANGES]. Thank you so they are kind of like underutilized resources that we were using as resources to cover Medicaid short falls. [SPEAKER CHANGES]. Thats basically what's been happening the last couple of years. And as the department, you'll see a provision that follows this money. That directs the department to ensure that they keep open those CDSAs that have been serving a lot of the rural areas or medically under-served areas. [SPEAKER CHANGES]. That is good to know. Let me ask this when it come to number 30, 31 dealing with oral heath section. It looks like there were previously 48 old time positions. Founded to the tantamount 1. excuse me 2.8 million dollars or so closer to 2.9. we are shifting it to the local health departments. Where we get them 1.6 million. Who are we gonna serve the same population the same need base when we are cutting them short by 1.2 million dollars. Because I think oral health is being one of those things that is obsoletely imperative. We need to do and I think of this organization of this day. That ?? a lot of free services. And I see those clinics operated and the lines are around the block with people trying to get in so knowing that this is only going to ?? our budget with Medicaid. How are we going to do this. How can we reduce it by 1.2 million and serve the same population. [SPEAKER CHANGES]. Most of the difference is between 30 and 31, 1.2 million, is the position that are listed and eliminated here. As well as the administrated positions and others. The funding for what was going to dental hygienist position. While you can transfer individuals form state to county. The funding we paid for those individuals is now moving to the counties. [SPEAKER CHANGES]. Is it anticipated that that would be sufficient to move the same demands levels. The same patient levels. [SPEAKER CHANGES]. It is anticipating that it would be able to serve 39 additional hygienist in those areas. [SPEAKER CHANGES]. Perhaps staff can share [SPEAKER CHANGES]. yes senator McKissick. That which you don't see here. This is just a general fund portion. The money that is going to the counties. This position had also Medicaid match coming in. so is anticipated that those county health department would get some Medicaid match for those dentals positions and their dental clinics. [SPEAKER CHANGES]. Thank you. Number 36 we are closing the alcohol and drug treatment centers this residential programs. Do we have a assurances that the counties and other organization can go out there and provide the same type of need, the same type of services. Cos I would assume that this. They might have been operating at cost that we should control and contain far more effectively than we have in the past. If some people that really do need residential programs ?? out patience facilities. So how do we get that population serve that we really need to be taken of the streets, and put in a place were is a controlled environment to help then overcome their alcohol and drug abuse problems. [SPEAKER CHANGES]. First of all so that this services are not provided by the county they are provided by the LME, MCOs that we currently are on a regional basis and not coming over. I'll also say that three ADACs centers in the state, are not providing state wide residential services for every one that needed it. Its not unusual to see people in areas in the state that would be two or three hours away from one of this facilities. They do serve individuals who are close then they do individuals that are further away, form their services within there populations. What I looked at, what my researches looked at as saying. That

best courses of treatment. Now there aren't--there are no magic bullets that are coming in. Provide treatments that involve an individual's primary care physician, that are ongoing treatments that also allow them to adjust to their new life in their current environment; versus taking someone out, putting them in a separate environment, getting them off the cycle and then sending them to another environment later thereafter. I mean, there are services that are, at times, seem to be more effective when they're provided closer to an individual's residency. And we believe--I believe that the community areas can do this. It's not that I don't think there aren't--we don't--we believe that there are individuals who have been well-served by this; there are individuals who have been well-served by services in their community. [??] moving forward--we just feel that we can--in this time--that when you have to bring these down to dollars and cents, we believe we can provide the services to the state in a better manner and fewer funds by not having three highly expensive residential treatments centers. [SPEAKER CHANGES] Okay, move on to number 39, the Wright School. I see we're closing it in its entirety, and that I find deeply concerning because I know I've visited that facility on a number of occasions. And, I've just heard amazing testimonials from the families that have had students that were--attended this facility, and I find it deeply distressing and concerning that we would be closing a facility that can have such a great need and demand, and I don't know where those individuals now are going to be served within our system. I mean, what are the thoughts about that population? [SPEAKER CHANGES] Well, first of all, this is not a new position for the Senate. This has been in the previous Senate budgets that have come across and looked at this costing and I say that it is quite--when you look at what we're spending on [??]estate, and what we're putting into the Medicaid program and other areas--services in the state as a whole--and the needs we have out there, and we continue to say that we're going to at $112,500 a bed, fund a part-time residential facility. [SPEAKER CHANGES] I--I would hope you guys would give greater thought and reflection to it. I know the cost is, perhaps, high; but when I've seen people who wrote me the transitions that their students had made that attended that facility, and I remember being there one day with Representative Dollar, and he heard and saw the same things. I mean, I would just hope that you would re-think that as a part of your considerations moving forward. Let me ask you about number 59; it's exchange premiums, with elective Medicaid eligibles. I'm skipping over quite a few other things in the interest of time. It looks to me as if, while we will be paying for these individuals who will be Medicaid eligibles, [??] part of a --getting insurance on a health benefits exchange that, simply by helping them get insurance, doesn't help them pay the deductibles or help them cover other expenses relating to their coverage. But you speak to that issue because it would seem to me that they would still, at that point in time, be [??] change the benefits they would receive today. And, you know, how--how it is anticipated--you know--it will be identified which, by the policy they will get, what the scope of services will be, what--I mean, they're going to have out-of-pocket expenses now to pay in connection with this in terms of going in and receiving services. But could you speak to that, somewhat? [SPEAKER CHANGES] I will. The Affordable Care Act, in--as it was passed and moving forward in its determining in the exchanges, I will say, reduces the co-pay and out-of-mocket [sic] paximums [sic] relative to an individual's poverty level, as well as to the percentage of their income, they would be charged each month for those services. We are picking up the--they will have lower co-pays, they will have lower out-of-pocket maximums, depending on where they're at on the scale. The exchange scale goes all the way from 100 to 400 in putting that in; but there's some variations that come across that--that adjust that for individuals of what--in their determination--and what an individual at 150% of poverty would be able to pay, moving forward. So, we're taking those recommendations and applying them to this system here for what the feds have kind of come up with in their wisdom. And I also think it's very important to know an individual's care, particularly in this case, w--[end of data]

...women's healthcare. We offered them a program that was available while they're pregnant and as soon as that was over we'll just drop you and now you have nothing to continue up for because once you're not a pregnant female, you don't qualify at 185% of federal poverty anymore, so we were providing a temporary patch plan that had some better services in it. I don't deny the fact that there's savings with doing this that's coming forward. But we take that individual and we say, well, the federal standards have set that a person at this would be able to pay these amounts on theirs. We pay their portion of the premium for them, which is an additional savings for that time period and they have something moving forward, particularly in a pregnancy, where they would have met the out of pocket maximum where potentially the co-pays moving forward. And after the program would now have deductibles and after the program, would now have an insurance plan that continues for them when during that annual period they would have already met a lot of those costs. [SPEAKER CHANGES] What are you basically, and correct me if I'm mistaken because the way I'm seeing it we're paying that premium that's covering these people that are between 133% and 185% of the federal poverty line, but they're going to have needs separate and apart from say in your instance, example, the pregnancy where they would in fact end up. Are you saying that we're still going to pay whatever co-pays are going to be required or anything else that would... [SPEAKER CHANGES] No, we pay their premium for the insurance. [SPEAKER CHANGES] The premium, that's what I thought. So I can imagine there will be a number of... [SPEAKER CHANGES] The exchange itself will reduce their out of pocket costs, their premiums and others, depending on their income level. [SPEAKER CHANGES] So you're saying the policy will take that into consideration based upon this case. [SPEAKER CHANGES] The federal policy that develops the exchange takes those into consideration. [SPEAKER CHANGES] OK. And I understand that, too, I'm just awful afraid that some of these people are going to end up with the short of the stick financially. That's why I raise that concern. And I see underneath there the companion item, we're now going to be limiting adults to 10 visits a year to a doctor. Do we have some idea of how many individuals might be impacted by this? I mean I understand there's some exemption here for chronic conditions but I don't know how many people will utilize these types of physician office services actually go that frequently. I mean somebody's going to have to be pretty sick to be going more than 10 times a year. So it actually doesn't seem like an unreasonable limitation, but do we know how many people might be impacted by this change? What percentage and when I say the number, I'm not looking for an absolute number. About what percentage? [SPEAKER CHANGES] Let's ask Mr. Stevo and Nat, answer that. Help you with that, Senator McKissick. [SPEAKER CHANGES] Senator McKissick, I actually do have the numbers, but not with me. I'll be happy to get those to you. [SPEAKER CHANGES] That would be appreciated, if you could. I'm sure there are other members of the committee that have other concerns separate and apart from my own, but on this particular, what were your presentation, can you go back into these costs and break out the imbedded costs that are attributed to the shortfall we have right now, compared to what it is in terms of growth that we anticipate? And I know when Madam Secretary was here and the speech, they talked about monitoring our costs all more closely moving forward, but can you disaggregated what we're looking at here in terms of these figures for year 1 and year 2 of this budget? Because one's at 434 million and then the other is 607. Can you help me out with this a bit? [SPEAKER CHANGES] Let's ask Ms. Susan Jacobs to respond, Senator McKissick. [SPEAKER CHANGES] Mr. Chair, Senator McKissick. The Governor's original budget that he submitted included a current year shortfall of $100 million. So his original rebases for Medicaid was based on that $100 million shortfall, which was very early in the fiscal year. The most recent information we had was a current year estimate of approximately $248 million in the current year. So of this rebase amount, at one point it would have been $248 million based on the most recent information we had from the Office of State Budget and the department. The high end of the range being projected by the Department of Health and Human Services, the Division of Medicaid, right now for the current year is $283 million. That's what's in the current House bill for the current year shortfall. And the $283 million is being anticipated in this budget as a recurring...

Or fall, so of the 434 million dollars you see, 283 million dollars is because there is a structural short fall to 83. [SPEAKER CHANGES]. Thank you Susan. Obviously this whole issue related to Medicare is something that is a big concern to all of us. We obviously have to do something to get us beyond this continuing deficits. I see on this next page here, you talked about community care North Carolina study. What is that study gonna accomplished and what is it that we hope to see accomplished with that. And ?? a lot of discussion with the secretary's office by moving to a manicure model. I'm trying to see where all of this pieces fit together in this jigsaw puzzles, interns of what we are going to be doing moving forward. There's a, I'm sure you heard the same thoughts, concerns and reservations raise by many in the health care community. Particularly among hospitals about the manicure model. And how is proposed that we are going to deal with that, with tree or four entities out there now. Competing and being assigned different persons some of which may end up with some high risk individuals, suddenly end up with lower risk ones. Can you help me with what we are planing to do here. [SPEAKER CHANGES]. I'm get to the provisions on page 171. This are following up on the particularly on the auditors report they coma out earlier this year. That would require to engage medical research for me, scientific ?? study by on actual data, to determine whether CCNC model saves money and improves health outcome. That is coming forward. I would assume that that would also be an actuarial involvement. ?? what we were intending what we would like to see, is that particular programs and others at CCNC is put out. What is been there effectiveness. What is been their call savings as well as there model as a whole. Moving forward I think that this is a babel information, as you move forward in developing what would be the future of the Medicaid system. [SPEAKER CHANGES]. Last two question and that is there were 57 private duty nursing limitations. I'm trying to see how that ties into the actual numbers of hour a day that people actually require, need typically private duty nursing services. If you were capping out that cost. Then secondly this hospital base rates that we are moving to the new regional system. We certainly wanted to make sure that our rural hospital are adequately compensated. But I also don't want to see our urban hospital short change in some respects. How are we gonna approach this with this new methodology to make sure that there is this equitable balance, interns of compensation levels for appropriate types of patients. [SPEAKER CHANGES]. Senator Brunstetter. I think we have kind of a breakdown that we can get to you at a latter point for each hospital in the system. What the impact would be of moving the base rate in coming forward. It is not, I would not care ?? this point. There is a large shift. But when you look at the profitably, of hospitals across the state the expandability I guess when you are talking abut the non profits, profitability is a little different number. There is not problems in our urban areas. There ability to move forward and bring on new practices. While there unbans are running deficits each year. Is not hard to look at your urban hospital to see what they're sending to rural areas already. Moving forward, we just doing that in the base rates. Your first part again, real quick. [SPEAKER CHANGES]. That was the private duty nursing. [SPEAKER CHANGES]. Private duty nursing. That is equivalent in the, the governor had separate recommendation that was dealing with the, changing the rates for LPNs and RENs down to the OPN rates. As well a twelve hour maximum. We took funding that was equivalent at the RENs level for the twelve hours, and set it as a daily maximum. That was coming forward. We didn't love it. We chose not to lower it to the OPN rates cos of the way there structure is kind of set up. And we did it a daily maximum, so if they take

lower rate for whatever different reasons they could access more hours so that amount is considered at the RN level at 12 hours, what that amount is that's now capped out at it's daily maximum and they're free as they have flexibility whatever flexibility they have to move around that they are free to utilize. [SPEAKER CHANGES] Thank you. [SPEAKER CHANGES] Senator Robinson did you have a question? [SPEAKER CHANGES] I have several. Senator McKissick, thank you mr. chair, Senator McKissick has said some and I'll try not to duplicate those but some I need some additional information on. I'll start from where he stopped in the back so it won't be so difficult Senator Hise to follow back to the hospital rate number 61, freezing those services, are you taking into account the larger hospitals to the smaller ones any overhead costs and is this going to threaten the collaboration cause a lot of the larger hospitals are the reason a lot of those smaller hospitals have been able to provide those services is because of that collaboration so when you do a base rate are you taking into account the overhead costs of those larger hospitals? [SPEAKER CHANGES] What we are looking at is specifically on 61 we're freezing the automatic increases which are sometimes inflationary or sometimes others that come into a program outside of anything else we are doing we're putting a freeze on those as we do for a lot of things kind of across the budget moving forward when you're bringing in revenues is where it's going for those base rates and others, I think our healthcare survives on those partnerships I think it would be I would say let me say personally it would be a grave mistake for the urban hospitals to begin to believe that they are going to step out of their partnerships while their funding remains intact in this state and they are going to abandon that process but I think there is a lot of opportunities that we are looking to make those rural hospitals more stable on their own without the need for those requirements. [SPEAKER CHANGES] Ok, another question but just a comment on that I think the fact that we are also expecting hospitals to absorb a lot of the emergency room visits not by having medicaid that we don't, we really shouldn't be threatening those relationships we need to depend on them and not kind of what I put what I said penalize them more. [SPEAKER CHANGES] I would see no indication that urban rates have higher uninsured than rural areas do. Matter of fact I would think the relationship you would see would be quite the opposite. [SPEAKER CHANGES] Well I know, I know but that relationship is going to have to be stronger because there's going to be more codependence is my point. To number 59 about, you referenced that as a specific for a pregnant woman and my questions are too that a lot of those women are in pregnancy care management programs so does this affect the funding for pregnancy care management programs in our state and when you mentioned services after the woman has given birth which is important because currently women don't have any they don't have the health services after that how long will those services continue? [SPEAKER CHANGES] The question is to whether how long the services would continue depends on we pick the time period that they would have been on medicaid, we pay the premium for them, depending on the case 22 dollars a month 25 dollars a month, as long as they continue to pay that premium moving forward they would continue to have that service as everyone else who's on the exchange at 133, 135 percent of poverty would have that option. Whether or not the services would be available to those or how they would fund medicare is currently they are accepting medicare as a provider and do not accept private insurance in that then I would suggest that they either that those programs would adapt and be able to accept private insurance moving forward and as you would find with most providers in the state the private insurance rates they would receive for services would be significantly higher than the medicaid rates they currently receive. [SPEAKER CHANGES] Follow up Mr. Chair on that particular one. I'm talking about the pregnancy care management programs are really funded through medicaid to the state am I right and that my question is am I wrong and if I'm wrong correct me and if this would effect the funding...

Lasorda secure management program for those literacy terrorists were stolen air supremacy about known as fun as humanitarian bowl will happen under this scenario that this to the polls and the purchase offer the exchange with the portions, for two of its own and that would impact will call sheet of which are encouraged and should mention that as a pilot to set the stage here is a work by senator AC thing that would pay the premium for the attack. MF tear the babies born to a person to one would have to pay cut back, premium costs is this what any other individual exchange , the other questions as each year the sub like to remind a committee that, we have about 35 minutes of some ago we select provisions to cover and also(SPEAKER CHANGES) four OK, I would apologize that said senator McCain’s to come home and found it, and I would do that again and again go back to a couple of DNA of um KHCD said A. Pulido 2 ERRECC 37 at home in turn can be used treatment centers, common sense there's several BS OC programs and limited by ES a minor league election looking back on am proud that local facilities in turn from umps Su said that(SPEAKER CHANGES) in the DS & Nelson has already and we're back but as we talk about closing the L.a. ever four a league of king and the community bank forces hospitals and some of these services include why we like you and the bells to absorb some of these are sheriff's additional funding would all go to be placed on the formula to the audience see as a player for younger system to provide services on with the private contractors as we seek to a little mention provide individual services like contract with the unions across state lines end of that would say that I am a with seven Chinook SS and concerns about bankers currently have long waiting lines or income of drug abuse services from CNN 2, that 227 early intervention services and staff explainer you can explain the land fear that we had nine D leasing the services of numbered shelter network B. Stewart had stolen some applets salaries and Federal but how many children are currently being Sarah reed and it left the challenge, it will be served on here under DL into bowls starts of the skills which starts in Robeson the connection information number Chilton apparently said Tom I think it would be out of the computer projection would be served that right now they're running a very high number of ANC sir bear in mind working at capacity now in some way that possibly cutting starts of the DS the ninth of San by getting the department flexibility and I think that they could do this without contacting services offer just looking at the accounting office's PR the geographical areas and the type of services are available in each would call the fact is that they would take into consideration that sentence and like to wait until the top about 55 until you go to the top of the documents on the street journal, Mary,(SPEAKER CHANGES) I have a right to cover again with her the money report of loud whining top of an Alaskan L.a. County reception DN: black is a proxy Arianne suite at the status quo will change their father tells the LKXLE agency letters and cards and has ever been to turn on what officials in provisions we get two was that the county assessor's will ballot minister of the joker subsidy for a school, through the joker subsidy on that may have something about the priority listing of four of warring parties for childcare subsidy certain of that there are just working families first of three ??....

individuals off. Individuals, I believe from my Smart Start Program for individuals who are enrolled in school and students, children of those second, and then move to individuals who are not prioritized. Moving forward, I don't know if anyone has any more information on what the enrollment criteria are for subsidies. I can get you ?? coming across, so I can get that as quickly as it comes through. [SPEAKER CHANGES]. OK. [SPEAKER CHANGES]. And we prioritize the distribution now to higher star facilities, 4 or 5 stars. [SPEAKER CHANGES]. OK. Just a follow up to that, Mr. Chair, while they are looking. Do I understand that some of the Smart Start programs won't be funded, or will all of them be funded the way they are funded now? Or you're going to leave, or the DSS is, will that change in terms of how the Smart Starts are funded through the DSS, or which ones will get so many slots, etcetera. [SPEAKER CHANGES]. The administration of the funds, so if you look at the funds as whole, where they were being placed are now placed in DSS. The money is moving, but that money was required to go out to individuals, kind of to begin with. To go out to centers and others to slot the numbers. You have ?? coming on, you have several things going on in DSS. You have, in certain counties, three different agencies deciding who's on what. This is an attempt to consolidate that and make sure DSS is doing that, kind of across the state. That they have the funds to administer it and keep it up. I'm moving forward as a provision coming later, very significantly more funding in this budget for individuals from birth to 5 to receive services within the subsidy system than there has been previously. [SPEAKER CHANGES]. OK. Just a clarification. So basically, how the funds are administered changes, but not necessarily slots to different counties? In terms of funding or allocations to different counties. [SPEAKER CHANGES]. There will be more slots to each of the counties based on their funding formula with a hold harm- There was a cut in previous years that said no county could go below this, there's a continued hold harmless so that we don’t continue to take them below that, even if their population changed. But predominately, this is making sure that we are providing more slots out there in the Child Subsidy Program. [SPEAKER CHANGES]. Why don't we go to provisions at this time and if time allows, if there's still any further questions about the money report we'll come back to it. Senator Hise, you need a drink of water? [SPEAKER CHANGES]. I might grab one. [SPEAKER CHANGES]. You can turn in your provisions document to page 116. That's the beginning of the Department of Health and Human Services. [SPEAKER CHANGES]. Beginning on 116, this is a provision that comes from the Department as to, that allows them to reorganize relative positions, operating costs that they can show cost efficiencies with. Moving forward, these are all subject to OSBM approval and include the identification of up to 32 existing positions. It allows them to get some flexibility in moving positions around, and others to run the department better. The next provision beginning on 117 follows the money item. This is the layout for the competitive process, which I'm sure we'll have a lot of individuals looking through, but it deals with the programs for autism, deals with brain injury, deals with substance abuse and addiction, deals with individuals of intellectual developmental disabilities, as all those different areas did. And moving forward, and we come down and we have 13 of them that are laid out here that’s coming forward in this provision for the different areas to be funded by the department. The Health Information Technology one is the boiler plate that's been in several budgets previously

On the coming four that remove two of the (871)-922-1201 home this is some cummerbund or a blissful system goes to the funding for MMI as on I will say that the wind blows the crossing my fingers and hoping in question, storing playing and everything else I've gotten this process autism assumption in our budget that has all been told him (SPEAKER CHANGES) I guess we'll have to go live date of July 1 on and so we're planning on Netware movie formats and, we're really playing on the discord to them and so on bedroom, 121 or two away Johnson was processes and women over on the issue several of the provisions in the morning like said by way of selling reports and others are these are coming from the agency requests for reducing the reporting of those required the general assembly hall way to accomplish with 26 is something we've looked and reports of services and mice were no longer be continued day as some secretaries and a pretty clear on the world from Birmingham with the tremendous match play 4 minutes in over your also we do take a look at what information we actually made on 126 home he owns the bridge and eligibility I will Colin L then, we get maintain the current eligibility standards of force, which of the two minds can be resolved in the courts are in a member so we have not a move to try and make a deal to build standards on and on the page 128 , 12 week two of this is a provision that requires only county park and so sure this is administered shelter substitutes with the talker subsidy rates another German allocation for miserable plain language is would not change sums to continue to come to room on as also won 31 a study of them we will begin to apply the midst of an identifier that we have and pretend to work force the two students and two children are receiving be a talker subsidy as well so(SPEAKER CHANGES ) we can begin to track of the film opened officials through that program just and our own we also will, for the early October on the issue since our students were stored on how we increase last year of their percentage of required badge from a 10% or 30%10% in cash 3% service is a we're continuing to push that of a windfall 14% mention the first year of 15% mention the following year of living three and then on a live in four of cash to all services to match are moving four of their funds without the transfer the minister of India sales arm was coming through one of those stranded on airs partnership, we have reduced mothers come in from the governor were for or put them there for Wahl com those 2136 and 137 of its provisions are 1¢ single four by weekend in the budget provision required to test into workforce are confirmed program assistance to measure the spicy and all moving out on a new study four of us is procedures are reporting job abuse when we come from some language reported doing the same program displayed services , 138 to 140 two, we're creating a pilot program which are used, tentatively on a 46 counties which we explore the utilization of tiered special assistant rights by which can service many individuals within the county based on their needs and others weakened by higher levels of five special systems to play and reduce ??.....

But officials remain on leave as much of it is the a general some loose and two of all that we will eventually move to a cure a special system for a statewide arm still regards I can move forward only in this pilot program will do some public health , 140 and 41, we have a permit for the home for lodging establishment increase of just such an arresting the fee is in the western association has come to us and as for us to increase the fees they are playing on and services and public health so they can expedite the process of inspections and others coming and are moving ahead 47 on a little years ago there may come as foreign armed services coming back, scoring four of your field strategy on page 141 we talked about the money provisions, falls in the elimination of the positions of moving four and one health departments on a 140 page 142 was beyond some closing of the children's film services of the four of six and (SPEAKER CHANGES) Ms. Wellesley cents two. Priorities on 143-1402 and 143 of the 8:30 AM program with a store we start looking at the one or soles medications to be played on the exchange consider an alternative would be better for us to play on Oakland’s another movie also better for this population are simply was premiums and while we're going to be covered under-covered in some of the current system solution please win, look at a four home the metal 149, some provision for closing the attack Sooners of this will close this will stop admitting you patients on July 1 of this will allow everyone in the army place that offers as four other women are complete the program on this one down for curing on page 149 on this is a procedure we have a long as we have expanded to killing four individuals with (SPEAKER CHANGES) Alzheimer's and others are the areas of service up to 130 HRS on we felt it was important to not have a certain extension a conversion of all these units coming in saying more special care units and I were flipping over without the immense absolute place a three year moratorium along with them so new special care units there are several exemptions and therefore requiring one and the something and for Shelby but without that was important process so that everyone wasn't ready to laugh from Wells on exchange for designation of a guess the biggest form an OS with 151 of all the savings and continue a year after year by investor buying and be coming in here with an unpredictable system is saying whether the weekend overruns of about 300,000,000 this year on to them is that the only one knows the cornea things over and some of the year's last year we had $150,000,000 hole during medicated the last minute body said that the insulin worried about the remembers when of 650 on we've got to be able to control her Medicaid calls that we've got to be able to four chairs with the new year with those costs are going to play quite frankly we can do neither until we reform the system of this is a provision of the allows the governor's office of rubio's begin with the process of the 1115 waiver of for Medicaid in developing on the process the suspect will take some more neighborhood of six months or maybe less maybe more all we also say that the odd governor will then submit his four application for the labor as well as via all details of his reform plan on and that the general ??..............

[Speaker changes.] ...assembly will approve the plan before it may be submitted to the federal government. ????? feel free to begin all the processes and those kind of things but cannot submit the application until they receive General Assembly approval. There is no way in the three weeks we kinda had in this that we can get through all the details of a Medicaid reform package and what needs to be done so that is why we're putting that process...we are not stopping the ball, we are allowing it to move forward but we are clearly putting in a process of General Assembly approval into that. This is in conjunction with the Governor so we'll begin that development and we will take that look at the full plan when we have it in front of us. [Speaker changes.]159 to 161 is the insurance premiums for pregnant women. 162-163 has the additional personal care services for qualified individuals. 165 to 166, this is a significant change dealing with administrative hearings, particularly when we identify over payments or, I guess I would say, fraudulent activities in the system. We, as a state, are in an interesting situation where we find them for the entire clock starts, if we have not recovered any funds within a year, we have to make the payment back to the federal government for their 2/3 share whether or not we've recovered any yet or not. Then we wind up in a position where they could file bankruptcy and you could never...file bankruptcy's a little different but they could fade out, they could disappear...there's all kinds of things that would make them unrecoverable that means by identifying it...or identifying an over-payment, you could just be costing us a 2/3 payment to the federal government. What we begin to do is take a portion of that payment from future payments of the provider during the hearing period over that process to make sure they're laid out, and that over a year period, we could recoup most of the...99% of those funds, kinda moving forward and make sure that we would be whole at the time we hafta make the payment back to the federal government. 169-170 is the shared savings plan with providers. 170, the assessment to a percentage. 171-172...171 is the community care outcome study and reporting. 171-172, we're setting per member, per month instead of being a flat...we're looking to set per member per month instead of being a flat per member, per month. We're doing it in a ????????????? that says for providers that are doing a better job, that are implementing more, we will set forth...we also say that CCNC will not provide a permanent...there will be a zero payment for prime member per month...per member per month for providers who do not, do nothing in conjunction...right now, CCNC...all of their treatments and others are recommendations and there is no requirement that the providers follow any of those. So we're trying to clearly put in place that you actually hafta not just sign up to receive the per member, per month...was our intent. We do several that are...Board for the institute of medicine, some changes there...the ???????? grants, some changes coming across there but I think in the interest of time and that we hafta...we have some community members that need to speak on this process...I think I'll leave it there. Sorry if I ran a bit over. [Speaker changes.] Thank you very much, Senator Hise, for an excellent presentation. And wanna thank the staff as well. At this time, are there..I have two members from the public who have signed up to speak and, if the first speaker, Mary Bethell??????, representing AARP North Carolina would come forward, ma'am. Welcome and you have two minutes. [Speaker changes.] Hi, good evening. I'm Mary Bethell??????? ?????? Director AARP, North Carolina. Thank you, Senator ????????, Chairman Hise also...committee members, I wanna talk to you about items 24 and 25 on page G5. And this has already been discussed a little bit. I wanted to build on a little bit of what....

Ms. Thomas says. In the effort of full disclosure I want to mention to you that I work for the North Carolina Division of Aging Adult Services that administers both of these programs for 30 years, worked in both of these programs. Certainly item 25 I recognize and understand the frustration of the members of the General Assembly about project care which is a program to support family caregivers a persons with Alzheimer's and not having this program state wide. I also was a family member for my mother who required round the clock care for 8 years who had Alzheimer's - we could not get this program for our family either because it was not offered in our county. Now having said that I am familiar with conversations right now to make this program state wide with the existing resources. 500 thousand dollars is needed to take care of the federal funding that is going away however. Now having said that though let me move to the home and community care block grant. The home and community care block grant is, as Ms. Thomas says, does allow counties flexibility in what they fund. There are 16 services that can be funded included respite care which serves a lot of persons with Alzheimer's. This program is targeted at people 60+ and most of them have incomes less that 200% of poverty and they are not eligible for medicaid so these are a lot of folks that fall through the cracks. Now this program has been around for a long time, however in the last 10 years there's 7,000 less people being served now than there were 10 years ago and the simple reason for that is because of the increase of cost of providing services and I have the data if you'd like to see this. Now 2 of the biggest services that are offered through this are in-home services and home delivered meals. They have huge waiting lists in North Carolina. Now the double whammy on this is that North Carolina is receiving 2 billion dollars, I'm sorry, 2 million dollars less in home and community care block grants the federal money that's coming in due to the sequester. We take another 2.9 million dollar reduction on top of the 2 million dollar reduction they're getting through sequester. This is really going to be an awful awful burden for these local agencies to be able to try to address the genuine need that's out there. I'll be glad to share data I have and to provide any other information should you have questions. Thank you. [SPEAKER CHANGES] Thank you Mrs. Bethel. Our next speaker is Adam Linker from North Carolina Justice Center. [SPEAKER CHANGES] Adam Linker from the North Carolina Justice Center, thank you Senators Pate and Hise. Setting aside some of the other concerns I wanted to speak very specifically about the provision of shifting pregnant women who we are covering into the exchange. I understand the desire to put some populations into the exchange but I'd be especially concerned about doing it now with pregnant women who we currently provide medicaid for. First the way the special provision was written it wasn't clear whether we intended to pay the full premium but it sounds like we are intending to pay the full premium. If a pregnant woman has used tobacco products of course we want to get them into a smoking cessation program but federal subsidies don't cover the portion of the premium that increases due to smoking so I want to make sure hopefully we are paying the full premium for pregnant women both who have used tobacco products and for those who have not. Second of all, I think there's just a lot of concerns about shifting people from medicaid to private insurance especially a vulnerable population like this. For example would a pregnant woman be able to lose insurance, lose her private insurance policy? That's a question. Second of all in medicaid a pregnant woman is not denied coverage or service because she doesn't have the copay amount. The copays are higher in private insurance so could they be turned away from service because they don't have the copay amount if they go into private coverage. There's just a lot of policy protections we provide for people in medicaid that are not there in the private insurance market. So I just hope we can take a closer look at that and make sure that we are not burdening pregnant woman because again North Carolina used to have one of the highest infant mortality rates in the nation. We've made tremendous steps in that by expanding medicaid up the 185% of federal poverty level and I just want to make sure that we don't regress in that. Thank you very much. [SPEAKER CHANGES] Thank you Mr. Linker

Been asked to be sure that anyone who has a comment from the public would be given the opportunity to speak. So if you have any information you'd like to relay on to the members of the subcommittee, I'd ask you to please come forward at this time. Senator Hise, I think you've answered everyone's questions. I don't see any. Are there any other committee members who have questions? Senator Robinson. [SPEAKER CHANGES] Thank you, Mr. Chair. It gives me a chance to finish up a little bit. Senator Hise, back to your explanations on, I want to ask you to reiterate what you said about after six months, if we have the system in place then, or recite that in terms of the waiver for Medicaid expansion. Go over that process. I wanna make sure I heard you clearly. I'm hoping I did. [SPEAKER CHANGES] Basically what this provision does, is it allows the department to go ahead, move forward, and the executive branch to go ahead and move forward on developing the waiver of, the 1115 waiver for the state of North Carolina. The demonstration waiver, as it's called here. However, that application and policy in its whole will require general assembly approval before it is submitted to the federal government. So what will happen, I would actually anticipate that we will see somewhere in that time period a special session called for us to be able to deal with this issue, particularly, in able to acquire passage of both houses. [SPEAKER CHANGES] Okay, another question, Mr. Chair? [SPEAKER CHANGES] Yes. [SPEAKER CHANGES] I want to go back to the CDSAs because I did not ask that question about closing the four. Where will those services be provided when those CDSAs close, if you're gonna close four. Where, where would services be provided. And, and will we sell loss of services to some of the children served under CDSAs? [SPEAKER CHANGES] ?? [SPEAKER CHANGES] Ms. Thomas. [SPEAKER CHANGES] Senator Robinson, we don't believe that services would necessarily be lost, because given the high amount of lapsed salaries, those services aren't being provided right now. So, but I think that's why the chairs did want to give the department a year to come up with a plan and determine those four so that it would minimize any impact on service loss. [SPEAKER CHANGES] Other questions? Senator McKissick. [SPEAKER CHANGES] Two quick ones. I noticed that in the special provisions, page 149, it says we're gonna eliminate a comprehensive report on medication related errors in nursing homes. It seems like we would want to know all about these medicated related errors in nursing homes. If we could find out, why are we eliminating this special report? [SPEAKER CHANGES] Senator McKissick instead i'll verify this. My understanding is that the federal funds that provided for that report and brought it out have expired. And that therefore, barring coming up with some significant additional funding, the continual federal program, the program ends because the funding is expired. [SPEAKER CHANGES] The funding expired. I see. And quick follow-up. How much money did we have for that? Anybody? Maybe the staff might know. [SPEAKER CHANGES] I believe Debra Landry might have the answer to that, Senator. [SPEAKER CHANGES] The previous funding was funded at $850,000 for that report. [SPEAKER CHANGES] Okay. Thank you. And a quick follow-up, if I could? It seems like something that would be good to know. I don't know how long that had been ongoing or what type of quality information we received from it. I just ask you chairs to give that some thought. I know we, it's always tight. I noticed on the partnership for children we're increasing their percentages again. [SPEAKER CHANGES] Give us a reference please. [SPEAKER CHANGES] On page 133. And the thing I wanted to make an inquiry of the chairs about, I know we increased their percentages last year, in terms of their local contributions they needed to come up with, is there a goal of ??

On Saturday the CIA to respond to the page, and the provisions to move, go to this page 117 a provisions of lay out the specific areas in which the funds will be designated by which will no longer made to take your agency or others by we're talking about , funding going 21 ended under prevention in the slaying of that we currently had two million dollars it was well in the body of equally among regions of the lead bank system of voters another competitor out there and will be providing that on statewide, it would allow the parts like stability as they currently breaking down the equal funding between a finger six regions am not mistaken,(SPEAKER CHANGES) two balanced in ward 821 overarching of them on recent sales are soaring association and sales of two which uses you some of them some have delayed or to apply the party and eventually like to make decisions which way the earlier reflected equal funding of CT 16 moving four all we do think the secretary's office two on is to transfer these funds the measuring the funds and works in so many of these areas already on its probably have a better position to continue to live from the general assembly has historically been a war would be in the future of it, make those decisions were recalled on the addition to that, perhaps in this direction that one would contemplate holding it might be better to five fund and ourselves this year fell off a special provision in all of staff to develop a plan a condition for a planned for the planet's year until they will be in place they can get their applications in a timely way continue to be funded by 237. (SPEAKER CHANGES) One where we're looking right now we know in the 20th on the role of something that might allow for what corporation transition action to read with interest rate will be as for the other funds, which have savings were contemplated with Mr. Action and I assume that the goal was to be like servants savings in the process from a cartoon all from what we have here is one lamb always the case today and I don't know if saying that exactly what goals collected into each received last year there is an industry that's the first there is no savings in this state is the data for the mall was required for a reduced budget items or they were we continue to Walter funding would be this level (SPEAKER CHANGES) I we just played no savings by doing this to move funds and all but two department is solely an administrative arm decision when you went to a landfill the transition bridge might be a better idea for being there and is doing quite like this year will we get all were 210010 and number 11 be a great case looks to me it looks as if we're a limiting and 2500 slots in year 105, Sr. two understand that there's some are sincere but which could be a subsidy plan created but the actual number of individuals that will be surgeons and difficult for me to determine based on the way I see this Lions club in the budget so maybe you can provide further on our liberation of what is believed we could be lives in terms of an affectionate; see more people are aware of the Ottawa see less in the end of the deaths were weakening of the-ball to give these kids ready and being in a minute or call the school system so they can you open a hole to withdraw cash and futures is the highest risk is startling beyond calendar subsidiary is not a new program is currently existing program and slaying of corners and said Mr. Markets is currently boasts more short program five as a priority for individuals and 34 and that if the current mortgage division said in the 34 and five star facilities on there that could provide some services of come up with the slot allocations we took an average cost of crawls under the current a subsidy system and greet a system of the funniest and when you take a dollar man with the same amount over becomes about 2500 realized from about 26, a place under current spending levels are more they do there is some variations on as a??................

Is the one season in which they surprise: search the numbers come see it as an outsider Mr. De Paris was found slain based on the opponents which received the red did not intend on fourth and bloody thing of them would be cheaper car racing track of settlements and a wedding message here in that we're just looking at his budget and finance still alive, she ran many of the questions that I like to reiterate the piece about the pregnant women and bringing secure management of the summer and telephone: (SPEAKER CHANGES) prince again and they are at least that means a headline them, Albert pang said he issues that can affect the bird from the birth weight excel at being French and their health is little solace to take a look FME a L for now we talking about whether DNA catcher club turning five disorders screening and NDS where shifting an awful name: where they can live different services PLMPLML dns but the pulse of the great issues of lamb ND 2 BLUNCL so they can work and letters and Packard bell NEC SSA concerned about the is where the L prevent LDAP to have your condition between old N2 ID exchange and the services are limited and then they can afford to pay A logon, they can pay the premium and air, the cult ACLF to some degree four L services that where?? (SPEAKER CHANGES) two private push us back in turn sell a transit services will ID card catalog in Dallas vs. two MB a condition sell at a concern very concerned about the seventh and eighth well I think you look at our smaller city and no one here in the ivy league school before with character developing those procedures are others on with players said levels in which they believe on individuals are excerpts a different party will be able to buy all that's the nature of the orchid formal characters past 4:00 AM a site that's why the 17 percentage of income only four of which are like it would do that with no place, I think it also misses the point of the individuals are from Medicaid two private insurance Oakland saw a lot more services on that they can receive similar technically a provider of they're no longer limited to only going to providers during the Olympics and Medicaid are they have a lot of other options out there that are within the contracts with private insurance and we'll find areas where doctors sure others relieving and not being Medicaid providers any more of these individuals to be prepared to continue to access for services rationally to only a wired Network Service providers are poorly received columnist here is I would also be concerned with a badly targeted back population tool ballpark as the polls to Fab ?? (SPEAKER CHANGES) will take other populations when talking about a bicycle and you population I have this population we're even Plata about this DL would have to make any partition that one in C, we have to start a program that provides satellite to take your pick a population of that in terms of people have less problems as also difficult in terms of content providers center Robinson I have targeted the many populations for this process, we're specifically prohibited from doing so for the children on in the state children's health plan until 7:31 on so while we cover them on a private insurance we can make it a private insurance on the exchange present prohibited back on Medicaid general some other way out from the Federal government on which we move four and this is the area they allow us to move forward with on and set the standards for you all were not recorded to begin Manuel 138% on and we've chosen going to 195 we're just going to make it for making us moving four and I think the long-term answer would be clear about providing access and the study is to get individuals or about 500 channel Federal poverty level onto the exchange be able to provide identified much lower calls them ever provided help balance each year, we collect the data around back to C how many are going into more chronic conditions that are in what ??..............

-ality rate rises, those other kinds of things, because that can happen. [SPEAKER CHANGES] I would also say I find no indications that say individuals have a higher infant mortality rate on private insurance than they do on Medicaid. [SPEAKER CHANGES] There are some members from the department who have been here and sat through all of this and I wanted to invite any of them who had any comments they'd like to make to please do so at this time. [pause] Glad you have you folks with us. Once again, are there any members from the public who would like to have any remarks? Seeing none, I'd like to thank Senator Hise for his outstanding briefing, and also thank the staff for for their assistance, and thank you from--members of the subcommittee and also members of the public for being in attendance. This meeting is now adjourned. [end of data.]