|Rep. Garrett made a motion to approve the minutes of the January 8, 2003
as submitted. On a voice vote, the motion carried.
Chairman Sali announced that the rules will be heard by the entire
committee and that review will begin next week. He further announced that
if any members of the Committee would like to cover a topic in more detail
and serve on a subcommittee to do so, should contact him as soon as
Joyce McRoberts, Deputy Director of the Department of Health and
Welfare, addressed the Committee. She explained that the Committee will
hear from two division administrators and followed by a question and answer
period. The Committee will then hear several short presentations from
Ken Diebert, administrator of the Division of Family and Community
Services, addressed the Committee. He explained that the Division is
designated as the lead agency for the operation of the system of care for
adult and children’s mental health, adult and children’s developmental
disabilities services, infant and toddler program, substance abuse services,
and child welfare services with the Department of Health and Welfare. The
Division is also responsible for the operations of the State’s three state
hospitals. He further explained that these hospitals, which include State
Hospital South in Blackfoot, Idaho State School and Hospital in Nampa, and
State Hospital North in Orofino, are operating at or near capacity and have
waiting lists of up to ten days. These hospitals provide intensive residential
services for persons with severe developmental disabilities.
He then discussed with the Committee budget concerns. He stated that in
State Fiscal Year 2002, there was a 9 percent increase in the number of
individuals who accessed the Division’s services and programs from the
previous fiscal year. The current budget for Fiscal Year 2003 is about 11
million dollars less than the appropriation the Department received in the
Fiscal Year 2002. Staff have been reduced in all areas with the exception
of Child Protective Services.
Mr. Diebert explained that the Division has been faced with many difficult
decisions related to how best to manage the reductions in funding. As they
considered how to best manage the current resources, they based they
decisions on the following priorities:
They worked to avoid major impacts in the programs that the Department
has statutory responsibility to provide, they made every effort to avoid
staffing and service reductions that would impact community, staff and
consumer safety, and tried to be mindful of the need to provide federally
required maintenance of effort funding for their mental health, substance
abuse, and infant and toddler programs. Had they not maintained a federally
prescribed level of state participation in these programs they would have
risked losing significant amounts of federal funding.
He then described the various programs that fall under the Division of Family
and Community Services.
The first program discussed was the Idaho CareLine 211. This is a bilingual,
toll free telephone information and referral service. Last year, there were
over 38,000 calls for information about health and human service providers
in the State.
The Children and Family Services Program is responsible for Child
Protection services, Foster Care, Adoption, Children’s Mental Health, Indian
Child Welfare, and Licensing of Children’s Residential treatment facilities.
The Child Protective Services program focuses on safety, permanence and
the well-being of children. They work cooperatively with the police,
prosecutors and the courts to address the safety need of children who are
abused or neglected. In 2002, there were 783 substantiated cases of abuse
and neglect in Idaho. He clarified that the Child Protective service staff do
not remove children who are abused or neglected from their parents. A child
can only be removed from their parents by the action of law enforcement or
a judge once the child is determined to be in imminent danger or cannot be
safely cared for within their current family structure. When this determination
is made, the staff is then responsible for providing a safe and nurturing
environment for the child to live until they can safely be reunited with their
family, or in some cases, adopted by other caring families.
The cornerstone of the child welfare system is the Foster Care Program.
Foster families provide for a supportive temporary home for children placed
in state custody. 2,260 children were placed in foster care in the state last
year. In Fiscal Year 2002, 92 children were adopted in the state.
The Children’s Mental Health program provides services to children who
experience serious emotional disturbances. These services are provided
through a system of public and private partnerships that offer out-patient, in-
patient and residential care. The State has been working to develop a broad
spectrum of care to meet the needs of children and their families with serious
emotional disorders based upon a monitored agreement with the Federal
The State entered into this agreement as a result of a suit filed against the
State known as the Jeff D. case. 3,766 children were assessed this past
year, which is 1,200 more than the previous year. The Department’s staff
provides crisis services, assessments, service authorization, provider
enrollment, training, and quality assurance. Approximately 85 percent of the
children who qualify for children’s mental health services are eligible for
Other vital services provided by the Division come within the programs for
adults who are mentally ill. Services include crisis response, evaluation,
case management, treatment, psychiatric evaluations, medication
management and counseling. The Division also provides court-related
support services and placement coordination with hospital or residential care
as required. The majority of treatment services for Medicaid patients are
provided through a network of private providers. In State Fiscal year 2002,
over 6,000 individuals received services from the Division’s mental health
programs. This number reflects an 8 percent increase. The staffing in the
regional mental health programs has decreased by 23 staff. The Division
has accomplished cost saving by reducing administrative staff and shifting
some of the assessment function of the regional mental health authority to
private providers. They have fewer staff to respond to crisis calls, work with
courts, support resource development and to manage and evaluate program
The substance abuse services program with the Division contracts out all
treatment services for their clients to private providers. Through
collaborative efforts with the courts, schools, Department of Correction,
Juvenile Corrections and the community, the system of care based on the
best practice models is being established in our state. In State Fiscal year
2002, 6,153 clients were served in this program. This is an 8 percent
increase from last year.
The substance abuse staff partnerships with the Idaho State Police for the
State’s Tobacco Project. This program is designed to reduce the sale of
tobacco to minors by education of merchants, retail permitting and
inspections. Since 1999, there has been a 12 percent drop in tobacco sales
Mr. Diebert then discussed the group of programs that provide services to
people who are developmentally disabled. These programs are designed to
provide care and support of individuals and their families with developmental
disabilities. The programs are designed to provide services for everyone
from infants to the elderly.
The Idaho Infant Toddler Program serves children from birth to three years
of age. It coordinates early intervention and treatment services for children
and their families. The program partners with families to plan and provide
comprehensive services including speech, occupational, developmental,
medical and social work services to enhance each child’s developmental
potential. 2,424 children were served last year, which is a 4 percent increase
from the previous year.
The Division provides intake, eligibility, determination, service authorization,
provider enrollment, and training for providers for developmental disabilities
services. Of the adults receiving services through the Developmental
Disabilities Program this past year, 93 percent of them qualify for the
Medicaid program. 79 percent of the children and 63 percent of the
individuals served in the Infant and Toddler Program are eligible to receive
Medicaid funds. More than 11,857 people with developmental disabilities
received services funded by Medicaid than last year. State staff available to
administer these services have decreased by 17.
He then discussed the various core services that the Division provides or
contracts out and the key functions that must be in place to assure the
efficient operation of the various programs and services that the Division
He explained that the work performed by the Division is complex and
challenging. The individuals served have multiple and complex needs that
the Department strives to find effective interventions that will assist them in
developing life skills so they may function as independently as possible.
Kathleen Allyn, deputy administrator of the Division of Medicaid, addressed
the Committee. She explained that the Division of Medicaid administers the
state’s Medicaid program. This includes developing and implementing
program policy consistent with federal requirements, managing the quality
and utilization of services, and overseeing the payment process for services.
She further explained that there are several areas of overlap with the other
divisions within the Department that also provide Medicaid functions.
Within the Division of Medicaid, they also carry out the statutory state
licensing of health care facilities through the Bureau of Facility Standards.
This includes inspections of any state-licensed facility, whether or not it
cares for Medicaid clients, as well as investigations of complaints about the
She then explained the difference between the Medicare program and the
Medicaid program. Medicare is also known as Title XVIII and is a federal
program that serves the elderly. Medicaid is a state program also known as
Title XIX which serves low income clients.
Medicare was established to cover the specific medical care needs of the
elderly and is available to most people over age 65 regardless of income.
Medicaid is the nation’s health insurance program for many low-income
Americans. Medicaid is a jointly-funded federal/state entitlement program,
administered by the states, that pays for medical assistance for certain
individuals and families with low incomes and resources.
In Medicaid, each state, within federal guidelines, establishes eligibility
standards; determines the type, amount, duration, and scope of services;
sets the rate of payment for services; and administers the state’s program.
Idaho has a basic program. There is currently on average, about 150,000
people on Medicaid, which includes about 105,000 children. The state has
chosen not to cover all of the groups or services that would be matched by
federal dollars. Idaho is projected to spend about $849 million on Medicaid
in State Fiscal year 2003, about $234 million of that in State General Funds.
Most people who use Medicaid can’t afford private insurance or need
services that are not available from private insurers such as services for
persons with developmental disabilities or traumatic brain injury.
The Department provides few direct healthcare services. Through Medicaid,
they support the existing health care structure. Idaho Medicaid pays more
in benefits in Idaho than Blue Cross and Blue Shield combined.
Because of the escalating costs of the program, Medicaid has intensified its
focus on the development of quality improvement processes and care
management tools that can create a healthier public and result in a more
efficient use of tax dollars.
Those eligible for Medicaid fall into three low income groups. These include
parents and children, the elderly and persons with disabilities.
Ms. Allyn explained that pregnant women and children in families with
incomes below 134 percent of the federal poverty limit must be covered by
Medicaid primarily covers hospital and physician care of the elderly. It does
not cover most nursing home or other long term care costs or most
outpatient prescription drugs. But Medicaid pays for these and other
services not covered by Medicare when someone is covered by both
Medicare and Medicaid.
Many elderly people must be covered by Medicaid because they receive
cash assistance through the Supplemental Security Income (SSI) program.
Others have too much income to qualify for SSI but “spend down” to
mandatory Medicaid eligibility by incurring high medical or long-term
Many people with disabilities also must be covered by Medicaid because
they receive cash assistance through the SSI program or because they incur
large medical expenses and meet their “spend down” obligation.
She further explained that it is not enough just to be poor to qualify for
Medicaid; an individual must also fit into a covered eligibility category. Many
people with low incomes, including childless couples and single, childless
adults who are not aged or disabled cannot receive Medicaid even though
they are poor.
Additionally, in 1997, Congress enacted Title XXI of the Social Security Act
which allowed states to provide health insurance for children in families with
incomes over the Medicaid eligibility level. This is the State Children’s
Health Insurance Program or S-CHIP. Rather than developing a separate
insurance program for CHIP kids, Idaho insures them through the Medicaid
program. Children from families with household incomes from 134 percent
to 150 percent of the federal poverty limit qualify for S-CHIP. At the end of
State Fiscal year 2002, there were over 12,000 children enrolled in S-CHIP.
By choosing to participate in Medicaid, Idaho must cover a minimum set of
benefits. These federally mandated benefits include: hospital care(inpatient
and outpatient), nursing home care, physician services, laboratory and x-ray
services, early and periodic screening, diagnostic, and treatment services for
children, family planning services, and federally qualified health center and
rural health clinic services. Idaho has also chosen the option of covering
additional services and receiving federal matching funds for those services.
These optional services include; prescription drugs, institutional care for
individuals with mental retardation, home and community based care for the
frail elderly and people with physical or developmental disabilities, personal
care services, services for people with developmental disabilities, mental
health services, and adult dental care.
Medicaid pays medical care providers directly for services provided to
Medicaid clients. Providers participating in Medicaid must accept Medicaid
payment rates as payment in full.
The Federal Government pays a share of the medical assistance
expenditures under each State’s Medicaid program. Idaho receives about
a 70 percent federal, 30 percent state match. For S-CHIP the federal match
rate is higher, with 80 percent of the program paid for with federal dollars and
20 percent with state general funds.
Ms. Allyn explained that federal legislative requirements have increased the
scope of the program to the point that about 45 percent of the Idaho
Medicaid budget goes toward meeting federal mandates. She further
explained that approximately 43 percent of the Idaho Medicaid budget is
governed by state law. In all, 88 percent of the Idaho Medicaid budget is
driven by either federal or state law.
Ms. Allyn then discussed with the Committee managing the cost of
Medicaid. She explained that because Medicaid is an entitlement program,
the state is required to pay for all medically necessary covered services that
are provided to persons enrolled in the program. The Department has seen
four budget cuts since 2001. In Medicaid alone, this has meant $115 million
in cost avoidance.
The Medicaid program is now undertaking more intensive review of
programs and services primarily focused on the high cost areas of the
program. The top six spending areas in the program are hospitals, nursing
facilities, prescription drugs, developmental disability services, physician
services and mental health services.
Ms. Allyn stated that Medicaid is working to increase enrollment in the
Healthy Connections program which links Medicaid clients with primary care
providers who manage their care. Through this program, Medicaid avoids
spending about $31 per month for each Healthy Connections enrollee.
She further stated that management steps are being developed for the
prescription drug program that could reduce the Medicaid pharmacy budget
by $42 million. These steps include denying early refill of prescriptions,
requiring prior approval of certain therapeutic drug classes, reviewing high
prescription volume clients, and the implementation of a preferred drug list.
Also, the Medicaid program has developed lower cost alternatives to
institutional care such as nursing home care or intermediate care facilities
for persons with mental retardation. Known as home and community based
waivers(HCBS), these programs allow eligible elderly and disabled
individuals to receive the services they need without having to be placed in
an institution. The costs for supplying the waiver services must be no
greater than the cost of the institution.
She explained that the Aged and Disabled Waiver or A&D Waiver is the most
widely implemented waiver in the state with an average of 3,600 enrollees.
The average annual cost of someone on the A&D Waiver is $13,000 per
year compared with the nursing home average annual cost of $38,000.
In summary, Ms. Allyn, explained that the economic predictions for fiscal
year 2004 show the need to maintain the current reductions and find more
ways of managing costs. But, unless the current projected revenues
increase, the state may also need to make significant reductions in the
people or services that are covered or the amount that is paid for services.
In response to questions from the Committee, the following points were
clarified by Mr. Diebert; the prevention programs for tobacco prevention is
focused on school-aged children and tobacco sales to minors are tracked
with a partnership program with the Idaho State Police. The reasons why the
Sate hospital is overcrowded was also discussed. Mr. Diebert explained
that in addition to population growth, there has been a decrease in bed
capacity in the past ten years. There is a decrease in staff and a significant
decline in federal and state funding.
In response to questions posed by Committee members, Gary Broker, from
the Department of Health and Welfare, addressed the Committee. He
discussed the overall funding of the Department and the overlapping of
Also in response to questions from Committee members, Dr. Tom Young,
medical director for the Division of Medicaid, addressed the Committee. He
discussed rising prescription drug costs. He explained that Medicaid is
going to an evidence-based preferred drug list, which will bring substantial
savings to the program. It will provide guidelines to physicians of various
prescription drugs that can be used by patients.
Kathleen Allyn discussed the eligibility determinations for the Medicaid
program with the Committee. She also discussed the fraud and abuse unit
which investigates both provider and clients.
Randy May, an administrator from the Division of Medicaid, spoke to the
Committee in response to questions. He discussed the eligibility of children
enrolled in the States’ CHIP program. He stated that 98 percent of CHIP
kids are eligible.
Rick Sutton, a pharmacist for 30 years, addressed the Committee. He
discussed the preferred drug list. He explained that it is scientifically based.
A profile is submitted to a scientific body and evaluated on specific criteria,
then evaluated by a panel of physicians and pharmacists and a
determination is made. He further explained that Medicaid will pay for a
product on the preferred drug list.
Dr. Ted Epperly, a family physician and chairman of the Family Practice
Residency Program, discussed the residency program the Committee. He
explained the program takes nine residents from other states and trains them
in family practice medicine. He explained that the residency program has
impacted the state’s Medicaid program in the following areas, education,
practicing physicians, and physician care. He further stated that the
residency program is tremendously underfunded and it is a challenge for the
state to make it work. He further stated that because of low Medicaid
reimbursement rates, many physicians choose not to treat Medicaid patients.
Most physicians treat zero to five percent Medicaid patients. He said that
every citizen has the right to quality health care and citizens must be willing
to pay more taxes to fund needed programs.
Jon Ball, an administrator and provider of Residential Habilitation services,
addressed the Committee. He discussed what a provider has to do to qualify
to be a provider for the state. He stated that he has received a 70 percent
reduction in his wages from the state. He further stated that a client in a
residential habilitation home is treated as a family member; and the facility
has an excellent ratio of care with providers to clients.
Bill Benkula, an administrator of intermediate care facilities for the mentally
retarded and facilities for the those with developmental disabilities,
addressed the Committee. He explained that ICFs/MR form a long term
care and training delivery system for individuals with mental retardation and
or developmental disabilities. These facilities provide a wide variety of
services based on client needs, which vary according to age and level of
mental retardation. In addition to providing a home like environment with
personal and support services, ICFs/MR serve as teaching and training
facilities. Many individuals who reside in these facilities live there from youth
to old age.
ICFs/MR vary from facility to facility and state to state, but are all bound by
federal regulations. A common goal among facilities is to assess what
individuals are capable of doing and to help them maximize their potential.
Mr. Benkula discussed the levels of mental retardation which include; mild
(IQ of 50-70), moderate(IQ of 35-49), severe(IQ or 20-34) and profound(IQ
He then discussed the federal guidelines that define mental retardation as
significant subaverage general intellectual functioning resulting in or
associated with concurrent impairments in adaptive behavior and manifested
during the developmental period.
He further stated that the trend in caring for these individuals over the past
20 years has been marked by a dramatic shift from large state-run
institutions to smaller, privately run facilities. The population of the Idaho
State School and Hospital has dropped from 1,200 down to approximately
100 patients today. Home and community based (HCB) waivers are also
He stated that individuals admitted to ICFs/MR must be receiving active
treatment services. Within 30 days following admission, an assessment is
made from facility interdisciplinary teams.
He further stated that because adults with developmental disabilities require
lifelong support, these adults are highly dependent on public programs to
finance their long term care needs.
Mr. Benkula also discussed with the Committee the Developmental
Disabilities Agencies(DDA’s) He explained that these agencies provide
rehabilitative and habilitative services to individuals diagnosed has having
a developmental disability. Services are provided in community based
settings in natural environments such as home, work, leisure, or center-based settings. Services provided by DDA’s promote independence,
participation and inclusion of people with developmental disabilities in their
neighborhoods and communities.
DDA’s are required to provide the following services; developmental therapy,
psychotherapy, speech and hearing therapy, physical therapy, occupational
therapy and evaluation and diagnostic services.
Kathy Gneiting, chairman of the Community Integration Committee, and
mother of an 8 year old son with autism, addressed the Committee. She
explained that the Committee first met in September of 2000. The CIC
makes recommendations to the Governor. The purpose of the committee is
to integrate people with disabilities in the community, school and workplace.
The four objectives of the committee are, to launch an anti-stigma campaign,
a state-wide assessment program, economic analysis and an effectiveness
Marilyn Sword, representing the Idaho Council of Developmental
Disabilities, addressed the Committee. She explained that the board
consists of 23 members who are appointed by the Governor for a three year
term. The board are policy advocates and collaborate with other agencies.
Greg Dickerson, president of the Mental Health Providers Association of
Idaho, addressed the Committee. The goals of his association include the
avoidance of the high cost of institutional care and the avoidance of
homelessness. There is a full menu of services available. He explained that
Targeted case managers are available to help clients cut through the
government red tape and get the services they need.
Ida May Whitman, immediate past chairman of the Mental Health Planning
Council, spoke to the Committee. She stated that the council meets three
times a year and reports to the Governor on the mental health needs in the
state. She further stated that there are approximately 43 members on the
council. There are three standing committees which include the children’s
mental health committee, administrative education committee, and a
committee to monitor and check statistics. She explained that the council is
in favor of having the “Jeff D.” lawsuit stay on the books.
Bill Southerland, president of the Idaho Assisted Living Association,
addressed the Committee. He explained that Assisted Living provides
assistance, where needed, to the Aged and Disabled population in a
dignified community setting. Persons who are not comfortable living alone
because of physical, mental or developmental limitations may receive the
personalized help they need to live as independently as possible.
Assistance offered includes, but is not limited to, housekeeping services,
transportation, bathing, grooming, dressing, toileting, walking, meal
preparation, access to health and medical services, 24-hour security, 24-hour staff availability, in-room emergency call systems, health promotion,
exercise programs, medication management, personal laundry services, and
social and recreational activities. He stated that there are 260 facilities in the
state and that most are in the 8 to 15 bed capacity range. He further stated
that the Aged and Disabled waiver patients, under strict federal guidelines,
can access certain Medicaid services to specific populations with slightly
above-normal restrictions. The Federal government sees waivered
programs as a long term savings so they provide an attractive match.
Keith Holloway, a nursing home provider, addressed the Committee. He
explained that nursing homes provide care for the most frail of the elderly.
There are approximately 85 nursing homes in the state, 30 of which are in
small rural towns and often the town’s largest employer. He further
explained that with the growth of waivered programs, the number of patients
in nursing homes has decreased in the last five years.
Steve Millard, president of the Idaho Hospital Association, addressed the
Committee. He explained that there are 46 public hospitals in the state and
18 are critical access hospitals. 50 to 60 percent of hospital patients are
Medicare patients, and 10 to 15 percent are on Medicaid. 30 to 35 percent
are privately insured.
Chairman Sali thanked the presenters and asked Committee members to
contact any of today’s speakers on their own if they had any questions. He
announced that the Committee will start rules review the following week.