MINUTES OF THE MEETING OF THE SENATE COMMITTEE ON FINANCE AND ASSEMBLY COMMITTEE ON WAYS AND MEANS SUBCOMMITTEES ON HUMAN SERVICES

Transcription

1 MINUTES OF THE MEETING OF THE SENATE COMMITTEE ON FINANCE AND ASSEMBLY COMMITTEE ON WAYS AND MEANS SUBCOMMITTEES ON HUMAN SERVICES Seventy-ninth Session The joint meeting of the of the Senate Committee on Finance and the was called to order by Chair Moises Denis at 8:10 a.m. on Wednesday, May 10, 2017, in Room 3137 of the Legislative Building, Carson City, Nevada. The meeting was videoconferenced to Room 4412 of the Grant Sawyer State Office Building, 555 East Washington Avenue, Las Vegas, Nevada. Exhibit A is the Agenda. Exhibit B is the Attendance Roster. All exhibits are available and on file in the Research Library of the Legislative Counsel Bureau. SENATE SUBCOMMITTEE MEMBERS PRESENT: Senator Moises Denis, Chair Senator Joyce Woodhouse Senator Ben Kieckhefer ASSEMBLY SUBCOMMITTEE MEMBERS PRESENT: Assemblyman Michael C. Sprinkle, Chair Assemblywoman Maggie Carlton, Vice Chair Assemblyman Nelson Araujo Assemblywoman Irene Bustamante Adams Assemblyman Jason Frierson Assemblyman James Oscarson Assemblywoman Robin L. Titus COMMITTEE MEMBERS ABSENT: Assemblyman Paul Anderson (Excused) STAFF MEMBERS PRESENT: Mark Krmpotic, Senate Fiscal Analyst Sarah Coffman, Principal Deputy Fiscal Analyst

2 Page 2 Mandi Davis, Program Analyst Jennifer Ouellette, Program Analyst Barbara Williams, Committee Secretary Edgar Cervantes, Committee Secretary OTHERS PRESENT: Brian M. Patchett, CEO/President, Easterseals Nevada; Chair, Nevada Commission on Services for Persons With Disabilities Kenneth MacAleese, Ph.D., Advanced Child Behavior Solutions LLC Deacon Tom Roberts, President/CEO, Catholic Charities of Southern Nevada Katherine Ryder, Treasurer, A TEAM NV Johnny Martin Ed Guthrie, CEO Emeritus, Opportunity Village Barbara Paulsen, Nevadans for the Common Good Barry Gold, Director of Government Relations, AARP Nevada Jodi Tyson, Director of Government Affairs, Three Square Food Bank; Food Bank of Northern Nevada Jill Gabel, Director, United Cerebral Palsy of Nevada Regina Daniel, President, A TEAM NV Scott Swain Pat Benke, Nevadans for the Common Good Pablo Valdespino, Autism Treatment Assistance Program Jill Berntson, Deputy Administrator, Aging and Disability Services Division, Department of Health and Human Services Edward Ableser, Ph.D., Administrator, Aging and Disability Services Division, Department of Health and Human Services Jeffrey Klein, Chair, Legislative Subcommittee of the Nevada Commission on Aging; President/CEO, Nevada Senior Services Janelle A. Mulvenon CHAIR DENIS: We will begin our budget closing process with public comment. BRIAN M. PATCHETT (CEO/President, Easterseals Nevada; Chair, Nevada Commission on Services For Persons With Disabilities): The early intervention and autism services we provide are some of the many services we offer. We offer high quality services provided by providers and by

3 Page 3 the State. The system has proven to be effective. Allocating at least $2 million to early intervention in budget account (B/A) could help with the transition, which could take up to two years. Additional funding for autism services in B/A could also help serve a larger number of children. Out of about 7,000 children who need our services, we only serve about 700. HEALTH AND HUMAN SERVICES AGING AND DISABILITY SERVICES HHS-ADSD - Early Intervention Services Budget Page DHHS-ADSD-41 (Volume II) Budget Account HHS-ADSD - Home and Community Based Services Budget Page DHHS-ADSD-30 (Volume II) Budget Account KENNETH MACALEESE, PH.D. (Advanced Child Behavior Solutions, LLC): I support funding for the Autism Treatment Assistance Program (ATAP) through the Aging and Disability Services Division (ADSD) B/A Through the services of ATAP, many autistic children have had their symptoms so reduced that they are able to function in the community and in school without special services. A unique feature of ATAP includes coverage for families who are in between insurance programs or families who may lose their jobs and may effectively lose their insurance. There are ways the State can pick up this funding for families who have high deductible plans or high out-of-pocket maximums. The ATAP has created innovative ways to give insurance assistance to leverage the State dollar further for autistic children so they receive the treatment they need. I ask the Committees to support ATAP in the ADSD budget. DEACON TOM ROBERTS (President/CEO, Catholic Charities of Southern Nevada): Catholic Charities of Southern Nevada serves more than 2,000 Nevada seniors through the Meals on Wheels Program (MOWP) which allows senior participants to continue to remain at home and independent. There are approximately

4 Page clients on a waitlist for the MOWP services. I have submitted an updated financial summary of the revenue needed to take care of the waitlist and create program sustainability (Exhibit C). We have also submitted pictures and stories of some of our clients (Exhibit D). The MOWP funding provided in B/A we support is not in regard to Catholic Charities, but it is about the clients we serve. HHS-ADSD - Federal Programs and Administration Budget Page DHHS-ADSD-18 (Volume II) Budget Account E-275 Educated and Healthy Citizenry Page DHHS-ADSD-24 KATHERINE RYDER (Treasurer, A TEAM NV): I will read from my prepared statements (Exhibit E) in support of developmental services. JOHNNY MARTIN: I am a disabled Vietnam veteran and have been a participant of the MOWP through Catholic Charities for approximately a year. I have a dog, and Catholic Charities also feeds him. I want to thank Catholic Charities and everyone who makes the MOWP possible. ED GUTHRIE (CEO Emeritus, Opportunity Village): I will now read from my prepared statements (Exhibit F) in support of developmental services. BARBARA PAULSEN (Nevadans for the Common Good): The biggest challenge the aging population faces is maintaining independence. Funding for programs like MOWP, the Adult Day Care program and the Jobs and Day Training Program is critical for our aging population to maintaining independence. The MOWP not only provides daily nutritious meals for our senior community but it also provides social interaction and safety checks. Funding this program will save the State money. There is a problem with the large number of individuals on the MOWP waitlist, and it would take a minimal amount of money to solve the waitlist problem. Nevadans for the Common

5 Page 5 Good urges the Subcommittees to fund at least $5 million to support MOWP and minimize the waitlist. BARRY GOLD (Director of Government Relations, AARP Nevada): With potential changes looming for health care in this country, there are a lot of Nevadans who will potentially lose their health care coverage, whether they receive subsidies from the government, are on Medicaid, or pay for their own insurance. The American Health Care Act is going to change and make insurance unaffordable. The Senior Rx and Disability Rx program, B/A will become more critical than before because people will lose their insurance coverage for medications. Being able to take medications keeps our citizens healthy, out of the hospital and saves the State money. Please fully fund B/A HHS-ADSD - Senior Rx and Disability Rx Budget Page DHHS-ADSD-12 (Volume II) Budget Account We have funded the Home and Community Based Services budget, B/A on a slot system. Each slot represents a person. Fully funding B/A is not just the right thing to do, but it is also fiscally prudent. The waitlist issue needs to be addressed. It is cheaper for the State to keep this community out of nursing homes. I ask the Committees to fund this budget as much as you can to reduce the waitlist to zero. JODI TYSON (Director of Government Affairs, Three Square Food Bank; Food Bank of Northern Nevada): Oftentimes, the highest cost of community programs comes from the staffing. That is not always the case with food programs. When a program's food cost and transportation costs exceeds a certain number of people, then the cost incurred from food and transportation services exceeds the cost of staffing. Three Square has started working with Catholic Charities to reduce their food costs by increasing our combined purchasing power. We have done our part in the community to try and reduce the cost as much as possible and now, we request additional support for the home-delivered meal programs B/A from the Legislature.

6 Page 6 Children's meals go to one location and feed a lot of students. Home-delivered meals make a stop at every household. Their reimbursement is a dollar less than children's meal reimbursements. JILL GABEL (Director, United Cerebral Palsy of Nevada): I support the increased rates for the Jobs and Day Training Program. The United Cerebral Palsy of Nevada services approximately 70 clients in the Reno and Sparks region and approximately 20 clients in Elko. The requested rate increases will benefit our disabled community. We are working hard to get this community into the Jobs and Day Training Programs to help them get jobs in the community. The increased rates will help us with consistency in our staffing and help our clients obtain jobs in the community. REGINA DANIEL (President, A TEAM NV): I am a mother of a special needs child who has been disabled since birth. We are in a service-needs community crisis because of the lack of appropriate funding. We need the right people to help the special needs community. We need people who are competent, experienced and tolerant to service our loved one's unique needs. What you do not do, family members have to do, because it is our responsibility to provide for our loved ones. We need compensation for our service providers. We need your help to help make the right difference to the special needs community. SCOTT SWAIN: My disabled son, David, is 32 years old and has severe intellectual and physical disabilities. We would like to express our concern regarding the funding for work programs for disabled individuals like David. David has a work routine at Opportunity Village that provides a specialized nontraditional environment that allows him to leave home each day, go to work and be as productive as his limited abilities will allow. Without this type of specialized environment, David would not be able to participate in a meaningful work routine. We would not have the skilled trained staff that is necessary to supervise him and assist with his workday activities. It is important for Nevada to retain funding for this type of nontraditional specialized work environment. Any reduction to this type of funding would result in exclusion rather than inclusion because our disabled community will be forced to remain homebound.

7 Page 7 Please recognize the importance of adequate funding to ensure quality services for David and others like him. We also encourage an increase of funding as necessary to provide skilled and trained staff who are valued for the services they provide. The current rates of compensation for employees of community organizations like Opportunity Village do not send a positive message to those who are hired. It makes it difficult to attract and retain the skilled staff necessary for David and those who have his type of disabilities. Please continue to fund these types of specialized programs that make it possible for David and others to enjoy meaningful work activities. We encourage you to increase the level of funding to ensure that quality services remain available and to adequately serve our disabled population. PAT BENKE (Nevadans for the Common Good): I have been a MOWP driver for many years. Many of the MOWP recipients do not plan to be on MOWP. The situation that led them to MOWP comes suddenly. One recent story is of an elderly individual who went to the hospital for minor surgery and returned home paralyzed. She and her husband are now MOWP recipients. I urge the Committees to appropriate this money for the MOWP so that the waitlist can be minimized. PABLO VALDESPINO (Autism Treatment Assistance Program): I support the funding for ATAP. We need more money to help the disabled community and save our disabled children. CHAIR DENIS: We will continue to take more public at the end of our budget hearing. At this time we will now transition to our budget hearing with B/A , Senior Rx and Disability Rx. MANDI DAVIS (Program Analyst): Budget account , Senior Rx and Disability Rx, begins on page 3 of the Human Services Joint Subcommittees Closing List #7 (Exhibit G). There is one major closing issue which is the decrease in the Healthy Nevada Funds. The Governor recommends Healthy Nevada Fund decreases of $403,566 in FY and $396,853 in FY as compared to FY actual levels, to align with the funding recommended by the Department of

8 Page 8 Health and Human Services to be allocated to the Senior Rx and Disability Rx programs. According to the ADSD, the decrease in the Healthy Nevada Funds is projected to generate a waitlist in the Senior Rx and Disability Rx program services. At the reduced funding level, if caseloads remain flat, the ADSD estimates the program would generate a waitlist of approximately 536 individuals is projected to develop in the Senior Rx program and 60 individuals in the Disability Rx program by the end of FY However, with the increasing need for this program, the ADSD projects a waitlist of approximately 3,173 by the end of the biennium. The ADSD has implemented measures to limit the number of individuals who are eligible in order to serve the maximum number of high needs individuals in this program. In addition, the Medicare coverage gap known as the "donut hole," also affects this program's funding. Under the current provisions in the Affordable Care Act, this coverage gap is projected to decrease until it is completely eliminated in calendar year The ADSD indicates that although the coverage gap is decreasing, the number of prescriptions being filled and the rising prescription costs have resulted in people reaching this coverage gap sooner. Once they are in the coverage gap, the out-of-pocket expenses for prescriptions are higher. The decreasing of the coverage gap was not considered in the projections for the biennium. ASSEMBLYMAN SPRINKLE MOVED TO RECOMMEND TO THE FULL COMMITTEES TO APPROVE THE REDUCTION OF THE HEALTHY NEVADA FUNDS TO SUPPORT THE SENIOR RX AND DISABILITY RX B/A , FROM $6.7 MILLION FOR THE BIENNIUM TO $5.7 MILLION OVER THE BIENNIUM, AS RECOMMENDED BY THE GOVERNOR. SENATOR WOODHOUSE SECONDED THE MOTION. ASSEMBLY: THE MOTION CARRIED UNANIMOUSLY.

9 Page 9 Discussion on other closing item 1, decision unit E-710, regarding replacement equipment, begins on page 6 of Exhibit G and appears reasonable to Fiscal staff. E-710 Equipment Replacement Page DHHS-ADSD-14 ASSEMBLYMAN SPRINKLE MOVED TO RECOMMEND TO THE FULL COMMITTEES TO APPROVE OTHER CLOSING ITEM 1, DECISION UNIT E-710 OF B/A , AS RECOMMENDED BY THE GOVERNOR AND GRANTS FISCAL STAFF AUTHORITY TO MAKE TECHNICAL ADJUSTMENTS AS NECESSARY. SENATOR WOODHOUSE SECONDED THE MOTION. ASSEMBLY: THE MOTION CARRIED UNANIMOUSLY. Discussion on B/A , the Tobacco Settlement program, begins on page 7 of Exhibit G. There are no major closing issues. The spending plan for the Fund for Healthy Nevada is recommended to decrease. The ADSD indicates that this program is intended to supplement Independent Living Grant programs but not intended to fully support them. The supplemental funding for these programs would decrease under the recommended funding levels as described on page 8. HHS-ADSD - Tobacco Settlement Program Budget Page DHHS-ADSD-16 (Volume II) Budget Account

10 Page 10 SENATOR WOODHOUSE MOVED TO RECOMMEND TO THE FULL COMMITTEES TO APPROVE B/A AS RECOMMENDED BY THE GOVERNOR AND GRANT FISCAL STAFF AUTHORITY TO MAKE TECHNICAL ADJUSTMENTS AS NECESSARY. ASSEMBLYMAN SPRINKLE SECONDED THE MOTION. ASSEMBLY: THE MOTION CARRIED UNANIMOUSLY. Discussion on B/A , Federal Programs and Administration, begins on page 9 of Exhibit G. This budget account provides funding for Grants and Resource Development, Elder Rights and Fiscal Services for the Division. There are three major closing issues. HHS-ADSD - Federal Programs and Administration Budget Page DHHS-ADSD-18 (Volume II) Budget Account Discussion on major closing item 1, decision unit E-275, regarding the increased funding for home-delivered meal programs for seniors begins on page 10 of Exhibit G. The Governor recommends increasing the number of meals provided to seniors through home-delivered meal programs by increasing General Fund appropriations by $750,000 in each year of the upcoming biennium. Funds are awarded through a competitive grant process. Existing programs that have received funding in prior years and have demonstrated an ability to successfully provide meals are awarded funding. Any additional programs that have waitlists are also awarded additional funding, if any funding is available. Currently, the ADSD indicates that only two programs in Clark County have waitlists. As of the most recent update provided to Fiscal staff, 308 individuals on the waitlists have been assessed and determined to be eligible for meals, while 818 individuals on the waitlists have been screened and are likely to be determined to be eligible for meals. That comprises a total of 1,126 individuals.

11 Page 11 E-275 Educated and Healthy Citizenry Page DHHS-ADSD-24 The funding awarded to senior meal programs is based on a flat fee of $2.65 per meal, per consumer, per day. Based on the increased funding recommended in the Executive Budget, the funding will likely support approximately 775 additional seniors in each year of the upcoming biennium which would not fully eliminate the waitlist. According to the ADSD, $1.9 million in additional funding will be needed to eliminate the waitlist at $2.65 per meal. This funding will support the added meals as well as the additional temperature control delivery vehicles and kitchen equipment needed to provide those additional meals. The ADSD indicates that one of the two programs with a waitlist is a city-run program and it is unable to provide any additional funding beyond the current levels at the reimbursement rate of $2.65 a meal. The city indicates that it would require a $10 per meal reimbursement rate in order to serve the individuals on their waitlist. To increase the reimbursement rate for that portion of the waitlist would require additional funding of $2.1 million over the biennium. The Subcommittees may wish to consider the following options: 1. Approve General Fund appropriations of $1.5 million over the biennium to fund home-delivered meal programs for 775 seniors in each year as recommended by the Governor. 2. If the Subcommittees wish to provide additional funding to address the entire waitlist, the following options could be considered: Increase General Fund appropriations by $1.9 million, for funding totaling $3.4 million over the biennium, to fund home-delivered meal programs at $2.65 per meal for 1,126 seniors in each year, and new equipment, that may or may not include: Additional General Fund appropriations of $2.1 million to fund home-delivered meal programs at $10.00 per meal for 386 seniors over the biennium.

12 Page Not approve the Governor s recommendation to increase funding for home-delivered meal programs for seniors. ASSEMBLYMAN SPRINKLE: Would Option 2 eliminate the waitlist under the first bullet point? The ADSD has indicated that funding for the waitlist at $2.65 would be provided under the first bullet point of Option 2. One of the programs with a waitlist has indicated that they would not be able to provide meals for their entire waitlist at $2.65 per meal. ASSEMBLYMAN SPRINKLE: Would that lead us to the second bullet point of Option 2? Yes, that is why that second bullet point is included in the option. ASSEMBLYMAN SPRINKLE: Under the first bullet point, even the secondary program will be receiving the $2.65 per meal. It would be up to them to come up with additional funding to get to the $10 per meal. Is that correct? Yes. If they applied for it and were awarded the grant funding, then that is what the outcome would likely be. ASSEMBLYMAN SPRINKLE: Out of fairness and equity for the program as a whole, I would consider Option 2, with the first bullet point. SENATOR KIECKHEFER: I would also support Option 2. The discrepancy between meals that cost $10 each and meals that cost $2.65 each is stark. Henderson needs to figure out how to serve more with what is allocated. Catholic Charities is able to do it for a much more reasonable price. Henderson should consider contracting this out instead keeping it in-house.

13 Page 13 ASSEMBLYWOMAN BUSTAMANTE ADAMS: There are only two programs in Clark County that have a waitlist. If we decided on Option 1, would it focus on Clark County and take care of their waitlist? The ADSD has indicated that grant funds are awarded based on programs that have a waitlist after the base funding is awarded to keep existing programs operational. Any additional funding is awarded to those programs with waitlists. Under their current recommendation, based on the fact that the only waitlists are currently in Clark County, funding would likely be awarded to those two programs, but it would not completely address the waitlists for those programs. ASSEMBLYWOMAN CARLTON: I am comfortable with the Option 2 and the first bullet point. If we could do more, we would do more. The State has not been there for these programs in the past. I am grateful that the Governor put this money into the Executive Budget, but this is the first time we have had this discussion. It is a step in the right direction to help address the waitlist problem. This is an excellent way for us to give support to these programs by addressing the waitlist. ASSEMBLYMAN OSCARSON: Have there been any requests for rural areas to receive additional funding in regard to these budget requests? There are significant waitlists in some of the rural areas that I represent for the MOWP. According to the Division, the only waitlists are currently located in Clark County. ASSEMBLYMAN OSCARSON: I can be supportive of the first bullet point under the Option 2, but I ask that we be cognizant that there are rural citizens that are on a waitlist. Rural citizens face the same challenges and sometimes more because the travel distances are more significant. I am requesting a report from the ADSD addressing waitlist issues in rural areas.

14 Page 14 SENATOR WOODHOUSE: I will also support Option 2 and the first bullet point. I am concerned about the 386 seniors under the second bullet point of Option 2. I understand Senator Kieckhefer's concern about the $10 per meal. Based on my understanding from previous hearings, the $10 per meal is because they deliver meals every day with limited resources. We need to take a big step forward. Option 2 is that big step forward. Maybe further down the road we can look at alternative ways to handle the other 400 seniors that are going to be in trouble. ASSEMBLYMAN SPRINKLE MOVED TO RECOMMEND TO THE FULL COMMITTEES TO APPROVE DECISION UNIT E-275 OF B/A , OPTION 1 AUTHORIZING GENERAL FUND APPROPRIATIONS OF $1.5 MILLION OVER THE BIENNIUM TO FUND HOME-DELIVERED MEAL PROGRAMS FOR 775 SENIORS IN EACH YEAR AS RECOMMENDED BY THE GOVERNOR, AND OPTION 2, FIRST BULLET POINT, PROVIDING ADDITIONAL FUNDING TO ADDRESS THE ENTIRE WAITLIST BY INCREASING GENERAL FUND APPROPRIATIONS BY $1.9 MILLION FOR A FUNDING TOTALING OF $3.4 MILLION OVER THE BIENNIUM TO FUND HOME-DELIVERED MEAL PROGRAMS AT $2.65 PER MEAL FOR 1,126 SENIORS IN EACH YEAR OF THE BIENNIUM AND NEW EQUIPMENT. SENATOR WOODHOUSE SECONDED THE MOTION. ASSEMBLY: THE MOTION CARRIED UNANIMOUSLY. Discussion on the second major closing issue of B/A , decision unit M-201, regarding an increase in the Long-Term Care Ombudsman Program caseload begins on page 12 of Exhibit G. The Governor recommends increasing the caseload for the Long-Term Care Ombudsman with additional General Fund appropriations of $127,227 in FY and $222,324 in FY The recommended funding would support three new elder rights

15 Page 15 specialist positions to visit and provide advocacy services to residents in long-term care facilities. M-201 Demographics/Caseload Changes Page DHHS-ADSD-22 The Division provided updated caseload projections, shown on page 13 of Exhibit G, for this program based on the actual caseload through March The caseload is projected to increase from an average of 719 cases per month in fiscal year (FY) to 775 cases per month in FY The three new positions would allow the Division to decrease their current staffing ratio down to their targeted ratio of 1 caseworker to 60 cases. ASSEMBLYWOMAN BUSTAMANTE ADAMS: Where would the specialists be located? The specialists would be located throughout the State. The Division may provide additional clarification. JILL BERNTSON (Deputy Administrator, Aging and Disability Services Division, Department of Health and Human Services): There would be one specialist in Elko, one in Las Vegas and one in Reno. ASSEMBLYMAN SPRINKLE MOVED TO APPROVE MAJOR CLOSING ISSUE 2, DECISION UNIT M-201 OF B/A , FOR THREE NEW ELDER RIGHTS SPECIALISTS POSITIONS IN THE LONG-TERM CARE OMBUDSMAN PROGRAM TO VISIT AND PROVIDE ADVOCACY SERVICES TO A PROJECTED INCREASE IN RESIDENTS IN FACILITIES OVER THE BIENNIUM AS RECOMMENDED BY THE GOVERNOR. SENATOR WOODHOUSE SECONDED THE MOTION. ASSEMBLY: THE MOTION CARRIED UNANIMOUSLY.

16 Page 16 Discussion on the third major closing issue of B/A , decision unit E-225, regarding the elimination of an administrative assistant position in the Taxi Assistance Program begins on page 13 of Exhibit G. The elimination of this position and operating costs would provide a reduction of expenditures of $48,807 in FY and $50,430 in FY E-225 Efficient and Responsive State Government Page DHHS-ADSD-23 Eliminating the vacant position would allow the Division to move savings that have previously funded this position into the Taxi Assistance program's direct service expenditure category in order to issue more taxi coupon booklets to recipients. Funding for the program is generated from a percentage of all cab fares in Clark County, which is transferred from the Taxicab Authority in the Department of Business and Industry, as well as from the actual sale of the coupon books. The Joint Subcommittees on General Government approved closing the Taxicab Authority's budget on May 3, 2017, with the recommended transfers to this program. There were discussions regarding the decreasing revenues and future sustainability of the Taxicab Authority due to the uncertainty of future revenues resulting from the introduction of transportation network companies. The ADSD indicates that the elimination of this position would not decrease services to recipients, however it would decrease the program's ability to provide education and outreach to seniors. The Division indicates this program currently has a waitlist of 218 people waiting to purchase coupon books. Outreach has been suspended but has not reduced the numbers of seniors seeking to purchase coupon books. ASSEMBLYMAN SPRINKLE MOVED TO RECOMMEND TO THE FULL COMMITTEES TO APPROVE DECISION UNIT E-225 OF B/A TO

17 Page 17 ELIMINATE A VACANT ADMINISTRATIVE ASSISTANT POSITION FROM THE TAXI ASSISTANCE PROGRAM AND DIRECT THE FUNDING TO PROVIDE ADDITIONAL COUPON BOOKS TO THE PROGRAM PARTICIPANTS THROUGH THE BIENNIUM. SENATOR WOODHOUSE SECONDED THE MOTION. ASSEMBLY: THE MOTION CARRIED UNANIMOUSLY. Discussion on the five other closing items of B/A begins on page 14 of Exhibit G. Other closing item 1 regards position reclassifications that have occurred since the Executive Budget was submitted. Technical adjustments are included to account for those reclassifications. Other closing item 2, decision units E-505 and E-905, regards a transfer of a heath information director into the Federal Programs and Administration budget from the Desert Regional Center budget. Funding totaling $86,617 in FY and $89,955 in FY is recommended to transfer with the position. The recommendation would change the position's funding source to cost allocation reimbursements. E-505 Adjustments To Transfers Page DHHS-ADSD-24 E-905 Transfer From Desert Regional Center To Administration Page DHHS-ADSD-26 Other closing item 3, decision unit E-671, is a salary adjustment for IT positions which will be determined by the full Committees when all other Statewide decision units are discussed at a later date. Other closing item 4, decision unit E-710, is the recommendation for replacement equipment. Other closing item 5, decision units E-720 and E-721, regards a new videoconference system and mobile device management software, recommending additional funding of $58,000 over the biennium.

18 Page 18 E-671 Salary Adjustment For Biennium Page DHHS-ADSD-24 E-710 Equipment Replacement Page DHHS-ADSD-25 E-720 New Equipment Page DHHS-ADSD-25 E-721 New Equipment Page DHHS-ADSD-26 SENATOR WOODHOUSE MOVED TO RECOMMEND TO THE FULL COMMITTEES TO APPROVE DECISION UNITS E-505, E-905, E-710, E-720, E-721 IN B/A AS RECOMMENDED BY THE GOVERNOR WITH THE NOTED TECHNICAL ADJUSTMENTS AND DEFER A DECISION ON E-671 UNTIL STATEWIDE DECISION UNITS ARE DISCUSSED AT A LATER DATE, AND GRANT FISCAL STAFF AUTHORITY TO MAKE OTHER TECHNICAL ADJUSTMENTS AS NECESSARY. ASSEMBLYMAN SPRINKLE SECONDED THE MOTION. ASSEMBLY: THE MOTION CARRIED UNANIMOUSLY. Discussion on B/A , Home and Community Based Services, begins on page 17 of Exhibit G. The ADSD provides services though ATAP, community-based care programs, the Independent Living Services program and Assistive Technology programs, which includes a program to provide telecommunications devices for persons with communication difficulties. HHS-ADSD - Home and Community Based Services Budget Page DHHS- ADSD-30 (Volume II) Budget Account There are two major closing issues in this account. Discussion on major closing item 1, decision units M-200, M-201 and E-228, regarding decisions to be made to ATAP begins on page 18 of Exhibit G. The Executive Budget recommends increasing the number of children served in ATAP from an average of 642 children per month in FY to an average of 819 children per

19 Page 19 month in FY The majority of case management services for ATAP is currently performed by contracted case managers. The Executive Budget does not recommend any State positions in conjunction with these decision units and the recommended funding would support the additional contracted case managers needed to support the increased caseload. On April 26, 2017, the ADSD provided updated caseload and waitlist projections for ATAP, which are shown in the table at the bottom of page 18 of Exhibit G. M-200 Demographics/Caseload Changes Page DHHS-ADSD-33 M-201 Demographics/Caseload Changes Page DHHS-ADSD-34 E-228 Efficient and Responsive State Government Page DHHS-ADSD-37 The updated projections would require additional funds totaling $910,126, including a $659,842 General Fund appropriation in FY and $1.1 million, including a $732,224 General Fund appropriation in FY The ADSD indicated that the caseloads recommended in the Executive Budget were lower than they would be typically to account for a projected lack of providers. The updated caseload projections provided by the ADSD are 57 children per month higher than the caseloads included in the Executive Budget for FY and 71 children per month higher for FY The ADSD offered no additional information regarding a corresponding increase in the number of providers projected to be available to serve the increased number of children in the updated projections. The table on the bottom of page 19 of Exhibit G shows the General Funds, Healthy Nevada Funds and the Medicaid reimbursements that have supported the program over the current biennium, as well as the funding levels recommended over the upcoming biennium. The ATAP received no Medicaid reimbursements for medical services, administration or case management for this program in FY The ADSD indicates that it is currently working with the Division of Health Care, Financing and Policy to receive Medicaid reimbursements for services provided for ATAP. The program is working with community providers to ensure a certification is obtained in an timely manner and Medicaid enrollment is completed on time.

20 Page 20 According to the ADSD, 36 provider agencies throughout the State, as well as the 9 individual board certified behavioral analysts (BCBA) and board certified assistant behavioral analysts (BCABA) that are currently contracted to provide treatment therapies for ATAP are insufficient to provide services to the caseload recommended for the upcoming biennium. The ADSD also indicated that most providers are at capacity for services provided for after school hours. The Subcommittees may wish to consider the following options regarding the ATAP caseload: 1. Approve the Governor s recommendation to increase the ATAP caseload to an average of 774 children per month in FY and 819 children per month in FY Modify the Governor s recommendation to increase the ATAP caseload to an average of 831 children per month in FY and 890 children per month in FY , based on the ADSD's most recent projections, which would require additional General Fund appropriations of $1.4 million over the biennium. 3. Approve the Governor s recommendation to increase the ATAP caseload to an average of 774 children per month in FY and 819 children per month in FY , and appropriate an additional $1.4 million related to the updated caseload projections to the Interim Finance Committee (IFC) Contingency Fund in FY , in the event sufficient providers are available and additional children, beyond the budgeted caseload, can be treated through the biennium. The ADSD would need to seek approval from the IFC to access these funds. ASSEMBLYMAN OSCARSON: I like Option 3, but I propose a hybrid of Option 2 and Option 3, moving the number of children that are in Option 2 into Option 3. This is a better option in case providers become available and we can provide even more services. CHAIR DENIS: Under Option 2 there are 831 children in FY and 890 children in FY , which would require an additional $1.4 million. What

21 Page 21 Assemblyman Oscarson is proposing is to maintain those numbers and substitute them for Option 3's numbers which are the 774 children in FY and 819 children in FY ASSEMBLYMAN OSCARSON: We are adding the $1.4 million accessed through IFC so if the providers become available, we can serve more children. It gives us a little more flexibility. CHAIR DENIS: Assemblyman Oscarson, are you proposing to increase the caseload? ASSEMBLYMAN OSCARSON: That is correct. SENATOR KIECKHEFER: I understand where Assemblyman Oscarson is going, but if we are going to budget them for a specific caseload, we should appropriate the money to serve that caseload. This would take the difference between the Governor's recommended caseload and revised caseload projections and make sure there is enough money to serve that enhanced caseload if you can actually serve them with the providers that are available. If we are going to approve the caseload numbers, we need to appropriate the money. Option 3 would accomplish what Assemblyman Oscarson is attempting to do and ensure that there is enough funding available to serve the revised caseload projections, but it also puts a requirement on the ADSD to come and prove their provider ability in order to access it. We can serve everybody under Option 3 while approving the initial Governor's recommendation caseload, setting aside some in reserve to serve the enhanced caseload if the providers become available. CHAIR DENIS: Can Fiscal staff clarify what it means, since $1.4 million is listed for both options? Option 2 would serve the updated caseload projections of 831 children per month in FY and 890 children per month in FY It would place the additional funding needed to serve that projected caseload in the

22 Page 22 ADSD's budget to serve that number of children. Under Option 3 the funding for the projected caseload would serve the 774 children per month in FY and 819 children per month in FY It would put funding for that caseload in the ADSD's budget. If sufficient providers become available over the upcoming biennium and they can serve up to 890 children by the end of the biennium, they can come to the IFC and ask for the additional $1.4 million that would be needed to serve the higher caseload. CHAIR DENIS: What Senator Kieckhefer was saying is correct. Option 3 covers the basic caseload by putting money in their account, and then they can move forward. The $1.4 million increase would go to a IFC contingency account. The Division would have to come forward and express a desire to serve the additional number of clients that is in Option 2, and the IFC would have to allocate it. That is correct. ASSEMBLYMAN OSCARSON: Option 3 was not clear to me. I wanted to make sure that if the ADSD is able to find providers, additional funds would be available if that money is set aside. ASSEMBLYWOMAN CARLTON MOVED TO RECOMMEND TO THE FULL COMMITTEES TO APPROVE B/A DECISION UNITS M-200 AND M-201, THE GOVERNOR'S RECOMMENDATION TO INCREASE THE ATAP CASELOAD TO AN AVERAGE OF 774 CHILDREN PER MONTH IN FY AND 819 CHILDREN PER MONTH IN FY AND APPROPRIATE THE ADDITION OF $1.4 MILLION RELATED TO THE UPDATED CASELOAD PROJECTIONS TO THE IFC CONTINGENCY FUND IN FY IN THE EVENT SUFFICIENT PROVIDERS ARE AVAILABLE AND ADDITIONAL CHILDREN, BEYOND THE BUDGETED CASELOAD, CAN BE TREATED THROUGH THE BIENNIUM. SENATOR KIECKHEFER SECONDED THE MOTION. ASSEMBLY: THE MOTION CARRIED. (ASSEMBLYMAN FRIERSON WAS EXCUSED FOR THE VOTE.)

23 Page 23 Discussion on the second portion of major closing issue 1 of B/A , decision unit E-228, regarding the conversion of contract positions to State positions is discussed on page 21 of Exhibit G. The majority of case management services are performed by contracted case managers. This recommendation would convert 25 contracted case managers to State positions. In addition, it would add two new supervisory developmental specialist positions who will supervise the new State positions. E-228 Efficient and Responsive State Government Page DHHS-ADSD-37 According to the ADSD, converting the contracted positions to State positions would create consistency in staff who manage the ATAP caseload, reduce turnover in staff conducting service coordination activities and increase the program's sustainability by allowing it to receive Medicaid reimbursements for case management and administrative activities conducted by the State positions. The ADSD indicates that the contracted case mangers meet the minimum qualifications for the State positions and that most of them are eager to apply to the State positions to get the enhanced benefits that come along with the State employment. ASSEMBLYMAN SPRINKLE: I am supportive of the Governor's recommendation. This increase in case manager positions is necessary and will continue with the program. Even with our last decision unit, there seems to still be so much going on in the last two years as we have addressed autism. The Legislature was not sufficiently updated during the Interim. Therefore, I propose including in our motion a request to have the ADSD return to the IFC to update the Legislature on where they are at with caseloads and especially to update the Legislature with information on providers. We do not have the providers to be offering these services. The Legislature has a responsibility to ask for more frequent updates from ADSD.

24 Page 24 ASSEMBLYMAN OSCARSON: I agree with Assemblyman Sprinkle. Updates are critical during the Interim. The ADSD has been more than willing to provide updates on a regular basis. We did it on some grant programs during the last Interim, and they would be happy to do if again. CHAIR DENIS: Before we make a motion, I would like Fiscal staff to address the letter of intent. In addition to the recommendation for conversion of contracted case managers to State positions, as well the addition of two supervisory positions, the Subcommittees may wish to consider issuing a letter of intent directing the Division to report to the IFC semiannually on the status of the ATAP through the biennium to include: caseload and expenditure data; the current waitlist and any experienced delays in services to children who are already being served; the number of providers contracted to provide services, including updates on the number of BCBAs, BCABAs, registered behavior technicians (RBT), and non-certified providers; updates on the ADSD's ability to bill and receive Medicaid reimbursements; updates on the transition of eligible children to Medicaid; and efforts to recruit additional providers. ASSEMBLYWOMAN BUSTAMANTE ADAMS: Will the 25 contracted positions stay in their area, and how many of those positions are located in Clark County? Those positions are likely to stay where they are currently based. I will need to seek clarification from the ADSD regarding how many contracted positions are located in Clark County. EDWARD ABLESER, PH.D. (Administrator, Aging and Disability Services Division, Department of Health and Human Services): Those positions will remain where they are currently based. I do not have the location of those positions, however, the majority of our population is in

25 Page 25 Clark County and the assumption could be made that those positions will reside in Clark County as well. ASSEMBLYMAN SPRINKLE MOVED TO RECOMMEND TO THE FULL COMMITTEES TO APPROVE DECISION UNIT E-228 OF B/A FOR THE ADDITION OF 25 DEVELOPMENTAL SPECIALIST CASE MANAGER STATE POSITIONS TO REPLACE CONTRACTED CASE MANAGERS AND 2 DEVELOPMENTAL SPECIALIST SUPERVISORS TO OVERSEE THE STATE POSITIONS, WITH GENERAL FUND APPROPRIATIONS OF $158,005 AND OFFSET BY REDUCTIONS IN CONTRACTOR COSTS OF $2.8 MILLION OVER THE BIENNIUM, AND ISSUE A LETTER OF INTENT DIRECTING THE ADSD TO REPORT TO THE IFC SEMIANNUALLY ON THE STATUS OF THE ATAP THROUGH THE BIENNIUM TO INCLUDE: CASELOAD AND EXPENDITURE DATA; THE CURRENT WAITLIST AND ANY DELAYS IN SERVICES FOR CHILDREN WHO ARE ALREADY BEING SERVED; THE NUMBER OF PROVIDERS CONTRACTED TO PROVIDE SERVICES, INCLUDING UPDATES ON THE NUMBER OF BCBAS, BCABAS, RBTS, AND NON-CERTIFIED PROVIDERS; UPDATES ON THE DIVISION'S ABILITY TO BILL AND RECEIVE MEDICAID REIMBURSEMENTS; UPDATES ON THE TRANSITION OF ELIGIBLE CHILDREN TO MEDICAID; AND EFFORTS TO RECRUIT ADDITIONAL PROVIDERS. SENATOR WOODHOUSE SECONDED THE MOTION. ASSEMBLY: THE MOTION CARRIED. (ASSEMBLYMAN FRIERSON WAS EXCUSED FOR THE VOTE.) Discussion on B/A 's major closing issue 2, decision units M-202 and M-528 regarding the increase of wavier slots, begins on page 22 of Exhibit G.

26 Page 26 M-202 Demographics/Caseload Changes Page DHHS-ADSD-34 M-528 Mandates - Olmstead HCBC Page DHHS-ADSD-36 The Governor recommends the total of 11 new positions to accommodate a recommendation to expand the number of waiver slots for 2 of the State's 3 approved Medicaid waiver programs. Additional funding of $1.4 million is recommended over the biennium to support these positions. This would include the Home and Community Based Waiver for the Frail Elderly and the Waiver for Persons with Physical Disabilities. The Division of Health Care, Financing and Policy has administrative authority, establishes policy and makes payments for services. The ADSD incurs the personnel and operating costs associated with overseeing and operating the waiver programs. CHAIR DENIS: We need to take a break from our budget hearing since we have just lost a quorum in the Assembly side. We will take public comment in the meantime. JEFFREY KLEIN (Chair, Legislative Subcommittee of the Nevada Commission on Aging; President/CEO, Nevada Senior Services): The Legislative Subcommittee of the Commission on Aging and the Nevada Senior Services endorse the funding of the wavier program down to a zero waitlist. The current budget provides a great step forward but does not go all the way to eliminate the waitlist problem. A 90-day waitlist for the frail elderly may mean that some people never clear the waitlist and are institutionalized. We also wish to endorse the Ombudsmen provisions in the Executive Budget. CHAIR DENIS: We have regained a quorum of both Houses, so we will now continue our budget hearing for B/A Major closing issue 2 of B/A increases wavier slots for two of the States' three approved Medicaid wavier programs. The discussion for this item begins on page 22 of Exhibit G.

27 Page 27 The Governor recommends seven new social worker positions to support an increase in the number of waiver slots due to standard projected caseload growth to support salary benefits and operating expenditures for the new positions. Decision unit M-202 pertains to caseload growth; it increases the waiver slots for 2 waiver programs based on the upcoming biennium's caseload projections. Additional funding of $286,654 in FY and $644,864 in FY is recommended to support salary, benefits, and operating expenditures for the new positions. The second decision unit M-528, reduces the waitlist to under 90 days for those services. The Governor recommends adding two new social work supervisor positions and two new administrative assistant positions to support increasing the number of waiver slots even further in order to reduce waitlists for those clients waiting longer than 90 days for services in the waiver programs. Additional funding of $169,223 in FY and $322,821 in FY is recommended to support the salary, benefits and operating expenditures of the new positions. The Subcommittees approved the addition of the recommended waiver slots when closing the Medicaid budget on May 5, contingent upon the approval of recommended positions in these decision units. M-528 Mandates - Olmstead HCBC Page DHHS-ADSD-36 ASSEMBLYMAN SPRINKLE MOVED TO RECOMMEND TO THE FULL COMMITTEES TO APPROVE DECISION UNITS M-202 AND M-528 IN B/A , THE GOVERNOR'S RECOMMENDATION TO SUPPORT CASELOAD INCREASES AND WAITLIST REDUCTIONS IN HOME AND COMMUNITY BASED WAIVERS, INCLUDING THE ADDITION OF SEVEN SOCIAL WORKERS, TWO SOCIAL WORK SUPERVISORS, TWO ADMINISTRATIVE ASSISTANTS AND ASSOCIATED OPERATING COSTS. SENATOR WOODHOUSE SECONDED THE MOTION. ASSEMBLY: THE MOTION CARRIED. (ASSEMBLYMAN FRIERSON WAS EXCUSED FOR THE VOTE.)

28 Page 28 Discussion on the two other closing items of B/A begins on page 23 of Exhibit G. Other closing item 1, decision units M-800 and E-800, regards cost allocations. Other closing item 2, decision unit E-710, regards the replacement of equipment. M-800 Cost Allocation Page DHHS-ADSD-36 E-800 Cost Allocation Page DHHS-ADSD-38 E-710 Equipment Replacement Page DHHS-ADSD-38 SENATOR WOODHOUSE MOVED TO RECOMMEND TO THE FULL COMMITTEES TO APPROVE DECISION UNITS M-800, E-800 AND E-710 IN B/A AS RECOMMENDED BY THE GOVERNOR AND GRANT FISCAL STAFF AUTHORITY TO MAKE OTHER TECHNICAL ADJUSTMENTS AS NECESSARY. ASSEMBLYMAN SPRINKLE SECONDED THE MOTION. ASSEMBLY: THE MOTION CARRIED. (ASSEMBLYMAN FRIERSON WAS EXCUSED FOR THE VOTE.) Discussion on B/A regarding the Early Intervention Services (EIS) Program begins on page 25 of Exhibit G. The EIS program works to identify infants and toddlers who have, or are at risk for, developmental delays, and provides services and support for families with children from birth though their birthday who have developmental delays in areas of cognition, communication, physical development, social/emotional development and adaptive skills.

29 Page 29 HHS-ADSD - Early Intervention Services Budget Page DHHS-ADSD-41 (Volume II) Budget Account There are three major closing issues in B/A Discussion on major closing issue 1, decision units M-200 and M-201, regarding caseload increases, begins on page 26 of Exhibit G. The Governor recommends increasing the projected EIS caseload from the average monthly caseload of 3,414 in FY up to 4,062 children by the end of the upcoming biennium. This recommendation would include the addition of 26 positions including 23 developmental specialists, 2 licensed psychologists and 1 clinical program manager. The recommendation also supports the rental of six new vehicles from the Fleet Service Division for staff to travel to meet clients. M-200 Demographics/Caseload Changes Page DHHS-ADSD-43 M-201 Demographics/Caseload Changes Page DHHS-ADSD-44 During the 2013 Legislative Session, the EIS program was approved to split its caseload so that 50 percent of children receive services directly from the clinical staff with the State and 50 percent receive services from community providers. This recommendation to increase the caseload continues with the 50/50 distribution over the upcoming biennium. The recommended caseload that is included here would serve all new accepted referrals to the program and is not projected to generate a waitlist. A technical adjustment has been made by Fiscal staff regarding a calculation error in the projected Medicaid reimbursements that were based on a higher percentage of the caseloads. A technical adjustment has been shown in this document, Exhibit G, to reflect updated revenue projections, which results in increased General Fund appropriations of $186,370 and decreased Medicaid reimbursements of the same amount over the biennium. ASSEMBLYWOMAN BUSTAMANTE ADAMS: How are the 26 positions allocated throughout the State?