Special Edition Gold Dome Report -
January 3, 2017
Members of the House Appropriations Committee held a number of Subcommittee meetings today in an effort to hear updates on Departments' budget requests for the FY 2017 Amended and FY 2018. Below are reports from the Health and Human Services Subcommittees' meetings.
This Subcommittee, under the leadership of Rep. Butch Parrish (R-Swainsboro), heard from the newly-named Department of Community Health ("DCH" or "Department") Commissioner Frank Berry. A number of legislators were in the hearing including retiring Rep. Barbara Sims (R-Augusta) and Reps. Pat Gardner (D-Atlanta), Regina Quick (R-Athens), Darlene Taylor (R-Thomasville), Carolyn Hugley (D-Columbus), Lee Hawkins (R-Gainesville), and Ron Stephens (R-Savannah). This Department oversees the State's Medicaid, PeachCare for Kids and State Health Benefit Plans. Commissioner Berry outlined that, since taking over the Department, he had learned further that divisions within the Department do not always know about initiatives that are being undertaken. Further, he discussed the issues that the Department has experienced with the Centers for Medicare and Medicaid Services' ("CMS") lack of action on waivers which DCH submitted (the revisions to the NOW and COMP waivers).
Berry talked about addressing constituent issues – particularly when lawmakers are contacted about "poor care" in facilities or when providers are being treated poorly by the State causing greater administrative burdens. He essentially stated that it was important to have a proper balance so that Georgians could get high levels of care (such as in hospitals or nursing homes) because of the use of electronic medical records. He stressed that it was important on how data is shared and used as well as how best to protect that data.
Health planning is another area which DCH oversees. In particular, DCH regulates the State's Certificate of Need ("CON") program for health facilities. Commissioner Berry said that if CON is eliminated, competition will force better quality of care. There is little competition in some areas for certain services and those that do have positive margins worry that deregulation may cause a hospital to close.
Office of Rural Health is attached to DCH. Berry noted that healthcare costs are skyrocketing and some hospitals may not make it financially. Closures of hospitals in rural areas will cause those citizens to drive great distances for care. He said that he would not want that for his family.
Commissioner Berry noted the enterprise support functions which are carried out across DCH. These include the following:
- Office of Information Technology
- Office of Financial Management
- Office of Human Resources
- Office of General Counsel
- Office of Inspector General
- Office of Communication and Legislative Affairs
Commissioner Berry mentioned that since coming to DCH he had learned that in one division within the Department he had found workforce environmental issues. He said that was unacceptable.
Care management organizations (or "CMOs") are engaged by the State to manage the low-income Medicaid program (Georgia Families), PeachCare for Kids, and Georgia Families 360 (the State's foster care and children within Juvenile Justice). Berry told the Subcommittee that he had tremendous personal experience working with children. He stressed that Georgia needed to improve their care and he was concerned about access to care (not just access through the CMOs). Further, he mentioned that the State needed to have an ongoing "look" at improving access.
In his overview of the Medicaid program, he highlighted that Georgia has a number of Medicaid waivers. These include:
- Independent Care Waiver Program ("ICWP")
- Community Care Services Program ("CCSP")
- Katie Beckett
He described the waivers as the "lynch-pin" to success. In particular, it was critical to have the NOW and COMP waivers with the Department of Justice settlement. DCH will have an emphasis on approval of those waiver submissions to CMS. Commissioner Berry told the Subcommittee that if constituents contact them about waiver issues – in particular about "bumping up" their waiver due to an urgent situation (such as a change in family dynamics) - then DCH will want to be responsive and that lawmakers should reach out to him and his staff.
One in five Georgians are on the State's Medicaid program. 54 percent of all Georgia births are paid for by Medicaid. 48 percent of Georgia's children have access to Medicaid and another 4 percent have insurance from the State Health Benefit Plan.
State Health Benefit Plan is a self-insured, self-funded plan for State employees and teachers. There was a 2012 Rule which has impacted a small number of retirees. Commissioner Berry explained that his staff had reached out to the affected members personally to discuss the Rule implications, which are only now impacting these individuals.
Lisa Walker, the Department's new CFO, provided a budget review, looking at FY 2016 and FY 2017.
2.6 million Georgians get services through DCH. 76 percent are covered by Medicaid (with 52 percent of those in Low-Income Medicaid) and 24 percent covered by the State Health Benefit Plan.
In FY 2016, the total funding for DCH was $10.8 billion (this was a total of $2.9 billion in State funds). 51.5 percent of those funds are used by the Aged, Blind and Disabled program and 44.5 percent are used by DCH's Low-Income Medicaid program.
PeachCare for Kids is now fully funded by federal funds due to the Affordable Care Act.
For FY 2017, there is a budget of $11.02 billion. 52.8 percent of that funding is targeted towards the Aged, Blind and Disabled program and 44.3 percent to Low-Income Medicaid.
Enrollment has increased in Medicaid over the years. This increase is due to more utilization as well as rising prescription drug costs. On average, costs have risen 5.7 percent annually. Enrollment growth, on average, has grown 3.4 percent over the last few years.
Under State Health Benefit Plan, in FY 2016 it had revenue of $3.2 billion. Expenses in FY 2016 were $2.8 billion. Ms. Walker noted that there was a $323 million surplus for active retirees and $109 million surplus for school personnel (looking at teachers and non-certificated personnel separately, it was found that teachers had a surplus but the non-certificated personnel had a large deficit). In all, there are 633,852 individual members.
Commissioner Berry noted that DCH had submitted its budget ideas to the Office of Planning and Budget in September. However, he has only been on the job just a few days and did not feel that presenting his ideas for the Budget when he has no involvement was the right approach. Thus, he asked for a couple of weeks to delve further in the Budget needs for DCH. Berry also mentioned that he had met with CMS. He had further found that it had received 200 complaints but only half of the Health Facility Regulation Division was staffed. In part, salaries for nurses were problematic – this made it hard for DCH to recruit and retain staff. The Budget request submitted to the Office of Planning and Budget did not address the salary needs.
Commissioner Berry intends to hear more from stakeholders. He noted that many stakeholders were offering guidance in addition to providing him input on concerns. He plans to focus on learning more from stakeholders.
Rep. Hawkins inquired whether CMS will move on the increase and if so when that might occur. Commissioner Berry said that DCH is working with the Special Assistant Attorneys General (Josh Belinfante and others) on this. They have met and it may end up that the State has to take some sort of legal action. There is another internal meeting. Commissioner Berry noted that the Department of Justice understands the issue with CMS and its lack of approval on the waiver submissions – he said that there is also "a disconnect" at the federal level. This matter with CMS is his top priority.
Rep. Quick asked about breakdowns with the State Health Benefit Plan. Rep. Taylor asked for a number of additional pieces of information – including further breakdowns on enrollment and employee's dependent costs. She also asked why DCH had not moved the Aged, Blind and Disabled program to managed care in an effort to control costs. Berry responded that he had not been told to go in that direction; however, while at Department of Behavioral Health and Developmental Disabilities, that Department had operated in a managed care environment with accountability and compliance. Berry reminded the Subcommittee that it was hard to think progressively when DCH's infrastructure needs repair. He remarked that the national election results will also impact the State's budget and what must be considered. Rep. Taylor asked about percentages of costs and asked if members could get direct medical care costs versus housing costs (for nursing homes). Rep. Hugley asked what the process would be like for "care complaints" received from constituents. Berry said that if the matter was urgent then DCH would intervene as needed; he did note that training was necessary for providers and that the State had a role in that training. Rep. Hugley also asked about rate increases – the primary care rate increases have been implemented and Berry noted that DCH will continue to chip away at those rates. He said, however, that other Medicaid rates needed increases. Rep. Gardner asked about the NOW and COMP waivers - he explained that those had not been provided the increases because of the lack of approval by CMS. She also asked about autism spectrum coverage and whether DCH had implemented the new federal guidelines. Berry stated that autism issues were high on the Governor's priority list; he and his staff are working closely with the Department of Behavioral Health and Developmental Disabilities and hope to address this issue. Finally, Rep. Gardner asked about regulations of residential adult mental health services. Berry stated that he wants to look into that but wants to make it easier for providers.
Human Services Subcommittee
Following the Georgia Department of Behavioral Health and Developmental Disabilities' ("Department" or "DBHDD") Commissioner Judy Fitzgerald’s presentation regarding what that Department requested, several members complimented her presentation and asked several questions. Rep. Tommy Benton (R-Jefferson) asked about the Developmental Disabilities' waiting lists and whether the Department was requesting additional slots for NOW and COMP waivers, in addition to the 100 slots that are in the FY 2017 budget. The question seemed to reflect an interest in additional slots. The Commissioner and Deputy Commissioner responded that the 100 new slots in the current budget were funded for one half year and their cost would need to be grossed up in the 2018 budget. In addition, the Department has requested 250 new slots for the FY 2017 Amended budget and 250 new slots for the FY 2018 budget. These new requests are each for partial years and would be grossed up in the following budget cycles. Commissioner Fitzgerald assured the Subcommittee that DBHDD can handle the additional slots.
Rep. Michelle Henson (D-Stone Mountain) asked about funding for the Community Service Boards ("CSBs") generally and DeKalb CSB in particular. The Commissioner explained how the fee for service system that DBHDD has instituted through the Georgia Collaborative ASO allows the busier CSBs to provide and be paid for more services. A CSB would file a claim for the services it provides and this mechanism can permit additional funding.
Rep. Bubber Epps (R-Dry Branch) expressed some frustration in departmental responses to legislator questions about particular constituents in need of services. His comment did not focus on DBHDD alone but reflected his experience with delayed responses and responses that reflected the lack of authority of a particular agency to respond to the question, without making a referral to the proper agency to help the legislator. The Commissioner apologized for this experience and committed to assist Members with their questions and needs.
The Commissioner was also questioned about the location of the two new mental health crisis centers requested by DBHDD and she responded that they are slotted for metro Atlanta and the Savannah areas, the two regions that don’t yet have one.
Department of Human Services Commissioner Robin Crittenden and Division of Family and Children's Services Director Bobby Cagle talked about that Department and Division's needs.
Director Cagle noted that in his Budget submissions for FY 2017 Amended and FY 2018 he had asked for additional funds for the Out-of-Home Care program. There has been a 16.5 percent growth in the number of children in care. To maintain that level of services for the year, $21.7 million was needed and for FY 2018, $29 million is projected to be needed.
In response to the DFCS testimony, Rep. Mary Margaret Oliver (D-Decatur) complimented the Department/Division on finding a route out of the Kenny A settlement agreement for consumers in Fulton and DeKalb counties. She particularly noted the issues around the State's avoiding the eligibility penalties. Further, she stated that the call center is the right idea. However, she was greatly concerned that there was no funding for additional caseworkers. The Budget, she described, appears to be very narrow. Cagle explained that the caseworker issue had been an ongoing topic of conversation with the Governor and the Office of Planning and Budget. If they focused solely on turnover, there would be a 500 vacancy rate to be filled. She asked what had happened to the funds in the Children’s Trust Fund, noting that there appeared to be legal challenges as the Fund is not managed in accordance with the Constitutional Amendment which established the Fund. Director Cagle responded that these funds are not under DFCS control or its budget. He stated that there were funds in the Office of Prevention and that Office was receiving the Safe and Stable Family Funds. She also asked about a constituent issue relating to TANF; Director Cagle stated that they are looking further into that issue and it may be a federal eligibility rule issue.
Rep. Tom Taylor (R-Atlanta) asked about the waiting lists. Commissioner Crittendon explained that they do engage nonprofits such as churches. Funds are distributed, for Meals on Wheels, to all twelve agencies on aging.
Rep. Bruce Broadrick (R-Dalton) asked questions about contracting issues that entities had encountered. Rep. Tommy Benton (R-Jefferson) inquired about what DFCS was doing to address staffing – Director Cagle noted that DFCS is working with the nine schools with social work programs and trying to have the State pay for students who agree to work for the State and in return get their education paid for each year worked. However, he noted that the caseworker positions are stressful with numerous caseloads, money issues and the sheer difficulty of the jobs. Thus, they have seen a 32-37 percent turnover in workers. Rep. Benton also inquired about the percentages of times that children are placed with family members. Director Cagle responded that family placements were 27 percent of the time but DFCS has a goal of 50 percent family placements as those are less traumatic for the child.
Rep. Tom Kirby (R-Loganville) asked about child support orders as those need improvement. Tangela Gray, the Division of Child Support Director, indicated that her office is working on this but also working towards meeting federal requirements.
Several members, particularly Reps. Harden and Benton, asked why DFCS is not requesting new funds for additional case workers. Cagle responded that there are a large number of vacancies which permit additional case workers to be hired and that caseloads can be lowered by filling vacancies.
Georgia Vocational Rehabilitation Agency ("GVRA") also made a presentation. Newly named Director Sean Casey outlined the five programs administered by his Agency. These include Vocational Rehabilitation, Roosevelt Warm Springs/Cave Springs, Business Enterprise Program (entrepreneurial opportunities to become blind vendors), Disabilities' Adjudication (social security determinations), and Georgia Industries for the Blind. GVRA has 40 offices across the State with two residential campuses. Its budget requests were flat per instructions. There is removal of funds for the Warm Springs facility in the FY 2017 Amended Budget because of the Augusta University contract but that returns in FY 2018. Rep. Oliver asked for an update on the transition of the Warm Springs facility to the Augusta University control. Director Casey outlined that he would set up a meeting to provide an update on this issue. Rep. Oliver also inquired about the amount of federal funds left "on the table" due to the lack of State matching funds. GRVA indicated that it was between $30-$40 million as they received $60-$70 million (and could reach as much as approximately $100 million). There is no real waiting list for vocational rehabilitation services but a list for those needing assistance at Warm Springs. Rep. Michele Henson (D-Stone Mountain) asked about the precise location of the Disability Adjudication Office in Stone Mountain; he could not provide her an actual address. Rep. Dempsey noted that the Warm Springs' situation was unique and that she thought it would be good to take the Subcommittee there after the Session.
The Georgia Department of Veterans Services also gave an update. Commissioner Mike Roby provided an update. In FY 2015, the Veterans Affairs agency paid $3.1 billion in compensation and benefits. 68 percent of the payments were handled by the Georgia Veterans Services. They also had $5.8 million in education benefits (tax free). He stressed that it was important for veterans to apply to receive earned benefits. Commissioner Roby noted the two skilled nursing homes (Milledgeville and Augusta) which the Department oversees in addition to the cemeteries. Overall, this Department has 52 field offices across Georgia. They also have an appeals division to help veterans with pension claims etc. November 11 each year is observed as Veterans Day in Georgia. Roby mentioned the work to recognize the Vietnam veterans with a certificate of honor – so far, there have been 240 ceremonies. In Milledgeville, there is a 60-bed nursing home unit which handles post-traumatic stress disorders, traumatic brain injuries and those who have lost multiple limbs – they are asking for added funds for this unit in addition to bond funds. The FY 2017 Budget is flat but there is a request of $1.9 million in the FY 2018 Budget for operations' needs. Roby stated that many long-term employees need pay raises; the need was found after a study was conducted. They have also found that many employees are leaving for federal positions because the pay is much better. Thus, they are requesting a 4 percent pay adjustments for 67 personnel and a 5 percent adjustment for cemetery and benefit personnel. The Department needs additional field offices and staff; they are trying to co-locate those offices where possible with other agencies to reduce costs – it would appear that 13 staff are needed. The Department is also trying to open a Women's Veterans Office, using one new position which will be housed at the central office. They have also asked for funds for a second vehicle (their current vehicle is ten years old). They also need to replace 25 percent of their IT equipment and have funds for telephone conferencing. Rep. Oliver inquired about waiting lists for their nursing homes; there are none. There have been reduced populations at the nursing homes due to deaths. The Department provided a published calendar to the Subcommittee members – however, they asked the costs of the calendar and the numbers printed (this is the fourth year of the calendar's publication which is approximately $11,000 for 25,000). Rep. Tom Taylor inquired about utilization of the facility in Milledgeville – that facility has 275 beds which consists of 210 regular patients and another 19-22 who are disabled patients paid for fully by federal funds. Rep. Taylor noted that injuries are much different now and service personnel have more deployments. Rep. Harden remarked that the Vietnam veterans' ceremonies have been helpful; he was interested mostly in the healthcare benefits and stressed he liked the Department's involvement in helping veterans navigate the benefit system. Rep. Henson stressed concern whether one staff member for the Women's Veterans Services would be enough and whether other staff could help field calls and provide help. Rep. Tom Kirby asked about the changes to requirements to obtain a disabled veterans' license plate in Georgia – previously a veteran had to show 100 percent disability and now it is 50 percent. He also asked about Gold Star Plates and asked for information on the costs of those plates.
Our 2017 Georgia Capitol team consists of Stan Jones, Helen Sloat, Chuck Clay, George Ray, and Logan Fletcher. We will also try our hand at tweeting this year – so follow us! @GDR_Live
The articles published in this newsletter are intended only to provide general information on the subjects covered. The contents should not be construed as legal advice or a legal opinion. Readers should consult with legal counsel to obtain specific legal advice based on particular situations.