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The House Committee on Human Services met on March 12, 2019, to take up a number of bills. This report covers only HB 288 (Sefronia Thompson), HB 342 (Cortez et al.), and HB 1617 (Deshotel et al.).

This report is intended to give you an overview and highlight of the discussions on the various topics the committee took up. It is not a verbatim transcript of the hearing but is based upon what was audible or understandable to the observer and the desire to get details out as quickly as possible with few errors or omissions.

 

HB 288 (Sefronia Thompson) – Relating to the personal needs allowance for certain Medicaid recipients who are residents of long-term care facilities.

Thompson opening comments

  • Residents of nursing homes currently keep $60 of Social Security allowance, this bill would increase that to $75.
  • $15 may not seem like a lot, but an extra $15 can let someone buy an extra pair of Pampers, so if they are having problems with incontinence they do not have to walk around in a wet pair of pants all day.
  • Last time an increase was given was in 2005, when an increase was given from $45 to $60.
  • Frank – Sometimes when we think about this we think that it is the government cutting a check. This is not the government cutting a check, this is their Social Security check going to the nursing home to cover cost, and this would change the amount they can keep from their check?
    • Thompson – Yes that is right.
    • Frank – Important to clarify that this is not the government writing a check.

 

Public Testimony

Sherry Hubbard, Texas Silver Haired Legislature – For

  • We call this the “personal dignity allowance”. This will alleviate the plight of senior citizens in nursing homes.
  • TSHL ranked this as the 5th most important resolution out of 48 related to senior citizens.
  • Seniors should not have to beg for these items in their last years.

 

Mary Patricia Smith, Texas Silver Haired Legislature – For

  • The personal needs allowance increase is one of the TSHL’s top-10 resolutions.
  • People in these facilities may already have illnesses, may have lost there home or other things. A small amount of money per month allows them a measure of personal freedom.
  • Having good, sturdy shoes can prevent fall risk. Additional allowance will help with costs like these.

 

Amanda Fredriksen, AARP – For

  • When someone is in nursing home they have given up all their income, and the $60 is all they get back for personal needs.
  • In many cases the only asset these people have left is their home, and after they pass the home will be subject to asset recovery by the state.
  • Additional $15 will go a long way in making sure these people can live a dignified life.
  • Frank – Asset recovery of the home is new info to me, can you explain how that works?
    • Fredriksen – The state has a lien placed on the home. This applies only in long-term care, not in other aspects of Medicaid.

 

Gina Carter, HHSC – Resource witness

  • Frank – We are paying about $140 per day for a Medicaid patient in long-term care, what does that pay for in terms of food and clothing in the facility? I support the additional funds, but there are some things that should be taken care of by the facility.
    • Carter – The personal needs allowance is for things that are not covered by Medicaid.
    • Frank – So clothing is not covered, are food and toiletries covered?
    • Carter – Some are covered, and some are not.
  • Meza – I see the word “minimum of $75” and “minimum of $60”, so are they allowed to get more than the $75 and if so how do they get more?
    • Carter – I don’t see the word minimum, but I see “not less than $75”.
    • Meza – In the bill it says, “not less than” but in the fiscal note and bill analysis it says “minimum”. If it is a set amount then why use the word minimum?
    • Carter – It uses the language “not less than” but we have never gone above the $60. I think the intent is that you do not go above the amount.
    • Meza – So if it is a set amount then the “not less than” language is unnecessary.
    • Frank – Given the way it is written, the appropriators could have gone in and raised it to $75 without this bill. So theoretically if there is extra money it could come in.
    • Thompson – You can contact a lawyer who drafted this bill why he legally drafted it in this manner, he would be in a better position to explain it.
    • Frank – If appropriations came in and said we want to give $80, then I believe Thompson would not want to restrict them from doing that. Setting $75 as a minimum provides some flexibility.
  • Clardy – LBB’s fiscal note is $1.26m per year in GR. Are there new matching funds created by us raising the limit, or are the FMAP funds coming from a set amount?
    • Carter – Cannot answer right now but can get an answer.
    • Clardy – If this requires us to shift $5m from the federal matching program, how does it affect other programs?
    • Carter – For those on Medicaid you would draw down the funding.
    • Clardy – If we can get more money from FMAP that would be good news.

Thompson closing comments

  • The $60 buys the shoes, clothes, etc., and every once in a while it is good to step out of the nursing home and get a McDonald’s.

HB 288 left pending.

 

HB 1647 (Deshotel et al.) – Relating to Medicaid reimbursement for dental services provided to adults with disabilities.

Deshotel opening comments

  • Bill would add to group eligible for pre-dental.
  • There is a large fiscal note, are working with Sen. Kolkhorst and the LBB because I do not think the fiscal note considers the emergency room costs versus preventive dental costs.
  • Frank – This is something that is a simple concept but difficult to figure out the costs.
  • Hinojosa – Regarding fiscal implications of this bill, I was surprised about the cost savings by keeping people from going to emergency rooms.
    • Deshotel – Yes and often the emergency rooms don’t address the underlying dental issue and the patient keeps coming back.
    • Hinojosa – Does the fiscal note take that into account?
    • Deshotel – Apparently not, we are working with Sen. Kolkhorst and the LBB to change the note.
  • Noble – How many dental related ER visits are there per year?
    • Deshotel – Do not know.

 

Public Testimony

William Sargent, Texas Advocates– For

  • Proper dental care is important.
  • Overall health begins in the mouth.

 

Brooke Hohfeld, Texas Advocates – For

  • Would go to the dentist more often if Medicaid provided dental coverage.

 

Stephanie Stephens and Michael Ghasemi, HHSC – Resource witnesses

  • Frank – It looks like there is no credence given to the thought that there will be prevention of ER visits, can you expand on your agency’s methodology?
    • Stephens – The preventative aspect of dental care is factored in. Home and community based services waivers provide dental benefits already. For all adults in Medicaid, the dental services available are on an emergency basis. We looked at hospital costs that could be prevented and cost that could be reduced in waivers. We are not able to estimate potential savings in medical services because they are more indirect.
    • Frank – We have
    • Deshotel – 630,000 individuals with disabilities on Medicaid?
    • Stephens – Yes.
    • Deshotel – Did not realize it was that large.
    • Ghasemi – That number represents adults and is an enrollment number. The cost analysis is based on those we believe will utilize
    • Deshotel – How much would people actually access the availability of preventative dentistry, would it be lower than those going to ERs?
    • Ghasemi – More people would use preventative dental care than would go to the ER.
  • Clardy – We all know one of the most important things for dental and overall health is nutrition and hygiene, was there any analysis on how the increased dental hygiene would decrease overall health costs?
    • Stephens – We do not question the benefits of oral health on overall health, when we do fiscal notes we are able to estimate direct offsets. We cannot estimate secondary health impacts due to the number of assumptions we would have to make.
    • Clardy – I do not think this is a reach or that it is hard to determine. I have to believe there is data on the effects of dental hygiene on overall health costs. I do not think it would be that hard to calculate the costs. This is not quantum physics, I could probably google the information in 10 minutes. I believe this can be done with reasonable certainty.
  • Deshotel – You said you did not consider secondary benefits, which is where the rub is between us and the fiscal note. I think most people would believe that it will save money in the long run if someone gets preventive care rather than emergency care.
  • Frank – Was interested in the waiver program where there are some amount of services. Outline the cost difference between fee-for-service, MCOs, and waiver programs?
    • Ghasemi – Fee-for-service and MCO costs based on where enrollment is today. Cost estimates were an average based on current dental cost.
    • Stephens – The waiver costs are generally done on an annual basis. We have a total cost for waiver dental services but not a monthly average.
  • Hinojosa – When Medicaid patients go to the ER for a dental problem, who pays for that?
    • Stephens – If it is classified as an emergency then it is covered by Medicaid.
    • Hinojosa – If it is not an emergency who covers it?
    • Stephens – Will have to check,

 

John Molina and Kody Kness, Imagine Art – For

  • Had to have emergency dental services and get 6 teeth pulled, would have been better if it was preventive.
  • Frank – What was the situation that caused that?
    • Molina – Swelling of the mouth.
    • Frank – What caused it?
    • Molina – Having trouble flossing at an assisted living place.
    • Kness – He had a bad tooth that went untreated, if he had routine dental coverage it would not have happened.

 

Dennis Borel, Coalition of Texans with Disabilities – For

  • At the ER you do not get dental services, you get opioids, painkillers and antibiotics which do not deal with the root cause.
  • It is accepted medical fact that poor oral health damages the rest of your body.
  • Regular preventive dental care is cheaper in the long run than not receiving preventive dental.
  • Frank – We will need to look at the best way to deliver preventive care.

 

Jeffrey Brunson, self – For

  • Cost is an important part of the decision, but the cost of doing nothing is much greater than the cost of providing preventive care.
  • The more that is done in prevention, the less is needed in hospital care and this will save money.

 

Name inaudible, self – For

  • Poor dental health resulted in 11% higher chance of breast cancer.
  • Frank – You would have benefited if this bill had been in place for dental coverage?
    • Witness – Yes it would have helped my dental health.
    • Frank – Was there a tie between dental health and breast cancer?
    • Witness – There was an 11% higher chance that I would get breast cancer by having a bad tooth that went untreated for years. Have trouble taking care of teeth because I depend on attendant caregivers.

 

William Gaventa, Texas Impact – For

  • Dental health is a big factor in quality of life for people.
  • Having a dentist who knows a disabled person would help the disabled get the care they need.

 

Ankit Sanghavi, Texas Health Institute – For

  • In Medicaid population there were 25,000 hospital visits for nontraumatic dental issues.
  • Going to the hospital for a dental condition will result in a painkiller which might provide temporary relief but will complicate the problem in the long term.
  • Frank – Was there any research on the best way to deliver dental care?
    • Sanghavi – The conditions that we studied were almost all best treated by a dentist and not in a hospital. Preventive care will provide a tremendous cost saving.

 

Deshotel closing comments

  • Testimony has clearly shown it is a cost savings in the long run to provide preventive care. We are working with LBB to better reflect this.

HB 1647 left pending.

 

HB 342 (Cortez et al.) – Relating to the period of continuous eligibility for the medical assistance program.

Cortez opening comments

  • Percentage of Texas children who are uninsured is double the national average.
  • Bill will remove red tape and prevent children from dropping on and off Medicaid.
  • Has been called by numerous stakeholders as “the most important children’s healthcare bill” this session.
  • Hinojosa – Like the bill, if we go a year long and stop the month-to-month, are the administrative cost-savings reflected in the fiscal note?
    • Cortez – Yes, and this fiscal note is much less than the from when I filed this bill last session.

 

Public testimony

Anne Dunkelberg, Center for Public Policy Priorities – For

  • Bill text is very simple, only changes one word, but the eligibility behind it is much more complicated.
  • There have been unintended consequences of past legislation that has resulted in some kids who should be eligible losing their eligibility.
  • 53,000 lost coverage due to administrative problems with things like paperwork.
  • Frank – Are those paperwork issues people not having the necessary forms or are they just not turning them in?
    • Dunkelberg – They look at 3rd party databases which can be out of date, and the families often get confused when they have to fill out forms every month. We want to make sure we are not using red tape to prevent people from getting benefits.
    • Frank – Agree with the red tape comment, but the idea of putting them on and leaving them on for as long as we can is concerning.
  • Hinojosa – Expand on best practices
    • Dunkelberg – Feds have for years encouraged states to adopt 10 months continuous eligibility.

 

Ben Raimer, Texas Pediatric Society and Texas Medical Association – For

  • We believe this is a best practice and we will get the best results if we follow these guidelines.
  • Costs in the fiscal note has been brought down, I think that is why the Feds made their change extending the CHIP program to a full 12 months.

 

Mary Dale Peterson, Texas Association of Health Plans – For

  • Support 12 months continuous eligibility.
  • Should not allow Medicaid enrollment to lapse due to red tape.

 

Ana Maria Garza Cortez, Texas Assoc of Community Health Centers – For

  • Families will get a letter every month to submit verification of income, which can become a barrier to healthcare.

 

Kathryn Freeman, Texas Baptist Central Life Commission – For

  • One of Texas Baptist Central Life Commission’s priorities is to expand access to healthcare for children.
  • Access to healthcare for children increases high school and college graduation rates.

 

Gina Carter, HHSC – Resource witness

  • Frank – There are 4,000 kids who lose coverage and only 400 should have, that is the number we have heard. What are the reasons these kids are losing coverage other than the good reason that the parents are doing well?
    • Carter – We do periodic income checks, which we do in the 5th, 6th, 7th, and 8th months but not necessarily for every child in every month. We have data and if we see certain information that the household is over the income limit we will send out a notice to the family.
    • Frank – They are covered for 6 months but you send them for the 5th month?
    • Carter – They are always covered through 6 months. We do the check during the 5ht month and then the notice would be sent during the 6th month and if we get that information it would impact the 7th
    • Frank – If they don’t verify the information would they be off?
    • Carter – If there is failure to provide the information their benefits will remove.
    • Frank – That is a big difference, because I don’t think anybody wants to keep somebody off that is qualified, but if someone is not qualified then those are the rules. Is the 400 number we have heard the number who respond?
    • Carter – Those are the ones who respond and were over the income threshold.
    • Frank – Is there a way to get the amount of the 4,000 who were under the threshold? Some witnesses have implied that none of those 4,000 were over the threshold.
    • Carter – Based on our data source all of them are above the threshold, but that is what we are trying to verify.
    • Frank – The truth is probably somewhere between the two.

 

Linda Litzinger, Texas Parent to Parent – For

  • Some conditions you cannot go to the ER because the ER does not know how to handle certain situations.

 

Adriana Kohler, Texans Care for Children – For

  • Providing health coverage is the most important thing we can do for children in Texas.
  • Value quality and consistent care.

 

Laura Guerra-Cardus, Children’s Defense Fund – For

  • Current system creates confusion for families.
  • There is 10 days from when the letter is generated, not when they receive it. Many families receive the letters after the due date.
  • Clardy – Has anyone thought that when the child goes for a checkup they do the paperwork there?
    • Guerra-Cardus – Some families won’t use the care they need because they don’t know if they have coverage, which results in delays in coverage.
  • Meza – My district is the worst in Texas for uninsured children, I hope what we are working on today will help solve that problem.
    • Guerra-Cardus – National average is 5%, for Texas it is 10%.
  • Frank – Continuous care and ER visits?
    • Guerra-Cardus – Non-continuous coverage have much higher ER visit rates and those visits tend to be more expensive.

 

Stacy Wilson, Children’s Hospital Association of Texas – For

  • Over 3.1m children in Medicaid, anything that impacts Medicaid disproportionately impacts children’s hospitals.
  • Gaps in coverage result in avoidable illnesses and other conditions.

 

Cortez closing comments

  • There is a lot of support for this bill.
  • Texas has the highest rate of uninsured children, this bill will help to bring that down.

HB 342 left pending.

 

Committee adjourned.