Senate Insurance & Commerce Meeting Jointly with House Insurance & Commerce

Members I call this meeting to order of the Joint insurance and commerce committee. Appreciate you taking time out of I know many of you are in the middle of campaigns and number of you have a driven Informatik town I think we've got some very important issues to take take up not the least of which are represented Pilkington's I. S. P.'s his catalog of we're looking forward to hearing the description of that. Of the members if you've I hope that well first let me take a motion of you should have the minutes of the last meeting before you the June twenty first meeting hope you've had an opportunity to review them if you have I will entertain a motion to adopt the minutes. Motion by representative wooden and second by. Senator Ferguson so I can. All those in favor of adopting the June twenty first minute minutes of signify by saying aye. Any opposed no and so the minutes are adopted of members the the lead issue that we're taking up today is one that to the constituents of several constituents referred to me and it is based on the by ministration has put forth a rule under rule promulgation that extends If you if you read it closely and and I think it is one of the exhibits that is contained in your records you may not understand the full import import of it talks about nondiscrimination but the the actual import of it is to require under any federal federal program whether it's Medicaid expansion or otherwise require that gender reassignment surgeries be covered under that rule and so public comments of period I don't know if it is still in effect but I do know that we have representatives from DHS they're gonna report to us on the public comment that they submitted to the feds on that particular rule so at this point if Mister white of mark why would come forward and anyone else that you have with you. Its market share of life linum sekarang. If you will identify yourself for the record and then you're free to To make any preliminary comments but also make references to the public comment that you submitted to the fence you're recognized thank Mister one more quite warm Human Services. Serra line and Department of Human Services. All right Mister remembers I thought what I do is give you just a brief overview of what this rule is how we got here and what the scope of it is and talk briefly through the comments that we submitted to HHS around the new rule I believe you have a copy of those comments in front of you and we'll talk a little about what rule do what the what the expected impact is as well as how we project that will be enforced by the fence an act that be happy to answer any questions so this rule has a little convoluted history there was a rule that was put in place by the Obama administration back in twenty sixteen that extended the reach of nondiscrimination provisions related to health care and health insurance in twenty twenty the trump administration removed those and modify the rule with a different version and so what this rule does is proposed to do not to emphasize this proposed rule this is not a final rule yet it is proposing to essentially undo what the trump administration had done around this and put some new language back in and the scope of the rule courses nondiscrimination particularly in the areas of sex and gender are it applies to Medicaid Medicare and it either directly or indirectly list as I read it applies across the board to all health insurance induces example no you I'm sure you inner sand that much health insurance in private employers is offered through employer sponsored plans that are governed by risa. And they recognized in here that they don't have jurisdiction to impose this requirement directly on those arrested plans but they do attempt to impose the requirement on the third party administrators and other vendors that operate those plants so that's why I say directly or indirectly this clear they're trying to get at all health insurance. Susan the provisions of the rule that that we've looked at we have focused more on the provisions around the issue of gender discrimination I'm particularly no the tent they stayed in there that want to apply this in the context of gender transition procedures and treatment it does mention other issues so for example subscription of pregnancy which lease raises the question of does that also include abortion as a termination of pregnancy and there are is the most provisions in there regarding how agencies treat individuals and applicants who are limited English proficient I'll just I won't talk much at all about those rules I think in looking of those I think we're mostly if not fully in compliance already with what they're proposing so we don't expect any significant impact from that. So for our comments that we submitted to HHS it is very much focused on the the legal side of this which is we think that HHS does not have the legal authority to impose this rule what they're doing is they're trying to take the reasoning and rationale from the both stock decision from the US Supreme Court R. which applied in an employment context into trying to bootstrap that in to health care and we think that setting aside what is a good idea or not you know in terms of the policy legally we still think they have the authority to do it I would think that there exceeding what was the most R. decision they're exceeding the authority Congress has granted them and that's the basis for the comments I would you have in front of you in front of you that we submitted. And along the same lines. The it just would not get too deep in the weeds are on the the court decision what they're trying to bootstrap is in both stock the court arrived at the idea that that discrimination on the basis of sex or gender includes discrimination this tied to gender identity and so they're trying to bootstrap that and apply that to gender transition treatments and other gender related issues. So in terms of what the rule actually do I'll tell you that I don't know for sure as I read it this rule is there's there's a difference between what they say in the narrative about what they're trying to do what they tend to do and the language of the actual rule itself and I think the in the day the course we're just gonna have to sort this out they I'm asking they will try to enforce this and so in one way or another to achieve their policy objectives it'll go to courts and the courts will have the final say in it And then one additional point. The always were make on this and this is another. well I think the rule is is distancing from I think not only their legal authority but also with the store please been policy for Medicaid and that is this the historically Medicaid has been strictly limited only to management medically necessary procedures and there's language in the rulemaking and in their discussion we're certainly gives the idea that they want to expand that talk more about procedures that may be more elective nature and that's certainly something that we're not interested in we we hold to that Medicaid is a payer of last resort it should not be the first right of of health coverage for individuals and for that reason Medicaid should limit itself to only medically necessary procedures. Last four on enforcement CMS they would have the ability to enforce this rule on the Medicaid program directly both are fee for service programs as well as our managed care programs we operate such as the passes for our home and for the coverages offered through qualified health insurance plans and through the market place that would be enforced directly but between CMS or HHS and those health plans that is not something that we would have a role in or have a have a say in And I believe Mr that that covers the key points of what sort what disappoints wanted to mention so that you're not talked about this before for the meeting. In terms of what the our home policies cover the formal Care Act set a series of essential health benefits that every health insurance plan has to cover your centrist forming their the agency that is responsible for enforcing that and for our plans that we use for our home we stick to the same essential health benefits and so coverage is determined by the insurance department based on those EHV requirements and and we've learned or what has been leased one state that is asked for and received permission from CMS to add gender transition or gender affirming treatment to that list of essential health benefits just based on our non expert opinion we don't believe that CMS has the authority to force that on stage and so that would referred to the insurance experts on that piece but just as we read that the members of the state and choose to do it is not something that the state can be forced to do with that Mr Osthoff and be happy to answer any questions thank you I Mark I have reached out to the insurance department who's here and Mr rand if you don't mind if the rain comes in kind of tag teams with you on this CMS issue especially related to what you reference that one state as requested That cover those coverages apply of you identify yourself for the record Mr grant thank you Mr chairman French Hill council and the I agree with mark Mr white there would have to be a federally mandated law that requires the states to cover transgender services in their essential health benefits until there is a federal law requiring it I don't believe HHS can impose is required okay. So is it typical let me and there are a couple members that what wish to ask questions but is it typical that these requests be made state by state S. as we've just seen it Colorado has made a request of the feds and and it has been green lit for Colorado but that would not necessarily apply to any other state or would not mandate upon any other state correct correct it would not apply in Arkansas okay right. All right going to first go to of representive with. Thank you Mr chairman of. I have a couple of questions for first one is mark you said that. Medicaid Medicare generally the second goal for cost or claiming expenses from them. The. This is This includes Norrell coverage health insurance with this applies to all of them yes it would I think that's what Mr white was trying to explain that you would apply to the fully insured market in the commercial market place because of the way I read the rule any insured issue were that takes federal financial assistance or any one of its companies would make it subject to this rule also would apply to private commercial market not just Medicaid. Okay I you know I will go into the Mr chairman if a Monday national I will go into the gender identity and all that stuff I don't I don't understand why the questions even ask own of Baptist health hazard one of their deals you know what were you were you what were you at birth or what one would you identify now well who cares what difference does that make but my my concern also there's a language in here this is we're limited English proficiency exist are we talking about those folks coming across the border down there extending healthcare to all of them and any any illegal alien in the country can claim under this no Sir the the language in there it only relates to how we communicate with individuals as a just as an example no we have a large population abortion lease islanders in Northwest Arkansas who are here legally through a chorus that were developed many years ago because of the nuclear testing that was done in the Marshall Islands we have meals individuals they speak little or no English and so we do have resources so that they can communicate with us in their native language so when provide paperwork and no applications in a language things like that but it does not expand eligibility but it doesn't say that. Well if that is what I understand and I I don't have a problem with that. Right it is I mean certainly I mean they can try whatever they want I just I don't see the language that to me gives them of a feasible bootstrap to do that but they want to do it with will taken to court. Because this is no problem at the border and and so I'm saying that they could the way this is recognized if it is proposed like this they could include those could in a. For all again I as I read it only applies the communication with the and so I don't believe it I don't see how this language could be used to to govern eligibility to make someone eligible for the program thank you thank you Mr chairman. Thank you. Representive wrecked. Thank you Mr chairman so but first of all thank you for submitting this comment. so as to make sure motion as if this rule were approved this would require. Our Medicaid program to include coverage for. These procedures is that right that's that is what is unclear because I think that's their intent I think that's what they're trying to get to I don't know the language does it because and not get too deep in the woods but wait for that language really glides over the entire question of medical necessity you know because we we make decisions for coverage based on medical necessity we we will not knowingly cover anything that is not medically necessary for that specific individual and so whether to make these categorical statements they make in some of the narrative that's where I just ate it he Chris lot of vagueness and ambiguity sure why I certainly agree on the medical Nessa's necessity versus verses elective point is there any estimate of what this would cost taxpayers how much taxpayers would have to pay. No not without knowing any specifics about how it would be applied to us or what additional coverage would have to make okay all right thank you. Represent radio I will and we did ask for participation in this hearing from seventeen and Blue Cross blue shield they have a given us exhibits that you have there is statements Centene statement is very brief BlueCross BlueShield gives a more detailed presentation the question we were asking them is how would it affect premiums or cost and if I am correctly analyzing Blue Cross blue shield's proposal it was was basically or their statement is that it would not affect because they don't believe that this coverage would be allowed that it's it's elective coverages so there would be no effect on premiums but that really kind of I feel that kind of dodges the question that you know if if it were forced on us what would be the net effect on all insurance plans let me go ahead and turn your Mike back on. Sure wide I guess I would just say I agree with the chair I mean I think I got a letter in the mail shortly after the session from Blue Cross and included a comprehensive list of pretty much every bill that we passed that impacted health insurance premiums and it included a dollar estimate for the amount of impact on each one of those so I have to imagine that this would have some sort of impact. Right thank you. Okay any other questions members of these witnesses to represent of Lundstrum. I want to thank you for pushing back the long term consequences of this are disastrous for these children when you look at cardiovascular disease cerebral vascular disease infertility type two diabetes osteoporosis of the State of Arkansas participating in something that would harm children I'm very pleased that you push back. Thank you Lundstrum and I will add one one point of the mission earlier. I think that's another element of this is that in cases where you all have acted to actually knows say this procedure can be or cannot be performed. To me that's an extra step beyond this and so on I'm really skeptical this rule could reach with the policy decisions you all made in that area. Okay. If I understand your your testimony and also just the the plain reading of the rule if it's not just applying gender reassignment therapies or treatments to. You juveniles and stop that even adults that if they want to undergo gender reassignment surgery which can be breast augmentation could the removal gente of whatever that there would be a requirement that it be covered under these under these plans correct I think there I think that may be part of their intent I don't know they've actually successfully done that with language and I and I and I guess just even going beyond that if for some reason there was a forced mandate to cover for instance breast breast implants with that open up the door then that any woman. That wants to have breast implants and have them covered. By these plans that that that would be an additional cost where we could see premiums explode I think if if if CMS if they start blurring that line between medically necessary and elective I think that's that's a very expensive road that puts down right okay representative wouldn't call and you can follow up with. The exhibit three C. three states Arkansas Blue Cross blue shield does not see any impact on premiums is the coverage ordered by HHS out of and advocate is to speak for them but hello can they make of this or are they implying that all this is going to shift to the federal government which will shift to the taxpayers of Arkansas. If this rule goes. What what how can they make a blank state but lacks a. I'd be really hesitant to speculate on what their intention was there yeah I just you would represent what you would need to talk to the issuer of insurance company thank they typically evaluate state mandates with an actuary who tries to calculate if they have to cover something they have to look at a lot of cost trends and I'm maybe their conclusion was that it would not significantly raise rates or it's just minimal so you would need to visit with the insurer or I'll be glad to visit with him for more detail you will up detail yeah I wish you would because I mean I agree with the chairman I'm if you start including. Elective surgery which was which all of what they're talking about here interest reassignment sex reassignment of this select the best of the decision of choice made by that person and I will pay for that and I don't think any taxpayer wants to play with that. I'll be glad to follow up with them to give more precise information thank you Mr in my section would be that if the issue is one of nondiscrimination so if the ruling comes down that this is under nondiscrimination it is medically necessary then then. Other other individuals could make the same argument where you're granting and again I come back to breast augmentation you're granting it under this one situation if you don't granted to me if you don't cover my surgery now you're discriminating against me right it does create a lot of confusion we start blending nondiscrimination with medical assisting coverage decisions because those are the others those are two things you wouldn't necessarily expect to be blended together right and and and I'm aware of research I believe that some psychologist or state are starting to argue the gender reassignment is medically necessary so. you said more than likely that a lot of this is going to end up in the courts and it would focus on that issue of medical medically necessary versus selective that's what I would project okay. A representative Gazaway. Thank you Mr chairman you know as I look over your. Policy statement number one I appreciate your analysis of the issue. And You know I I tend to agree with that one issue that comes to mind is. In the previous legislative session we passed a healthcare conscience Act and we have hospitals around the state that are affiliated with. yes religious institutions St Vincent's for instance with the Catholic Church Baptist. You know I have I have to wonder how that act which protects my understanding is a health providers right to conscience interpret maybe perform certain procedures kind of what the interplay is between that and what's being proposed by the federal ministration is it possible that we could see institutions and providers opt out based on conscience has there been any thought to that and how that might can play on it and I will say I have I remember reading that act back in the session and it's been a while so I don't want to go by member on that I will something for Medicaid standpoint. Enter it we would I think we will always want to recognize a healthcare provider's conscience and not forced not trying to force then provide some service they feel violates their beliefs typically for Medicaid and just wanna speak more broadly than just this issue our obligation is not so much to force a particular provider to provide a service as it is to ensure access so if there's a from if this if broader A. won't provide this for this individual then we need to have available other options for that beneficiary and that's just very broad axe this requirement applies across all of our services. Representative Lundstrum thank you base maybe you can help me with this one now that for example Blue Cross blue shield I'm sure others will say this won't happen right increase. Correct. That's what they say okay but I'm not seeing the actual study to evaluate whether or not that's accurate or not so I think I promised representative would not follow up with him because I to copy you on that okay with with the carrier I don't see how it's even possible I mean some of these procedures and the complications of follow it run into hundreds of thousands of dollars so we need to remember this conversation come back and ask for a rate increase right thank you can't have it both ways are great. Okay thank you. Members any additional questions for for these witnesses. If not thank you very much you for appearing at thank you of. Mark for the statement that you submitted to HHS. Okay members as I mentioned you do have to exhibits in your packet that are statements from Centene in Blue Cross blue shield and as you've just heard from booth ran with the insurance department he will attempt to get some clarification on this premium issue I don't have anything additional under this particular subject heading so now we will move to the I. S. P.'s representative Pilkington would you like to. Go to the witness stand and and give us a summary of if your ISP's. Okay. And I'll just note I am just for right now skipping over number one which it was referred to us by representative Wardlaw to think it was a referral from A. L. C. so we will go to a deed to the five which the authors representive Pilkington. Thank you chair Lowery the first. Interim study proposal that we have is to modify the insurance requirements of electric scooters this actually is a change to a bill that myself representative Grant Hodges Senator Breanne Davis and representative David Whitaker it all worked out together in the session before last we set the insurance coverage a million dollars and actually in the time being between that I'd heard from several smaller companies that they thought that that was too high a burden to get to certain markets and so I'm just simply wanting to help out some of the smaller companies that may want to go to some smaller communities that aren't as large as as say like a little rock or Fayetteville so just lowering that from a million Are no less than one million to no less than two hundred fifty thousand dollars and and for an occurrence of two hundred fifty our two hundred fifty thousand dollars aggregate so that's that's all that is just a change in the amount they were requiring. Let me clarify for got to flip the page that there are three other ISPs on the on the backside so correct feel free to give as much as the bongo and I mean I won't go okay I we get we can make this fast Actually I would like to hold this one the one to prohibit come to not compete this came out of some desire to expand entrepreneurship in Arkansas but I've had some conversations with us and fellow members and I would actually like to just hold this one right now and and not take it up today if that be okay the next one is the mandate that insurance policies cover screening for depression of birth mothers at the time of birth this is one that you invested a paper recently that were actually add gains national attention that one of the ways we can improve our. mortality rates on mothers is to have to freshen screens and so it's actually fascinating because we it's. They project that would be a cost savings for the state because obviously if we're lowering the amount of mortality among mothers that's better for the state so this is that just to make that as a requirements and it's based off that study that came out of you and mass the next one is an actor par screen for depression of birth mothers a time birth is for insurance policies that one was for the make sure I get this right as for insurance policies. On a second it is the exact same. What is for Medicaid one is for insurance companies but I can't. Sh. Okay which I guess possible that they they could be. Well together in yeah okay okay that's was keep going. The next one is to raise the rate at which we reimburse. Live births for the same as caesarean sections so one of the things especially if you're in the meeting we had to add you a mass for public health was uh we've been seeing a rise and Murtada rates for for mothers in this country especially in Arkansas we've also seen a rise in the amount of C. sections we do and that for the record I don't there's nothing wrong with C. sections there is there a right procedure on the right course of action but recent studies of actually come out to suggest that because the reimbursed at a higher level that's the reason why we're having more C. sections is because we are incentivizing providers to do this is to have more those and obviously there's more complications with C. sections in there are with libraries which are less less complications and safer for the mother so obviously with our band going it is in place you know we're expecting have more births here in this state and so I really didn't do anything that would lower the amount for a C. section since we're already having a lack of OBGYN providers in the state so I I wanted to raise the amount for life birth and that's that's what this one is. The next one is to exempt certain products from sales and use tax is the paying taxes co sponsored by representative in it he's here is today this is the bill we have last time to for feminine hygiene products to get rid of that sales tax so exact same bill I'm just getting prepared for for next session. Then we go to the next one which is an act to amend Arkansas income tax for an income tax rate for employees who encouragements for paid family leave this came out discussion with certain pro life groups about as we go and Look at what we do now in a state that has banned abortion in almost all cases what we can do and one of these things one of the suggestions wise to not force companies offer paid family but incentivize them to and this was one of the ways to do it it's it's capped at the amount of wages for the employee for the time that they take off and can be no more than that and it is different than the other proposal I had had when we talk about during the special which was related to companies that provide abortion services are travel across states this is not related to that piece of legislation which I know it's shared with many of you I don't have a cost on this I've asked referred B. L. R. I just haven't received it yet but obviously that is a big. A big discussion point on this on what it would cost stated we did proceed a pursue this policy but having said that I think this is more of a care and less of a state policy and like I said if we're expecting expected to be and a pro life state that takes care of young families and women I think this is the second policy idea to lease pursuant to study in the interim which is why we have an arm studies. And and that's a all of mine for this committee. Okay you were certain you have any questions. Without objection I will just a pool of or batch together numbers two four five six seven and eight there's no objection I will take a motion representative Pilkington for us to adopt all of those ISPs yes I can okay your motion the second. Checking for anyone Okay I'm sorry I'm not seeing hands I mean I see the hands but not seeing the bodies representative brown as a second okay all those in favor of us approving ISPs to for. Five six seven and eight signify by saying aye. Any opposed say no and there's no opposition fantastic day Senate support thank you representant. And will take up even the representative Wardlaw is not here my understanding is ISP number one is a referral from a LC Hi speed twenty twenty one dash one thirty two of of the ninety third General Assembly requests that the house committee on Insurance and Commerce conduct a study of health insurance coverage reform in this state and recommend policies and procedures to implement this state strategic plan for health insurance coverage. If there are no questions I will entertain a motion representative. Ferguson and second by representative. Allen. All those in favor signify by saying aye. Any opposed say no. And it is adopted. Members of the any additional business to come before the committee. Thank you for coming in from your various parts of the state and so I will at this point to take into a motion to adjourn represent Pilkington moves which are representive within seconds and all those of favour returning say aye. And we're Jr. Thank you.