ALC-Administrative Rules
Video
Transcript
28 documents
Machine transcript
May contain errors. Verify important quotations against the official video.
About transcript accuracy
- Source
- Whisper
- Model
- ggml-large-v3-turbo.bin
- Processing date
- October 5, 2026
Speaker 1
1:30
the administrative rules subcommittee of the
arkansas legislative council will come to order i'd like to remind those that wish to
comment on a rule to go ahead and sign in be sure to specify the rule on which you wish to comment and then we'll be taking up those sign-up sheets momentarily co-chair any comments
before we get started all right well we'll move into our agenda
first we'll be with at we'll take up item b these are the agency's rules for the month and first up we have at b1 department of commerce state insurance department if their representatives will come to the
table. You may have a seat, and if each of you will introduce yourself,
Speaker 25
2:43
you may present the rule. Mel Anderson deputy commissioner for financial regulation Arkansas Insurance Department if you'll yeah there
Speaker 28
3:15
you go feel Amanda Rose Arkansas Insurance Department associate counsel
Speaker 29
3:18
okay Chris Irwin chief analyst Arkansas Insurance
Speaker 28
3:29
Department all right you're recognized present rule. This is an amendment to 23 CAR Part 9, formerly Rule 15. It's an amendment to our holding company system rule. It's a National Association of Insurance Commissioner model regulation. The companion model law was passed during this year's General Assembly. It's Act 261. The law and the regulation work together to establish new tools for financial regulation
of insurers and that are a part of a holding company group. A holding company group is defined as two or more affiliated entities, one or more of which is an insurer. The models require the filing of a group capital calculation by the ultimate controlling person in the holding company group. There were some formatting changes made, but the substantive change to the rule made by this amendment is the addition of the group capital calculation requirement. Again, that became law this year. The model regulation also provides direction on how to proceed when an insurer in a
holding company system is placed in supervision, seizure, conservatorship, or receivership. Both the model law and this model regulation are national accreditation standards this year. The amendment provides guidance and instruction to insurers on how to comply with the new regulatory tools established in act 261 which will allow for more effective regulatory oversight this rule is necessary to provide insurers and regulators with direction regarding implementation
of act 261 members you've heard a presentation of the rule are there any questions seeing none without
objection the rule is reviewed and approved Thank you.
Thank you for being here today. Next up, we move to item B2, State Board of Election Commissioners.
If you would, have a seat and introduce yourself to
Chris Madison
Unverified
5:39
the committee. Thank you, Mr. Chair, members of the committee. My name is Chris Madison. I'm
Speaker 41
5:45
the director of the State Board of Election Commissioners. Jonathan Kendricks, attorney for the State Board of Election Commissioners.
Chris Madison
Unverified
5:50
Thank you. You're recognized to present the rule. Thank you, Mr. Chair. We have two rules for the committee's review today. The first rule is amendments to the rules on poll watchers, vote challenges, and provisional voting. Principally what the proposal is is kind of gives a little more defining on what poll watchers can and cannot do within the poll.
We had some issues in the last election. There was some confusion about that and some conflict in some polls, so we wanted to define it a little more. And also lay out the lines of communication. If poll watchers observe things that are not being necessarily resolved in the poll, they can contact the poll supervisor or they can contact the State Board. I'm happy to answer any questions about that rule, 7-CAR, Part 91. Any questions from the members?
Seeing none, without objection, the rule is reviewed and approved.
You're recognized to present the second rule. The second
Chris Madison
Unverified
6:40
rule we have is the amendment to the appointment regarding certified election monitors. The state board selects monitors and sends them out to observe the conduct of elections. One of the things we ran into is keeping monitors. And one of the reasons we have a hard time keeping them is we were paying them $100 a day. So they would go work anywhere from 14 to 16 hours, and we were paying them $100. So this basically changes that to $300, plus it defines the training pay, the observation pay, and then the report writing pay.
And with that, I'm happy to answer any questions. Any questions from the members? Seeing none, without objection, the rule is reviewed and approved. Thank you for being
here. Thank you, Mr. Chair. Thank you, members of the committee. Members, we're going to move to item B3, Treasurer of State, Arkansas Financial Education Commission.
Michael Harry
Unverified
7:50
If you would, introduce yourself to the committee. Good morning. I'm Michael Herriam, the Chief Compliance Officer and Director of Government Affairs for the Treasurer of State. All right, you're recognized to present the rule. Our rule is pretty simple. What we did is we took out the requirements and the membership requiring, I guess, DEI requirements. So we're just changing our rules to be in compliance with Act 938. All right, members, any questions?
Seeing no questions, without objection, the rule is reviewed and approved.
Thank you. Thank you for being here. Members, we're going to move to item C, and I would ask, let's see, C1 is Department of Education. And we're going to, without objection, we're going to hold this over for a month. Members, this is a request to be excluded from reporting requirements. And previously, we had granted such requests to the Department of Commerce.
There's a little bit of an issue as to who should write or implement the rules, so we're going to hold this over for a month to see if we can have some further discussion, and also next month we'll have both the Department of Education and the Department of Commerce. So without objection, we're going
Speaker 43
9:17
to push that for a month. All right, we're going to move to C2,
Speaker 56
9:43
Department of Human Services. Good morning, Janet Mann, DHS Secretary.
Speaker 57
9:47
Elizabeth Pittman, Director for the Division of Medical
Services. And just as a reminder for the benefit of the committee and the public as well, in those instances where an agency believes that a rule is not necessary for the operation of a newly enacted law, Act 595 of 2021 allows the agency to submit a written request notifying the subcommittee of its intent to not adopt the required rule and requesting that the rule be excluded from the agency's monthly updates on rulemaking. and so that's
what we're here on and i'll recognize department of human services to present
Senator Missy Irvin
Unverified
10:22
their request thank you sir our request today as we sent a letter in december of 2025 we have one two four acts that were passed in last
Senator Breanne Davis
Unverified
10:34
session that we have indication from our federal partners that we will not be able to implement as passed therefore we feel that we may not be timely or not be able to effectuate some effective dates of 9-1 and 1-1 for certain bills so we sent the letter with the intent to inform y'all as we work through the process of what happens next
did i miss anything if you could could you just go into a little more detail i mean i know you've laid it out in the letter but just for the benefit of of the committee as a whole and the public as well if you could just kind of go through in detail the mechanics of what exactly has happened and what has brought
Senator Missy Irvin
Unverified
11:20
you to make this request. Yes, sir. I'm going to start and I'm going to ask Director Pittman to also add some of the details.
Senator Breanne Davis
Unverified
11:26
So the first act in our letter is 567, which is
the Diagnostic Lab Services Annual Cap Charge for Chronic Pain and Pain Management. CMS has indicated that due to a comparability section of the federal statute, we cannot implement as passed. We're trying to work with them on different options that will still fit, but we just don't know what that looks like yet. It also has an effective date for rules of 1-1, which is why we felt the need to include it in this letter. The remaining acts, 568, 967, and 1025, are all
dental related. They have various components that CMS has given us feedback in writing. I believe we included those letters and emails on those of what some of their concerns were. I believe the largest one was Act 1025, which was dental rate and annual limit increase. They have said that we cannot, due to comparability, cannot create a separate group and pay at a different pay scale and so that leads us to what do we do next they gave us three options
in an email and a letter to consider after meeting with the dental association and others there
Senator Missy Irvin
Unverified
12:45
was a fourth option thrown out that was uh late last week
Senator Breanne Davis
Unverified
12:50
i believe so we are working through that process of what to do and then act 568 and 967 relate to specifically anesthesia and past dental, which one of those acts has not formally been put on RAI, but they have indicated
they have concerns about limiting it to academic institutions. So I'll stop there and ask Director Pittman to add additional details. Thank you. That
Speaker 67
13:18
was very well stated. I would just echo that all three of
Chair
Unverified
13:22
these, A, B, and C, have comparability issues per CMS, the issue primarily being that Under comparability, you have to offer the same benefit and services to all individuals eligible for Medicaid. And we're tying these to a special diagnosis in the case of the diagnostic lab service to chronic pain
or in the case of the dental bills to having a special needs diagnosis or a developmental disability diagnosis. That's the crux of the issue
Senator Breanne Davis
Unverified
13:48
with CMS. They have presented options in the dental area, whereas in the lab area, it's a mandatory service by CMS. you have to offer it to everyone that is eligible for Medicaid, so there are fewer options there. And so that's where we are with CMS in those discussions, and we are trying to work through how to best proceed with all of these, trying to maintain the spirit of the bill and meet the
federal regulations at the same time. Unfortunately, because of those timelines, I don't know that we're going to meet the statutory timeframes of, I believe it was 9-1 for the rate bill for dental, and January 1st for the lab bill, and we obviously won't. We're past all of those deadlines for the lab and radiology bill. And one
additional question, and I know we're going to have a number of questions from members, but you
mentioned that there are three, now maybe four different options that you're looking at, and if you could just help me to understand what those options are,
And then my two kind of sub-questions to that are, are those options, in your opinion, allowed under Arkansas law? And secondly, would they accomplish what is intended by the act that was passed by the General Assembly? Sir, I'll do the best I can to explain some of these. So
Senator Breanne Davis
Unverified
15:06
CMS first, let me say, is very form over substance. So they list all options, even if they... Sorry to interrupt, but I
think that we're probably going to have some questions for the Dental Association as well. and I would want them to be thinking about the same types of questions
so we can try to figure out what's what between the differing opinions on this. Yes,
Senator Breanne Davis
Unverified
15:27
sir. Thank you. So they list all options whether they actually think they're viable or not just because they say this is really an option. So let me start with that. So they gave us three written options. The first one is to create a limit, an expanded limit, for everyone that receives dental services. So in the bill, you said to move the limit from $500 to $1,000 for those with a special needs diagnosis only, adults. We're talking about adults.
They said give every adult in Medicaid the additional $500 and then use medical necessity criteria to determine who can get that expansion and who can't. That, by definition, will mean more people will get it than what you had originally intended in the act, which is going to be a higher fiscal impact than what we had originally anticipated. The second option would be to create a 1915C or 1115 waiver for dental services for special needs populations. There is nothing that would prohibit that.
There's a couple of issues with that. It is a very time-consuming process to do that. So it's about a 9 to 18-month process, depending on how backlogged CMS is, and there is no ability to retroactively apply any of those waivers. So there would be no ability to get a retroactive date for those. it would only be going forward that is something we have a call scheduled with cms to discuss the viability of that option i would say there there are a lot of parameters around that typically with a waiver you have to limit it to those that meet institutional level of care you offer slots you
have to be eligible to get that slot before you can actually receive the services so you you can't retroactively apply those services either there's no retroactive eligibility in a waiver so there's all kinds of limitations on that that we don't typically see in a dental service. That said it is an option we are exploring. The third thing they mentioned and this is the one where I gave you that caveat they even said they don't love this option but what it is is to take your optional dental benefit because we do not have to offer dental benefits to adults. We could create our
entire dental benefit around what we think the special needs population needs. So sedation dentistry therefore everyone would get sedation dentistry based on the medical necessity of sedation dentistry that also doesn't seem like a very great idea in our minds because then we're taking our entire dental population the majority of which do not have special needs and trying to fit them into this bucket of people with special needs so that is the third option it's probably the least um doable so but
Chair
Unverified
17:59
that is the third option that cms offered the fourth option that
Senator Breanne Davis
Unverified
18:04
came out of the conversations with the dental providers and representative mayberry was to actually split the rule into basically two pieces take the rate increase for children and oral surgeons dental services going ahead and move that forward and then figure out the special needs population dental separately in these other
conversations thank you all right so we're going
to go to questions and myself and the co-chair we've agreed to allow non-members to ask
questions but obviously as this goes on there may become a point where we have to rein it into just the membership so I just ask everybody to be mindful of that. Let's see Representative Mayberry you're recognized for a question. Thank
Representative Julie Mayberry
Unverified
18:53
you and thank you for the discussion last week and as you see we came up with option number four so I'm hoping that maybe you had some more information to share on option number four and I'm still kind of hearing just what we discussed last week and so can you bring us up to date how
quickly could the pediatric portion of this be implemented to get at least that part going can you give me more details that is one of
Senator Breanne Davis
Unverified
19:21
the questions that we have posed to CMS about splitting it up how fast we could do that and then the second part of that question is can we preserve the 9-1 date that's what they've not answered us on because when we put out public notice to preserve the 9-1 date and then did public comment on the entire rule if we break it apart we
would like to try to preserve that as much as we can I don't we don't have an answer we have been in contact with CMS back and forth and they asked us who should be joining the call to which option would you like to discuss and we we want to discuss all of them plus this so that's why we don't have any additional follow-up information i do believe you asked us also last week what would it cost if the adult benefit went from 500 to a thousand i do have that an estimate on that today um it would we spend approximately
20 to 24 million dollars on um adult benefits um looking at last year and what has been spent
Senator Missy Irvin
Unverified
20:23
this year and doing some estimates so it would be approximately a 10 to 12 million dollar increase in totality
Representative Julie Mayberry
Unverified
20:32
okay so if i'm understanding if you if you chose option number one and option number one allows us to go retroactive to the september date that was out there allows everything to move
into place but increases the cost by about 10 to 12 million dollars in my understanding that correctly that's the most expedient option that's out there I understand it's a more expensive option but it's the most expedient option that keeps the intent of the bill to preserve higher dental dental rates for our dentist is that am i understanding that correctly i believe
Speaker 85
21:17
so i i'm cautious on most expedient
because it's cms um so that's why i'm hesitant they will
Senator Breanne Davis
Unverified
21:23
still have time to review and comment and what we don't want them to do is completely make us start over okay and if they do make us completely start over with a state plan amendment that's 90
Representative Julie Mayberry
Unverified
21:35
days okay and i do realize 10 to 12 million
dollars is a lot more i think that the original cost we were estimating about 32 million dollars we're talking
Senator Breanne Davis
Unverified
21:43
about a whole lot more yes that would be 10 to 12 million above the a portion of the 32 that would be tied to the pediatric rate increase that i don't have broken
down between the entire bill so it would be more than the original 32
Senator Missy Irvin
Unverified
21:58
million dollar estimate that was given during
Representative Julie Mayberry
Unverified
22:02
session okay so let me let me follow up with this i know at the end of last session we set aside a hundred million dollars for medicaid has that been utilized yet to this point and are there other things that you plan on bringing up in the next month or two that would require us to use that money um so in other words this money is set aside right now can we utilize
Senator Breanne Davis
Unverified
22:30
that money right now to to fill in that gap so to this date we DHS has not asked to access the hundred million dollars that was set aside for Medicaid that process to ask and request that money is actually above my pay grade so I'm going to have to defer on that part we I would have to work with the partners at DFNA and obviously the governor's office on accessing that all right Representative
Speaker 30
22:57
Mayberry, if you have further questions, we'll get you back in the queue if need be.
Okay. Representative Eves, you're good.
Representative Wooten, you're recognized for a question. Thank you, Mr. Chairman. Ms.
Representative Jim Wooten
Unverified
23:13
Mann, as background information, how long has it been since this dental group have had an increase?
Senator Missy Irvin
Unverified
23:24
According to their emails, it's been
Representative Jim Wooten
Unverified
23:27
18 years. 18 years. My question would be, in contact with CMS, did we just make a request, or were we emphatic?
Did we give them factual information and then make a plea that we had to do something to help our dental profession? Yes, sir. I didn't mean
Senator Missy Irvin
Unverified
23:52
to cut you off with your question. Apologies. Yes, sir, we submitted the rule as the act was written. We've had conversation back and forth. We've had ongoing conversations with the Dental Association. We started getting questions during the 90-day time period that they have to approve a state plan amendment. And early December in email, we found out they were not going to approve it.
They made that official either December 8th or December 15th. So, yes, sir, we tried to enact what was passed to get it implemented. It had an effective 9-1 date. We put it out for public comment the day before, which is required with CMS because it would have a rate increase. Then we also put it out for public comment for the entire rule as required to implement a state plan. So we did, in all good faith effort, put that rule plus these other rules plus our other rules out.
Representative Jim Wooten
Unverified
24:49
Yes, sir. follow up if i may with with cms did they how quickly did they respond um i will jafar
Senator Missy Irvin
Unverified
24:58
to director pitman so during conversations we
Senator Breanne Davis
Unverified
25:01
we had early indications there were going to be some issues it took quite a while for them to put those issues back in writing to us formally so that we could actually see our options and understand the issues so it
Representative Jim Wooten
Unverified
25:15
was quite a while yes sir before cms to send it back yes sir well what about the waiver
is that a is that a viable alternative it
Senator Breanne Davis
Unverified
25:26
is a viable alternative it just takes longer to get it approved and it would jeopardize the 9-1 date of the of some of the rates and so that was one of our concerns that we can't we can't honor the 9-1 date so we needed to inform this body did i
Representative Jim Wooten
Unverified
25:44
understand you correctly it takes 18 months to get a
Senator Missy Irvin
Unverified
25:49
waiver yes sir it can take anywhere from 9 to 18 months depending on their backlog there's a lot of
Senator Breanne Davis
Unverified
25:56
public comment period at the state level
and the federal level that takes approximately 60 additional days and then they can take up to six months to a year to review any type of waiver so um we in our past experience we've had waivers pending for multiple years so um we're just trying to it i would love to say that we could do
Senator Missy Irvin
Unverified
26:19
it faster i just can't guarantee it representative we'll let you
get back in the queue we've got a few people lined up here i'm gonna go
to senator ervin you're recognized for a question thanks
Senator Missy Irvin
Unverified
26:31
thank y'all um so back to what um representative shepherd was talking about the language and
the legislation so on option four does the law that we have passed allow for what you're talking about to split and go forward with part of it but not the other part putting my lawyer hat on yes i believe we could sever severability
Speaker 75
26:53
under the the language of severability we could treat the provisions
Senator Breanne Davis
Unverified
26:58
of the law differently and going ahead and move forward with the rates so we are looking
at that the main issue is will cms allow us to use the public notice we've already done for that rate increase to get back to the non-1 date and that's kind of what's pending with cms right
Senator Missy Irvin
Unverified
27:14
now and the part of this bill though that you said could go forward was the um which part the pediatric one the pediatric rate increase for
Speaker 101
27:21
children's dental services and then the i think there's a provision to raise for oral surgeons dental services is the
Senator Breanne Davis
Unverified
27:27
language of the bill yeah oral. That's what I'm looking at. Those two pieces. I'm not entirely, we don't, are not sure
about the language around special needs dental rate increases, but that's again, tied to a diagnosis. So that would need
Senator Missy Irvin
Unverified
27:41
to be fleshed out with CMS as well. Yeah. Cause you can't do carve outs. Right. Okay. So, um, on, uh, so, so what you're saying though, is you could say dental services for adults um that we would be able to pay for anesthesia services for all adults for all adults yes ma'am but clearly some adults would need it other adults wouldn't but there's no way
to just limit it to people with special adult especially correct you can't tie it
Senator Breanne Davis
Unverified
28:17
the category you can't tie it to that diagnosis you can tie it to medical necessity criteria okay but that is
Senator Missy Irvin
Unverified
28:25
by definition going to be broader than a diagnosis. Okay. So you could do medical necessity. Is there any type of a process where currently we're allowed to, uh, authorize that, uh, service with an existing Medicaid patient? Is there a process that you could? Yes, ma'am. We're using
Senator Breanne Davis
Unverified
28:46
a single, it's called a single case agreement process right now. We're doing it primarily with uams we have done it with a few other dentists okay but it's primarily being done with uams where we enter into an agreement for that particular patient medicaid client primarily special needs and then they do the dental services for them for beyond the dental limit okay okay so so in
Senator Missy Irvin
Unverified
29:05
order for that we would just need to change the legislation we're doing that now with with uams and we also have done it with another but
Senator Breanne Davis
Unverified
29:14
i'm talking about this bill yes ma'am right this bill
Senator Missy Irvin
Unverified
29:18
we would need to rewrite this bill to allow for the existing process to occur. Yes, ma'am. But that could or could not have a fiscal impact. I mean, initially you would have a fiscal impact that assumes that every adult would then get sedation, but that's an, you know, I guess that's the only way you would be able to calculate that fiscal impact. Is there a different way to calculate that fiscal impact? I don't know. I mean, that's just something to think through. You don't have to answer. On the other one, and I just want to make sure I'm understanding this correctly,
with the Diagnostic Lab Services Annual Cap for the Chronic Pain and Pain Management, is that another case where we're creating a carve-out based on a diagnostic code? Yes, ma'am, because it's tied to the diagnosis
Senator Breanne Davis
Unverified
30:05
of chronic pain management. And they're not offering, the only option there is to give everyone a limit increase or do nothing, Because it is a mandatory service, so we can't offer it in a waiver or anything like that. Right. Okay. Okay. All right.
Chair
Unverified
30:22
Thank you. Representative Johnson, you're recognized for a question. Thank you, Mr. Chairman.
Representative Lee Johnson
Unverified
30:29
So a couple of things. On the 1025, the cost that you're talking about, man, it seems like I'm talking really loud. That feels really loud, man. So, like, the 1025, I'm understanding you're saying it's an extra $10 million, $10 to $12 million estimate on top
of the calculations for the pediatric extra costs. Is that right? That's just based on raising the cap for every adult, right?
The way I read that bill, that bill doesn't carve out any special needs. Well, it does, but what
you're saying is we can't carve out special needs, so the only way to accomplish the bill would
Senator Breanne Davis
Unverified
31:04
be to go from $500 to $1,000 for every adult. Yes, sir. That was one of the questions we were asked last week when we were meeting is, what would happen if the entire adult population went from 500 to 1,000. So we did ask our finance and our data team to run what was spent on adults only for SFY-25 and then up to last week for SFY-26.
And so we took that, annualized it, and came up with that estimate of what would happen if we doubled it. So that was a rough estimate. Yes, sir.
Representative Lee Johnson
Unverified
31:35
To be clear, that doesn't have anything to do with sedation dentistry. that's just dental costs for adults correct right so so if I look at the other two bills 568 and 967 those are the other two bills once the pass and once the if I understand your issues with those I guess I don't understand the issue with one of those but one of those the issue is by they don't like that we want to send them just to dental schools academic institutions however we define
that yes sir that was one of the problems that doesn't have anything to do with
Chair
Unverified
32:07
special needs or adults or that's just this dental school issue so that bill i think i can't remember the number i think it's 568 yeah yeah i believe you're right and that bill had two distinct issues per cms and we never formally submitted that to cms full transparency we were having the conversation around 10 25 i mentioned that bill to them and they preliminarily told me it was going to have problems uh to be two specifically one being because you were giving the extra 3750 to individuals with special needs or, and I am terrible at saying this, cranio, maxill, facial.
Representative Lee Johnson
Unverified
32:35
I'm not sure that's what we did in that bill. So we define high complexity dentistry or something like that. We
created a new definition within that act around high complexity. Now, special needs was a criteria
of that definition, but there was also all these craniofacial
Chair
Unverified
32:50
things, right? Yes, sir. And because it was tied to those two things, they did indicate that would probably be an issue. They also indicated it was a freedom of choice issue among providers if you limited it to only academic medical institutions and so that we would need in that case basically a 1915b waiver
to say you can only go to these certain providers yes
Representative Lee Johnson
Unverified
33:10
that that issue seems easy to me i mean that's that's an easy issue i mean the reason that came up in the session because these were the people
that raised their hands so they were willing to do it right i don't i don't think you're going to see a flood of people raising their hands saying hey we're willing to do this work so i think that issue is easily solved you just say okay everybody can do it i don't think the fiscal impact for That's tremendous because, again, the reimbursement compared to the pain of the process of providing the care is not going to balance out. You're still going to have the same people doing it.
I guess I'm getting back to this idea that we were adding a definition around, and I forget the exact words, high complexity. And then I think if you look at the other bill, the 967, all we were doing there is we went in the PASS Act and we added a definition of sedation dentistry. And we opened up that for claims. What was CMS's issue with that
Chair
Unverified
34:00
act? I don't know that they had an issue with that. With that one, we've actually put it into the past contract
Senator Breanne Davis
Unverified
34:07
today. We've implemented that today, that they cover sedation as part of the dental.
Chair
Unverified
34:12
And so they don't have an issue with that one?
Representative Lee Johnson
Unverified
34:18
The CMS doesn't have an issue with that? No, they don't have an issue with us putting that in managed care, sedation dentistry. So is there a definition of sedation dentistry in our Medicaid act or whatever? Wherever we put in this high-complexity definition, I guess what I'm getting to is, like, we've created this definition of sedation dentistry, and we've said we're going
to have a charge for sedation dentistry that's within the passes. Do we have something similar to that within fee-for-service Medicaid?
Chair
Unverified
34:45
I don't – I mean, we offer sedation dentistry to anyone in Medicaid that needs it up to our limit.
Representative Lee Johnson
Unverified
34:53
You do that to medical necessity? And I don't want to get down in the weeds, but what I'm trying to get to is, like, if their issue is with, like, we're parsing out special needs in the adult in 1025 to some degree because they require sedation. A lot of folks with these issues require sedation more complex, right? And if CMS doesn't have an issue with us creating a different fee schedule around sedation dentistry, it feels like there's a way to create a separate fee schedule, right,
that would be fine for adults. You mentioned medical necessity. I mean, we have that ability within DHS to say who qualifies medical necessity for sedation dentistry, right? It feels like that's a way to maybe get to this in a cost containment way that doesn't single out special needs adults, any adult that qualified for sedation dentistry. And the same way with this high-complexity care. just is that something you think we could look at is that yes i do i do think
Chair
Unverified
35:53
we can look at it and
that is we we are actually meeting with finance to talk about how we could look at this differently um i think it becomes how do you define medical necessity and like i said it's by definition going to be broader than what you put in the act because it's going to be anyone that qualifies not anyone with this particular diagnosis but you don't
Representative Lee Johnson
Unverified
36:11
have an idea of the cost if we were to just limit it to say sedation dentistry as opposed to open it up to every adult
Representative Jeremy Wooldridge
Unverified
36:17
no we haven't looked at that yet okay that's what the meeting we're we're going to set up is about okay thank you
Speaker 157
36:25
appreciate it representative woldridge you're recognized for a
Representative Jeremy Wooldridge
Unverified
36:27
question thank you mr chair um my question you
i remember us talking about this in committee and you said a while ago it's been 18 years since our dental partners have had a rate increase so it's my understanding that currently or i think i remember this correctly from committee that less than half the dentist in the state will see the medicaid population client so if this rate increase doesn't go through and that diminishes even further what's DHS's contingency plan to get dental services to this population if we if we don't have any dentists in the state that are willing to continue to provide the service I'm not quite sure I know
Senator Missy Irvin
Unverified
37:02
how to answer your question because I don't know about 50 percent
or less that are seeing Medicaid
Senator Breanne Davis
Unverified
37:08
patients I don't have those statistics to be able to answer that part. I will say that we did transition dentistry out of managed care and back to fee-for-service late last year, I believe it was November of 24, and we have seen those expenses continue to be level and grow. We've not seen anything diminish. And then to expand on the 18 years,
they were in managed care for seven they also have had at least two
Senator Missy Irvin
Unverified
37:47
to three rate in rate reviews the most recent rate review showed approximately three to five codes that would need to be adjusted to be in the
Senator Breanne Davis
Unverified
37:58
averages of other states so while there's one school of thought that it's been 18 years since they've had a rate increase we have done the rate reviews to show that in previous
years they have been in line with other surrounding states also removing the managed care removed and administrative level that now we are spending on being able to spend on paying claims and so i i will just leave it at that okay um i guess i'll
Representative Jeremy Wooldridge
Unverified
38:29
clarify that i appreciate your response and i'll clarify that maybe with the dental association if they come up to testify but I guess my understanding I've visited with with dentists around the district that I serve and that's my understanding that there is a diminished group of providers that are willing to continue to see
that population and I just have concern that if this rate increase isn't implemented as the legislative body passed it the governor signed it that that would probably shrink not grow but Thank you, Mr. Chair. Representative
Chair
Unverified
39:01
Eaves, you're recognized for a question. Thank you, Mr. Chairman. This may
Representative Les D. Eaves
Unverified
39:06
be a question to you, Mr. Chair. We got a letter apparently from a law firm, and it's probably the same or similar letter that we got from the Dental Association. There's two paragraphs that I wanted to kind of reference here.
It says, CMS's December 15 correspondence does not conclude that Act 1025 is incompatible with federal law. To the contrary, CMS's comments reflect routine, SPA review concerns, and identified specific compliance issues with the proposal as submitted that may be remedied by DHS. There's another paragraph that says, critically, CMS did not state that the underlying policy goals were impermissible. Instead, CMS expressly referenced alternative approaches, including medical necessity-based benefit structures and waiver authority as potential pass to compliance.
taken together. The CMS letter supports the conclusion that sufficient and lawful pathways exist to obtain federal approval of the act's changes if pursued through appropriate mechanisms. So it seems that the, if I'm reading that right, the Dental Association and this law firm have a different opinion on what's actually happened here. So, and you mentioned earlier that we may get the Dental Association or someone to come up. So at the proper time, I'd like to ask them some of those questions or at least respond to
those two paragraphs. Yes, well, we have asked them to be available and to answer questions,
and so we'll bring them to the table at some point in this process. We still have a few questions here in the queue. Senator Dismang, you're recognized.
Senator Jonathan Dismang
Unverified
40:38
Thank you, Mr. Chairman. And really it's just about the precedent of where we are, right? I mean, so there's oftentimes we will pass legislation directing DHS to do something, And that's how we get to the end result, you know, that the legislature wants as far as policy direction for DHS.
And during the session, on many, many issues, members were begging from input from DHS about why this – different items, not just this particular area. Certain things may work or not work or their cost may be higher or not higher and that sort of thing, in which DHS did not really provide much of any information or engage on a number of different issues. My concern is we've got through the process. There's a bill that's passed and we're saying, you know what, despite the bill, we don't want to run the rule. I appreciate you not saying
it. It's better than letting it drag out and never running the rule because I've experienced that for two years before, not too long ago. And I think it was because DHS didn't want to implement the rule regarding the law that I had helped pass in the legislature. So I get there may be problems and that CMS may say no, and maybe there's things we don't understand, but if we're not even going to attempt, then I think it's going to be an issue for future issues, you know, future policy issues that we may have that we're requesting or demanding that, you know, that y'all
take a particular action so i guess historically my question is i mean how often do we say you know what we're just not going to run a rule in relation to a law that was passed by the general assembly i
Speaker 93
42:21
don't know yes sir i don't know that we get
Senator Breanne Davis
Unverified
42:25
that option we have to implement the acts we can't implement the act currently as the law was passed with an effective date of 9-1 And during session, we did testify about this bill that it could have issues with CMS.
We also testified about the lab and diagnostic that we felt that CMS could have issues with implementing this. So really with having to implement all the rules, and it takes a year for us to implement rules sometimes to get them through. Or two, or longer than that. Yeah, I'm very well aware of that one, unfortunately. But we, I guess, I didn't want to get to June and say, oh, by the way, this is causing an issue.
We're pivoting and doing this. We worked with CMS, tried to implement what was passed, and when they said no and had to say it formally because we could not work it through the 90-day process, they took it off the clock, DHS felt the need to inform you all that we're probably going to have to pivot, and it may take longer than the 12 months to implement something. And I can't guarantee, or DHS cannot guarantee, excuse me, that we can effectuate the 9-1 date or the 1-1 date.
So really, DHS was trying to come out of an abundance of caution for the rules is why we sent the letter in December to the Rules Committee. But
Senator Jonathan Dismang
Unverified
43:54
the goal is still to have full implementation of the law? Yes, sir. In the rules, you're just going to
Senator Breanne Davis
Unverified
44:03
think if we have a conversation with CMS and we can do the severability, the question is can we keep the 9-1 date for the rate increase without having to start over while we pivot to the waiver for the special needs?
That's one question. And then the other option at the very first option was could we do something else, which I don't remember right now. I apologize. But a waiver will never have a retroactive date. DHS will never be able to honor the 9-1 date. So if we can break it apart and try to honor that 9-1 date if CMS will allow it and then move forward on the waiver, that's one option. Then the first option, which I'll defer to Director Pittman to bring up again, hopefully we will be able to honor the 9-1 date.
Speaker 125
44:49
Okay. That was applying the increased limit to the entire population with medical
Senator Breanne Davis
Unverified
44:54
necessity criteria I think the only issue there for for the 9-1 date would be if we have to redo so the 9-1 date is related to the rate page when you change a rate you have to put it out for public notice for the providers to comment on so we have to put it out at least a day before the rate takes effect if we have to change that rate page we may lose that 9-1
Chair
Unverified
45:14
effective date for that other than that we should be able to preserve it that's the conversation we intend to have with
CMS representative Johnson you recognize for a question thank you
Representative Lee Johnson
Unverified
45:28
mr. chairman just to clarify so it does look like you're asking for the ability not to promulgate rules on four different acts one of them I don't think there's a
problem with I'm just trying to clarify that 967 which is the one where we define sedation dentistry in the past act and then now I tell you telling me the password do i don't know that we need rules we don't need rules that's just some questioning it's in this packet so for clarification's point we don't need to do anything on that one people the the people that are in the passes right the people that are on the the waiver right
now they are open to get sedation dentistry services from anyone in network with any of the passes willing to provide the services for adults kids anyone with special needs that qualifies for the waiver can get those services through the passes right now yes sir we've defined
Chair
Unverified
46:21
uh sedation dentistry in the past agreement what they will cover what fee for service covers all of that has been outlined in the past agreement and we
Representative Lee Johnson
Unverified
46:29
don't need a role to implement that from a population standpoint when
we're talking about in not in 1025 adults with special needs what percentage of
those adults with special needs are, I mean, how many people do we have outside the waiver in that population? I have that number not
Chair
Unverified
46:48
on me today, Representative, but I have pulled that for this purpose because we initially planned on using the pass to define that and then realized there's a group of adults that actually have special needs that are attending our adult day treatment facilities that are not in the pass. And so I have run that number
Representative Lee Johnson
Unverified
47:07
and I can get it to you. It just feels like the
sentiment of the General Assembly was to provide dental care for these people with special needs, right?
And it feels like that is a higher-intensity service than the average adult in Arkansas needs for dentistry. And it feels like that was surrounded by this idea of sedation dentistry. And we already are doing that now for a large percentage of the population of Arkansas through the passes, if we have providers willing to do it and network with the passes, right? So figuring out what that extra population is and can we get them into the passes, right? Is there opportunity to move them in? Because it sounds like we're in good shape in the passes. Is there opportunity with that small population to define something like sedation dentistry and reimburse for that differently?
It just feels like the cost doesn't have to be we raise the bar to every adult in Arkansas. Not that I'm not for that for my dentists out there, right? Like, I think all of the providers in Arkansas and the Medicaid space are looking for increased rates across the board. I'm not saying you don't need a rate increase for adults across the board. I'm just saying it feels like we're making this more complicated, possibly, than we have to. And certainly, you know, estimating costs at a higher pace than I think we maybe need to. All that said, I have one more question about the cost.
If we did just go with the simple idea of we're going to raise adult rates for everyone from $500,000 to $1,000, That extra $10 million, that's future cost, right? I mean, what fiscal year would you anticipate those costs hitting your budget? If everything, if you went ahead with that process, that extra $10 million, when does that, when are you going to have to start paying claims on that? If
Speaker 101
48:53
I think it would be April or May of this year would be earliest.
Representative Lee Johnson
Unverified
48:56
So almost at the end of this fiscal year,
right? And I'm assuming that would be a ramp up. So most of the costs that you would incur would be in the next fiscal year. And I think we as a legislative body will have an opportunity in the fiscal to decide whether that's in the budget or not, right? I mean, that's our responsibility as legislators. So if it's our intent and we want to raise adult dental rates, we don't have to necessarily dip into the $100 million Medicaid set-aside. We could put that into the next fiscal budget.
Is that, I mean, that would be a logical way to pay for this as well. I think that would be up to y'all. Right, right. But if we did that,
necessarily dip into the, okay. Just making sure I understood all that. Thank you. All right. Members, we're getting
back into, I think most everybody's had an opportunity to ask a question. We're going to bring the Dental Association up just momentarily, and then we'll bring DHS back up. But before DHS goes for their break, before we bring them back, you know, one of the things that as I look at this, there's kind of the practical elements of it as far as what was intended and the benefits to be provided.
I also have a concern just from, and Senator Dismang, I think, touched on this as well, is like at the end of the day, we passed a law. And so when you look at these four acts, I think there's four acts that are implicated by this discussion. They're relatively short. Now, I understand that it's changing definitions, which ends up being a much bigger issue. But just quickly, I just want to walk through each of these.
And if you could, just give me just the kind of the short answer of what the issue is. Now, I think that what I understand from Representative Johnson's question is Act 967 concerning the definition of sedation dentistry, that can be implemented. That is something that you can implement. You can promulgate rules to take
care of that. No? We don't need
Chair
Unverified
51:07
rules. We have implemented it through the PASS agreement by defining sedation dentistry inside of the PASS agreement.
okay so so you can comply with 967 yes sir all right and have okay
good so then that leaves three acts so there's uh let's see 567 which relates to diagnostic lab services and it just it changes the dollar amounts and then it has uh basically you're supposed to codify rules so what is the issue with being able to implement this that
Speaker 155
51:37
is the comparability issue um it's lab services are a mandatory
Chair
Unverified
51:41
service by cms every medicaid state has to offer them and because we're tying the
Senator Breanne Davis
Unverified
51:46
increased limit to a diagnosis of chronic pain management it violates the comparability provision
of cms okay so that's that's the issue with
that yes sir so then we go to 568 this is uh relates to high complexity oral health care it provides a definition of of what a provider is i think representative johnson asked about this and uh it provides additional language related to the reimbursement rate so what's the issue with this act there's
Chair
Unverified
52:16
two issues with that act cms is say
stating that we are tying to a diagnosis uh based on special needs and craniofacial max i can't say that word but
Senator Breanne Davis
Unverified
52:25
the the disorder the craniofacial issues and then the other issue is limiting it to a certain provider okay academic medical centers okay
so that's the issue with that yes sir all Right, and then finally, 1025, this relates to adult with special needs dental services cap, and it provides for an increase in the reimbursement rate.
Chair
Unverified
52:48
Is it a similar issue with that? Yes, sir. It's tied to the limit being increased from $500 to $1,000
for a special needs diagnosis. And so one of them can be implemented. It is implemented. Yes, sir. Three of them you have issues because of what CMS will or won't allow. Yes, sir. And then you also have a timing issue as far as trying to work out if there's another way to accomplish that. And so it becomes, I mean, some of the comments I'm hearing from folks are like, you know, it's almost like picking, do you violate the law from a timing standpoint?
Do you violate the law by not implementing? But I think it was important to look back at the acts, because at the end of the day, that's what, no matter what everybody's intent was, this is what we passed. All right. I'm going to ask the Dental Association to come to the table, and then we can bring DHS back to the table after their time. So if they'll come forward and introduce themselves, and I believe we have some questions for them.
Billy Tarpley
Unverified
53:59
Chairman Shepard, Chairman Dease, members of the committee, my name is Billy Tarpley. I'm Executive Director of the Arkansas State Dental Association and have been for 29 years. I have asked our attorney, Trevor Hawkins, and also attorney, Jaden Atkins, to join me here. It was Trevor and Jayden who prepared the letter that was referenced earlier in which we tried to make it clear that the Dental Association believes that there is a path forward to implement Act 1025.
I can't necessarily speak to the others, but certainly on Act 1025. And I think to try to bring a little more clarity to it, that act very clearly had two separate components to it. One was an increase for Medicaid fees for the pediatric portion. So when we say pediatric portion, that means age zero to age 21, which is more like 18. But that's the pediatric portion. That is the regular routine dental care that you receive as well when you go to the dentist.
So that's one component. The second component dealt with setting a separate cap for dental services for regular adults versus special needs adults. Throughout this last legislative session, it was very clear that there was an interest among legislators to do something for our special needs population. And that's where the separate cap came from. Now, the adult program, it is true, Arkansas or any state does not have to do adult Medicaid.
Well over half the states do. In fact, only a very few do not cover adult in some form. We have not a comprehensive plan for adults. We have a very limited plan for adults. When this program was written back in the mid-2000s, it was written without input from the Dental Association, and it's continued to be problematic. but you know what that that's the program we have we tried to to work through that to make it better but separate and apart from that issue it's been our understanding that DHS has not moved forward
on implementation in fact they've even asked you for permission not even to come talk to you about it but they haven't moved forward on act 1025 because of a potential hang-up on the cap for adults without any reference to the regular Medicaid, which is going to affect the large number of dentists who work and function in your communities. So at any rate, when we saw the letter from the secretary, it very clearly to us said, we don't only want to be released
from coming to report to you, but it clearly says DHS does not intend to adopt rules for the identified acts, just not going to. So what that said to us, alarms were going off in our head and our phone was blowing up from dentists who were saying, wait a minute, I'm prepared, I'm willing to stay in the program if this fee increase comes along because I can't continue to go broke doing Medicaid dentistry. So that became a hot-button issue for all of you. So having said
that, I'm departing for my regular remarks because we have heard information today from DHS that has not been delivered to the Dental Association. In fact, we had to reach out to DHS to find out anything we didn't even know they had contacted cms until we asked that in early december and we were told well yeah they don't like some of it so uh senior administration is going to talk about what next steps are without any input from the dental association at all do they have to reach
out to the dental association they don't have to but boy howdy look at this dog and pony show we're all having to go through when this could have been worked out before the legislature even convened We asked DHS for a formal meeting, a roundtable meeting, legal, and everybody else was there to say we have a big problem with our dental fees. No matter what you may hear from surrounding states, we have a big problem, and we're reaching a potential critical shortage situation.
So at any rate, we did our best to work within the agency. We only came to you when it became obvious that there was no other option for dentists to try to say, we're trying to save this program. Remember, dentists are the boots on the ground in Medicaid dentistry. It's none of us. I'm not a dentist. I don't do dentistry, but dentists are the boots on the ground. They are the engine that drives this program in all dental care in the state of Arkansas. They were the ones who were coming to say, we have a problem, and we need to try to solve that issue.
So, Mr. Chairman, if you don't mind. Well, I think we already have some questions. I'm going
Senator Tyler Dees
Unverified
59:18
to recognize the co-chair for a question. Yes, sir. Thank you, Mr. Chair. And thank you for being here today, and thank you for your opening comments. Just two quick questions for you. And, Billy, I forgot your last name. Tell me your last name. Tarpley. Tarpley. Yes, sir. Thank you, Mr. Tarpley. So you just mentioned that you reached out to DHS asking for a roundtable, discussion on rates. When was
Speaker 192
59:39
that, roughly? That was months and months before the legislative session.
So before these acts were approved? Oh, yes, sir.
Senator Tyler Dees
Unverified
59:46
Okay. Absolutely. Thank you for that timeline. And then going
back to your response to the CMS response to DHS, has the association submitted their recommendation for the rulemaking on these? Have you submitted in writing, case in point, what you believe would allow DHS to comply with the statute and to comply with CMS concerns?
Billy Tarpley
Unverified
1:00:15
Have you sent that to DHS? Yes, sir. We did that through Mitchell Blackstock Law Firm, who Trevor represents. So in his comments to Secretary Mann, it was addressed to Secretary Mann. And has DHS responded to your recommendations? Not to our knowledge, no,
sir. Okay. Thank you. Yes, sir. So I have a question, and you all were here during all the questioning of DHS, And you heard, I think, my initial question I referenced to ask that you guys be prepared to answer as well.
So you've heard that there, I guess, are four options or three that were referenced by CMS, one that I think has been discussed with Representative Mayberry and with various stakeholders. So can you tell me, is there anything you disagree with how DHS responded to that? And if so, can you identify what that disagreement is and what's the basis for how you feel differently? Mr. Chair, if
Speaker 199
1:01:11
you'll allow, I'd like Trevor to answer that.
Speaker 200
1:01:16
Thank you all for, excuse me, this weather's got my allergies all messed up,
but I thank you all for being here. And the broader context of this, the reason we're here today is to stress that Act 1025 is workable. And we're willing to put our name on that. We're going to help or willing to help DHS in getting through that and implementing policy changes in Act 1025. Now, this sort of discussion about options and what to pursue conceptually
from the day that Act 1025 was signed by the governor, there's two overarching things there, the rate changes and then the cap change. DHS is given the mandate from the General Assembly to pursue whatever mechanism they can federally to get those two things approved. And so there's branching logic or options to enact each two separately. But what they chose to do here is implement them as one ball, you know, one group to CMS.
They submitted that informally to them and just got some routine feedback questions. Hey, what about this? Hey, did you consider that? There's nothing in the letter to CMS that says anything that they've refused to approve any of these changes, nor is there anything in there that says that the intent of Act 1025 can't be effectuated. I think here, you know, hindsight's 20-20, they should have pursued them separately.
They should have done the rate change first, separately as an SPA, like they did. And that's what they've indicated to y'all, that they're trying to pursue keeping that that way so that they can keep that September 1st date. The comparability issue that they mentioned, that's lumped into the rate cap, the $500 to $1,000 increase. That doesn't apply to that first half. That's the one where there's room for us to discuss and figure out what the root is.
In my opinion, kind of high-level looking at it, it's either working through a medical necessity option or an 1115 waiver. That gets rid of that comparability requirement. It doesn't apply there, so CMS wouldn't reject that. And they said in their letter, which was attached as an exhibit, I think it was important for you all to see CMS's letter and that there's not anything in there that says, hey, you know, we're not going to approve this.
We need follow-up. And the truth is the reason CMS sent this letter in December 16th is because they were asking these questions in October and never got a response as far as we can tell. And so they had to send this formal response asking for these follow-up questions, and this starts a 90-day clock. If DHS doesn't respond to this formal letter December 16th, they've got through March 15th, CMS just quits considering these things. And so that's why we're here today pushing for continued oversight and accountability, that they continue working forward, respond to CMS, effectuate these changes.
Speaker 202
1:04:47
and we're willing to help in any way we can.
Senator Irvin, you're recognized for a question.
Senator Missy Irvin
Unverified
1:05:04
Hold on, let's see. There you go. All right, thank you. On the issue as it relates, I have several different ones. on
act 967 um i think what was said by dhs was that it was tied to an academic institution
and so that's why that one could not be implemented um under what cms replied can you respond to that senator i wish i could uh we we were not
Billy Tarpley
Unverified
1:05:30
part of um the inner workings of that but dr ashley mcmillan from the lyon college of dental medicine is here if you wanted to ask that question specifically yeah i
Senator Missy Irvin
Unverified
1:05:41
do we we can come back to that but i do want to talk about that because when you're talking about high complexity um dentistry it's only going to be you're not going
to be able to do that in a general dentist's office i mean you're going to and i think we've got to understand what we're talking about here these are uh cases where you absolutely have to sedate somebody and perhaps even put them to sleep in order to do the dental care that's necessary. So that's most likely, and correct me please if I'm wrong, but what are the necessary physical things that you have to have in your dental office to be able to do that? Do you have
to have an anesthesiologist or a CRNA to do that? Do you have to have an operating room? Are there specifics about sedating a person and putting them under general anesthesia um within i would just say a clinic for dentists that you answer that that would
Billy Tarpley
Unverified
1:06:45
practicing dentist and okay and i'm not one but that but but we actually have a general dentist and a pediatric dentist here in the audience and either one of them may be able
Senator Missy Irvin
Unverified
1:06:56
to answer that along with dr mcmillan okay so i mean i know oral surgeons obviously do this because they have to sedate and put you under when they are removing wisdom teeth, things like that, and doing oral surgery. And I know that what I'm getting at is really trying to understand the true fiscal impact of these types of situations outside of academic. I would love, because not everybody can travel to an academic institution, and I know that they're already doing this, so I'd love to hear from them about that.
And then I'm going to move to my second question. So if that's allowed, on the issue, so you're specifically asking for DHS to continue to pursue a rule on specifically Act 1025 of the portion where there is no issue. Is that your ask?
Billy Tarpley
Unverified
1:07:52
Our ask is twofold. That's certainly the first part, to go ahead and move on the pediatric portion of Act 1025.
Separately from that is the, we understand that a waiver could be required for the special needs portion in increasing the cap to $1,000 versus $500 for everybody else. Totally understood, which is why we wrote into the bill the need to file for a waiver or any other instrument of assistance to be able to secure that. But there's no reason DHS can't act on the pediatric portion and then deal with the waiver for special needs as a separate issue.
Speaker 200
1:08:33
Okay. Is that accurate? Yeah, both parts of Act 1025 are workable, and there are meaningful paths forward to pursue both parts. It's just one might take a little bit longer than the other, and that's hard to say. CMS, under the previous Trump administration, was actually really quick at approving waivers 1115 and so it's dhs needs to do everything at the state level they can to get it approved and then cms that's out of our hands you know but there are things that they can do to pursue both parts of it it is entirely workable as written
Senator Missy Irvin
Unverified
1:09:08
okay so i'm just trying to understand our action here as a committee um and mr chair you might be able to talk through this with me but um are we the action that we have before us what are our options to accept the letter or do we can we make an action that reflects pursuing and directing one of the options um what what's our that's what i want to know
so as i understand it they've dhs has made a request
under act 5 595 to be excluded from the rulemaking requirement we have the authority to exclude them from that rulemaking authority. And so, I mean, that's simply would be the question. If there is a motion to exclude them and that motion passed, then they would not be required to promulgate rules. If, if that motion
were to fail or if there was no motion, then the, the law, they still are under the obligation to, to promulgate rules consistent with, with, uh, with Arkansas law. Okay. All right. Thank you. I may have
Senator Missy Irvin
Unverified
1:10:28
questions later, but thank you. And those rules
promulgated would come through our committee through the normal rulemaking process. Representative Wooldridge, you're recognized for a question. Thank you, Mr.
Chair, and thank you all for being here.
Representative Jeremy Wooldridge
Unverified
1:10:47
Same question that I had asked DHS earlier. It's my understanding after visiting with the dentist in the district that I serve that less than half the dentist in the state are currently accepting medicaid patients i guess i wanted to ask is that your understanding is that accurate not accurate are there more than that less than that yes sir
Billy Tarpley
Unverified
1:11:08
thank you for that question that that is our understanding the uh at one time the last figure i saw was 64 percent but that was pre-pandemic and every year that that number has declined because of the increased cost
post-pandemic of providing dental care for everybody not just medicaid patients because Medicaid gets the very same care, quality of care, that regular private pay patients do. But probably the simplest way, and this may sound a little trite, it is not meant to be trite, but probably the best way to answer that question is to call the dentist in your district and ask how many of them are Medicaid providers. And I think the answer will be shocking. I really think it will be, not because they don't want to be,
But because there's a certain amount of margin in any business at which you can say, I'm willing to break even or even lose a little money, there is a humanitarian issue to this. And that's why dentists have remained in the program so long after an 18-year drought without any increase at all. In a perfect world, there would be a built-in annual increase. So we don't have to come back and do this all over again. And dentists don't want to come and bother you.
They just want to take care of patients and take care of their staff and take care of the practice and keep moving on. This has been an unnecessary interruption in their time and your time. It didn't have to be this way. But, yes, sir, it's our understanding it's less than half. Well,
Representative Jeremy Wooldridge
Unverified
1:12:40
I appreciate that response. And I guess my one small follow-up question, if allowed, Mr. Chair, would be that it sounds to me based on your testimony that that there's been an effort for a collaborative relationship between the association and DHS you feel like that maybe
that's been one-sided or not reciprocated but I just want to know on the record you are willing to work with the department on behalf of the dental association to figure out a way for us to move forward with this because ultimately I think we all share the same concern that we want our Kansans to be able to receive access to the treatment and to the care that they need especially in rural parts of the state where, you know, dentists aren't on every corner. So I just want a commitment from you all that you're willing to work with DHS to find a way to move forward. Absolutely. Yes, sir.
Representative Jim Wooten
Unverified
1:13:26
Representative Wooten, you're recognized for a question. Thank you, Mr. Chairman. I want to pursue Representative Woolridge's question. Are you telling us that 64% several years ago accepted Medicaid patients, but today the percentage has decreased to the point where that half of
the dentists in Arkansas are not taking Medicaid? Yes, sir. Did I understand that correctly?
Yes, sir. That's our understanding, yes, sir. Okay. And you contacted DHS, you said several months before the last session, So in 2024, it's several, would be several months. In 2024, you made contact with DHS and explained to them the problem that dentists
were facing in the state. Correct. Yes, sir. That's correct. And that's correct. Yes, sir. And then you stated, I want to be sure about
this, you stated that you had met with DHS or a roundtable or a task force or whatever you want to call it.
discussion but you heard things today from DHS that you haven't been told is that correct that is as a representative of the dental
Billy Tarpley
Unverified
1:14:46
profession in this state that is correct and I want to be really clear about about the comment that they've stayed in regular contact with us regular contact means that we have reached out to try to get an update and very often it's it's too late now now everything has worked according to requirements we had the webinar we've had public
input we participated in it we had a lot of dentists who participated in in that webinar so everything has gone along there but we just don't want to repeat what happened in the mid-2000s when we came up with an adult dental program without input from the dental community we don't want that to happen again this is a this is a benchmark of where we are right now and we didn't have to be here if we had gotten proper response from DHS now basically in the early meetings
we were told we can't do anything because there's no money back in the days of Medicare a correction of managed care we would go to DHS and to talk about the fee issue DHS would say we'll go to the two MCOs you have two MCOs running Medicaid go to them tell them that that's where the money is go and talk to them we go and talk to the MCOs they say no we're on a set p.m. p.m. we can't do anymore go back to DHS that's seven years wasted right there of trying to say we're in we have a
critical problem looming on the horizon if we don't take action so we've come back again and And now we're sitting here and Representative Wittman, you've been in this process long enough. When you think those of you who are a little more seasoned will know that dentists are not in a habit of coming to the legislature saying we need more. We simply don't do it. The philosophy of the dental community is let's identify a problem, let's recommend a solution, and then let's get back to work taking care of patients.
That's just the way the dental mind works. The large majority of dentists in Arkansas are sole proprietorships. They run their own business. They do intake, they do exams, they do treatment, and they do discharge out of the very same facility. And so dentists, by necessity, are very business-minded, and it's hard for a dentist to understand how we could have gone through all this process and then be told, no, you have to go to the legislature. We've come to the legislature, and look at this.
Look at what we're having to do simply because it's been 18 years since dentists have had a fee increase. A modest fee increase is all we ask for, 60% of the 50th percentile. Now, I'm telling you, that's pretty low. We talk about comparing it to surrounding states. Look at the new information. The only state that pays less of a percentage of a dentist's normal fee is Texas. Every other state, Mississippi is very close to us. There we are, a neighboring Mississippi, but we're very close to that.
But you know what? Your constituents don't live in Texas. They don't live in Mississippi or anywhere else. Oklahoma is lower. I'll do that. We're Arkansans trying to take care of Arkansans, and that's why we're here to say the increase that's asked for and was approved by the legislature and signed by the governor, She signed it on April 22nd to create Act 1025 provided for a very modest recommendation and a solution that the dental community needs.
Representative Jim Wooten
Unverified
1:18:19
So in reality, what DHS is proposing goes contrary to what the pay grade, upper pay grade said that they agreed with when the governor's office. and then contrary to the law that we passed, they're doing the opposite. They're denying
it. Between April 22nd, when it became Act
Billy Tarpley
Unverified
1:18:41
1025, and until the next time there was any activity was in October. So however many months that is, is how much of a dead zone we had.
When waivers could have been filed, when we could have been moving forward in preparation to meet the September 1 deadline date to implement the rate increase. So now we're, you know, we were told after that time, keep seeing Medicaid patients and we'll make sure your payment is retroactive to September 1. In the meeting, in the team's meeting we had with DHS, that representative Mayberry requested, we were told moving forward,
We don't even know if we can do it. We don't know if we can go back to September 1. And so obviously, you know, that's not what you said. That's not what you approved in Act 1025. So I guess as much as anything from the personal point of view, if you allow me that, if I'm told by my bosses to do something and I don't do it, they invite me to clean my desk out. Now, I retire in two months. They have two months to do that, and maybe they will. but at any rate the the implication is that you made a directive the governor approved it
it was supposed to be done and it hasn't been done and here we are just now hearing more new information the option four would be great that they talked about option four would be wonderful move forward with
Chair
Unverified
1:20:09
the pediatric portion let's deal with the waiver on special needs later so yes sir okay yes sir
Senator Kim Hammer
Unverified
1:20:16
senator hammer you're recognized for a question thank you mr chair i'm
give a layman's interpretation what i've heard this morning sitting here listening when dhs comes up they can counter whatever you're going to answer what i hear is we passed a piece of
legislation we gave it to dhs uh typically agencies would respond by writing the rule that would implement this but they have said that dhs has or feds have signaled that we can't do it on the basis of that they're coming for us and saying we can't write that rule um then my response to that might be something along this line you don't know until you ask for it so if we get the if we get the rule written and get it sent up to them that's when we're going to find out and if it's something
we got to modify and change then we can modify and change based on what an actual rule written would be presented to them that's layman's term from everything i've listened to this morning my off base
Speaker 200
1:21:12
or am i on target go ahead senator hammer you are on target and and the the point here is that CMS was asking these questions, these routine follow-up questions about how it's being shaped by DHS in October, and as far as we can tell, they never responded to those, and that's the impetus for this December 15th letter from CMS setting those formal questions,
and those are just routine follow-up that any state agency has to deal with and work through, and so you are on point. All
Speaker 108
1:21:45
right. Thank you. Thank you. Representative Mayberry, you're
Representative Julie Mayberry
Unverified
1:21:51
recognized for a question. Thank you. In passing this bill, we made a promise not just to dentists, but to parents, to patients, to people with special needs, that we hear you. They were here.
And I can't back down on that promise. I can't look at them in the eyes again and say, I'm sorry it didn't work out. I know we promised it so we've got to do what we can and so we were really clear in the bill in the writing and I and I want to read to everybody the last three lines and it says the Department of Human Services shall apply for any federal waiver Medicaid state plan amendment or other
authorization necessary to implement this section so not only did we give them the authority you would agree with this because giving the authority is just a may statement we didn't say may you may do this we said you shall which says do anything and everything possible and that's what we told dentists and dentists and I'm going to ask you to explain in a minute some things that dentists people maybe that they've hired recently um to or have kept on because they knew that this money
was coming but then also to the to the families that are affected by this who were saying we need this um this this was a promise and i just want to point out the shall statement so if there was concern that we needed a waiver that could have been started a lot sooner correct it could have have been started in june or july and maybe we would be further along maybe even to the very end of the process at that point would you agree with that and can you also tell me what some dentists
perhaps have done to um expecting these new rates yes ma'am
Billy Tarpley
Unverified
1:23:49
thank you representative mayberry some some dentists particularly those in rural areas where these services are needed desperately some have added on an operatory it's not inexpensive to add an operatory in a dental office because they're so highly regulated some have hired additional staff and told them to to start september 1 now they're four months into it paying people when there's really not enough to do
but they want to keep the staff and they don't want to they don't want to fire someone so they're looking for quick for quick care but but to drill down a little farther on that dr jerry friend who's a pediatric dentist in Conway is seated beside me in the audience. As a pediatric dentist he said if any if anyone could come and look in the faces of the children and the parents when they bring their kids in for care or if any of you could come to our Arkansas Mission of Mercy where we
will treat close to 2,000 people over two days and look into the eyes of the people that we're talking about here it it it cast it in a completely different light so I know we're not talking I know we're not talking the um uh the humanitarian side we're talking numbers we're talking dollars but we're also talking intent and purpose and use of the legislature passed for intent and purpose act 1025 which spoke to these very issues and issues and amounts that were brought forward
from the dental community to say that this is this is where we are that this is what's needed dentists desperately want to continue in this program but again as we talked about earlier every business only has so much margin and therefore reduced income reduced revenue reduced profit everyone can bear a little bit now we've gone too far now we're talking 18 years and it's it's just too much. It's time for action, and that's what the Dental Association is asking for.
Representative Julie Mayberry
Unverified
1:25:51
Okay. Thank you, and thank you for legislators being here and being a part
of the discussion. I hope that what we are able to do here today is to put a pause on accepting this letter and continue discussion and come back and maybe find some other solutions. I know DHS is listening, And they also need to hear from legislators what our wishes are. And I hope that it's
been loud and clear that we want to make this work. Thank you.
Speaker 227
1:26:22
Thank you, Representative. Senator Love. Thank you, Mr. Chair.
Senator Fredrick J. Love
Unverified
1:26:28
And I want to go back to just a few things. Number one, now, Mr. Tarpley, is it your testimony? because we heard from DHS that there have been three rate reviews in this time period of 18 months. Is it your testimony that there have not been any rate reviews? Because you said there hasn't been any change in 18 years as far as the amount that dentists are receiving.
So I just want to try to
Speaker 213
1:26:58
clarify and bring that together. Yes, Senator
Billy Tarpley
Unverified
1:27:02
Love. I can't contest that there have not been dental rate reviews. I'm sure that there have been rate reviews. The last one that I recall that occurred, I believe, before we went into managed care, and I'm not certain about that, and I don't want to misspeak, but the last rate review that I recall revealed that Arkansas dentists were being paid in an amount that was similar to surrounding states.
Since that time, surrounding states have been having this same conversation. They've been raising rates, and we have not. And so what at one time, what 18 years ago appeared to be a very favorable reimbursement rate for dental Medicaid, has aged like anything 18 years old would do. And so at any rate, I can't say that they have not done rate reviews. They have not been annual rate reviews. To my knowledge, they haven't even been biannual rate reviews. So I can't say that they haven't.
But I don't believe anything has been done recently. Certainly, we have data that's prepared by the American Dental Association that rates every state according to reimbursement rates in a variety of different levels. And the numbers I quoted earlier were from that statistic.
Senator Fredrick J. Love
Unverified
1:28:16
Okay. And then the second question I have, or just to wrap this up, you're coming before us. What is the ask? Because your attorney said there's two things that could be done.
So could you restate the two things that you desire to
Speaker 208
1:28:36
be done right now? Yes, Senator Love. It's the overarching that there's
Speaker 200
1:28:42
two things that Act 1025 shall directs DHS to pursue. One is the rate increase. Two is the cap increase for adults with special needs, the $500 to $1,000, our ask, generally speaking to DHS and what we want to support them in is
separating those two things, effectuating the rate increase now rather than later, and then pursue what is likely going to need to be a waiver, a little bit longer process for the cap, the $500 to $1,000 cap increase. And so our ask today is the pretext of what we're here for is this letter told y'all that we intend to not adopt these rules because CMS is going to refuse to approve them. We believe that to be patently incorrect,
and we're asking for y'all to maintain oversight. Otherwise, we're talking about 18 going on 19 years for a rate increase. It's going to be 20, 25 years. And so y'all's oversight and accountability measures, and just the fact that we're here talking about options says that y'all need to maintain oversight on this and so that's our ask is to not accept this letter as true and continue oversight in ensuring the DHS pursues act 1025 and these other acts that
y'all y'all have passed okay all right thank you thank you mr. chair all right members I think that's all the questions we have right now thank you to the dental association for being here and answering questions I've had a number of members that are I think wanting to make motions we do have one member of the public
Speaker 44
1:30:25
that has signed up and so I'll ask Leslie Faulkner
Speaker 234
1:30:28
to come forward. Thank you, chairs and committee members. Thank you. Yes, thank y'all.
Ms. Faulkner, welcome to Rural Subcommittee. Y'all are free to have a seat. It'd probably be easier to be closer to the mic. If you will, hit the button and introduce yourselves, and then you're
Speaker 239
1:31:07
welcome to make your comments. Okay, I'm Leslie Faulkner, and this is my daughter Skylar Faulkner. She's 23. I'm also a retired special education teacher, And now my new job is Beacon of Hope, and I help adults with complex disabilities find resources in Garland County.
Thank you all for working on this, because it's so important to our friends, my former students, other people with intellectual disabilities, physical disabilities. When we all were talking about the waiver and how many people are in the past or in the waiver, I am finding that there are so many adults in Arkansas that have not even signed up for it. The wait list to get on it, three to five years. So these people are having dental issues and need this.
So even if you say we're going to do only the people who are going to pass, there's still many Arkansans that need so much dental help. And I would hate to see that those people are not being benefited by this as well. i don't know thank you for your for your comments does
anybody have any questions seeing none thank you thank you for being here today all right members that's uh that's all we
have on public comment i did say earlier i'd bring dhs back to the table i as i mentioned there a number of folks wanting to i think make motions does anybody have questions for dhs or Or does DHS want to come back to the table? All right. If there's Representative Eves. I actually do have
Representative Les D. Eaves
Unverified
1:32:54
a question for DHS. I'm sorry. I'll be quick. Okay.
Yes, sir. Welcome back. Specifically regarding 1025, and you heard the testimony of the Dental Association saying that, and if I get this wrong, feel free to correct me, but that it appears that DHS was using the two ideas in that bill, the rate change and the cap change, together. From what I understood, the Dental Association to say is those could be broken apart and looked at individually. Is that something you did or that you can do?
Because we need to do whatever we can to get this population taken care of. And so we need to sort of look outside the box a little bit. I mean, I know the bill contemplated a lot of different things, but can
Senator Missy Irvin
Unverified
1:33:53
you address that? Yes, sir. So actually, I think we're all talking about option
Senator Breanne Davis
Unverified
1:33:56
number four, which is the same thing, of breaking it apart. That is the option that came out of the phone call that we had with Representative Mayberry and the Dental Association, and I believe a dentist or two, there were five or six people on the call late last week.
So that became their request. And we said we would add that to the list from the other three things that had been listed and that we would reach out to CMS, which we have done in trying to get those answers. So yes, sir. Okay, so you
Representative Les D. Eaves
Unverified
1:34:27
contacted CMS about option four and splitting those two apart? Yes, sir. We
Senator Breanne Davis
Unverified
1:34:31
have contacted them about exploring all of those options, and we added number four to that. They gave us the first three in their letter, and then we said we would add the fourth one and discuss it with them.
Representative Les D. Eaves
Unverified
1:34:44
Any idea? I've heard some time frames regarding a waiver, and I know that takes a long time. But specifically regarding, I guess we're calling it option number four, what kind of time frame are we looking at to get an
Chair
Unverified
1:34:59
answer from CMS? So that's one of the questions we have pending with CMS. Right now we have submitted that state plan amendment. The way that CMS's time frame works is once you submit, they have a 90-day clock. So we submitted in September, so we had a 90-day clock from September. When these issues arose, they arose orally.
That was accurate, and we had a conversation. They said they would put options back to us in writing. We waited for quite a while to get those options back. when we finally did, they actually put the spa on what they call request for additional information, which means they've actually taken it off that 90-day clock. So they currently don't have a time frame for us on that spa. Is that good or bad?
Speaker 145
1:35:39
It's their way of preserving that 9-1 effective date while we work through issues. All right, that's fine. Thank
you. All right, I think that's all the questions.
Representative Gonzalez, do you have a question? All right, a quick
Speaker 250
1:35:56
question from Representative Gonzalez. Thank you, Mr. Chair. So how did we get to this being option number four? Because from the dental testimony, it seemed like this should have been option number one. How did these things ever get combined? I'm not that familiar with the bill, but it seems like maybe it was a legislative intent that they were separated and went as two different things to start with. And now here we're talking about this is a final option.
Senator Missy Irvin
Unverified
1:36:22
Yes, sir. I'll start, and Dr. Pittman will add on. But thank you for the question, because I
Senator Breanne Davis
Unverified
1:36:28
would like to clarify that this state plan amendment went out for public comment, and the Dental Association did comment on this, but never brought this up until CMS raised some questions about breaking it apart. So we took the act as a whole. We did communicate with the Dental Association in April after the bill was passed about buying the book that they had used for some of the rate increases to then start the work on drafting the rule and looking at our system changes.
We then did communicate with them that it was going out for public comment and through that process. So through the biweekly meetings with CMS, when they began to tell us about some of the issues and working on that and then put it in writing, that's how we've progressed to where we are. today.
Speaker 155
1:37:18
And I'll just add that the bill, the way the bill was written, the 9-1 effective date applied to the whole thing. And so
Chair
Unverified
1:37:25
DHS, whether rightly or wrongly, assumed that the entire bill needed to move forward as a package. When we submit state plans to CMS on the subject, we like
to do it all at one time because you don't want to open the same page multiple times and be confusing. So we did submit it as a package wanting to move the whole thing together because we believe that
Speaker 67
1:37:43
to be the intent of the legislature for that 9-1 effective date to apply to every provision in that bill. And so we wanted to try to preserve that for everything that was there. And so that was our assumption, rightly or wrongly. And we do realize now that we do need to split them apart to be able to move one piece forward separate from the other. All right.
Speaker 26
1:38:10
I'll give you a follow-up. All right.
Speaker 250
1:38:12
Thank you, Mr. Chair. Did you know or have reason to believe that that would cause things to hold up or to slow down and get
Chair
Unverified
1:38:21
denied? No, sir. I did not. We knew that there may be issues around comparability, around treating different populations differently, but to know that the limit versus
Speaker 67
1:38:29
the rate would be an issue, no, sir. We did not have that information. Representative Painter, you're recognized.
Thank you, Mr. Chair. I have a motion.
Representative Stetson Painter
Unverified
1:38:42
Okay. Let's hear your motion. Motion is to not exclude DHS from reporting requirements for Acts 567, 568, 967, and 1025 of 2025. Okay. Just to be clear, that motion is,
that applies to their total request. That's all for us? Correct, Mr. Chair. Okay.
We have a motion. Is there a second? Second. We have a second. Is there any discussion? senator urban you're recognized for discussion yeah
Senator Missy Irvin
Unverified
1:39:14
thank you um i think being able to hear
from the academic institutions from private dentists and so forth that we should bring this to public health and kind of really work through these issues so that we'll we'll make that happen um as far as discussion on this i think i think right to i think it is important to have the reporting and the oversight from this committee. I do want to, though, express there are some clear problems with some of these bills. And, I mean, I'm a sponsor of one of them.
And so, you know, however that is reported to this committee, I think, is important. And then I think on 967, Act 967, my suggestion would be just to have a separate report on 967 saying that there are no rules required for this to be enacted and then stating in your report to the subcommittee next month on that one particular bill that's my suggestion to you guys
is to to make that your report on 967 which at that time I think then would be accepted by the some subcommittee um on 567 i think for me personally um i knew that to be an issue during the session um and i can't remember if that was brought up in testimony or not but i think it was in the public health in my committee it was that that was going to be an issue because you can't just you can't provide 1800 in diagnostic services just for one provider and not for every provider
and that was clear to me when we were voting on that bill um and you know we try to communicate that but it we weren't successful at communicating that when it was voted in I mean just to be fair I'm just letting the legislature know that um and so I think those are real clear and so I would just break these apart and have a report for each one of them as to like where we are in the process and for discussion purposes I support the motion this was the discussion I kind of wanted to have Because at the end of the day, it's about collaborating and working with you guys and with us to figure out how to do this.
Because we definitely, if I pass a bill or any of my colleagues pass a bill, we expect it to be implemented. We expect there to be a process in place. But we also expect, you know, that all stakeholders are engaged and involved on the front ends of how these things are crafted and as they move forward, obviously. So that's my discussion on this. those are my suggestions and for the benefit of the legislators and the sponsors of the bills and all the stakeholders we will have a thorough public health committee meeting on these options
and how we can proceed with them and what that timeline looks like as well as hearing from any private dentist that may or may not be able to provide these services so that might be more clearly defined in the process that we already have for authorizing sedation with adults that kind of thing which we already have in place and to be able to hear from our academic institutions i think that would be important thank you mr chair any
other discussion hearing none all in favor of the motion say aye any opposed the motion passes
thank you to dhs and the dental association and for all that we're here to
testify today thank you members we're going to continue now we're going to move to item d this is a continuation of our review of the group three agency rule reports under act 781 today we have the division of higher education its report is in your packet the report outlines each of the agency's rules and it is categorized into the rules that they are recommending to repeal and those that they
recommend keeping and continuing to enforce. Would someone
from the agency please come forward to present the report? You're
Speaker 260
1:43:35
recognized. Good morning. Still morning. Courtney Salis-Ford for the Department of Education Division of Higher Education. And yes, as you stated, we are here to present our report on the current rules in effect for the division of higher
education we have 32 rules in effect we're asking that three of those be repealed two of them because they've been replaced with new rules the third one because of the removal of authority for the rule and conflict with other current law and asking that we be allowed to continue with the other 29 rules to continue administration of higher ed programs and scholarships and I'm happy to take any
questions any questions seeing none I have a motion
motion to accept the division's request is there
a second so we have a motion to accept the division's request to repeal three rules and keep and extend its other rules as outlined in its report with the repeals effective upon adjournment of the Legislative Council meeting Friday January 16 2026 is there any discussion hearing no discussion all in favor say aye any opposed the motion carries thank you thank you for being here
Members, we're now going to move to E. These are updates concerning rulemaking from the 2023 regular session. We have representatives from Commerce, Corrections, and Education here to answer any questions that you may have about their outstanding rules. A written update from each was provided to staff as of January 1st and is included in the agenda.
Does anyone have any questions for any of these agencies. Seeing no questions, we thank the agencies for appearing,
but seeing no questions, we'll move forward. And
then finally, item F, we have our monthly written updates by agencies concerning rule making resulting from the 2025 regular
session these updates are in your packet are there any questions related to those hearing none we will file the january 1st monthly written updates is there any other business to come before the subcommittee co-chair all right hearing none we are adjourned
Unknown speaker
1:46:21
I'll be right back, I'm gonna go.
Agenda
A. Call to Order
B. Rules Filed Pursuant to Arkansas Code § 10-3-309
C. Agency Requests to Be Excluded from Reporting Requirements of Act 595 of 2021
D. Evaluation of Rule Review Group 3 Agencies Pursuant to Act 781 of 2017 and Act 65 of 2021
E. Agency Updates on the Status of Outstanding Rulemaking from the 2023 Regular Session Pursuant to Act 595 of 2021
F. Agency Monthly Written Updates Pursuant to Act 595 of 2021 Concerning Rulemaking from the 2025 Regular Session
G. Adjournment
Documents
Speakers
Speaker 1
Speaker 9
Speaker 8
Speaker 10
Speaker 12
Representative Matthew J. Shepherd Chair
Unverified
Speaker 25
Speaker 28
Speaker 29
Chris Madison
Unverified
Speaker 41
Michael Harry
Unverified
Speaker 43
Speaker 56
Speaker 57
Senator Missy Irvin
Unverified
Senator Breanne Davis
Unverified
Speaker 67
Chair
Unverified
Representative Julie Mayberry
Unverified
Speaker 85
Speaker 30
Representative Jim Wooten
Unverified
Speaker 75
Speaker 101
Representative Lee Johnson
Unverified
Representative Jeremy Wooldridge
Unverified
Speaker 157
Representative Les D. Eaves
Unverified
Senator Jonathan Dismang
Unverified
Speaker 93
Speaker 125
Speaker 178
Speaker 146
Speaker 155
Billy Tarpley
Unverified
Senator Tyler Dees
Unverified
Speaker 192
Speaker 199
Speaker 200
Speaker 202
Senator Kim Hammer
Unverified
Speaker 108
Speaker 227
Senator Fredrick J. Love
Unverified
Speaker 213
Speaker 208
Speaker 44
Speaker 234
Speaker 239
Speaker 145
Speaker 250
Speaker 26
Representative Stetson Painter
Unverified
Speaker 260