Aging & Legislative Affairs- House Children & Youth Subcom.

We are gonna get under way and the very first piece of business is adopting minutes from our last meeting is there a motion. From. Thank you. Thank you okay we have a motion to accept the minutes okay all those in favor say aye. Anyone opposed thank you very much motion is adopted okay we're gonna get under way again I'm state rep Julie Mayberry and we've been conducting some of these meetings over the last few months I appreciate so much the number of legislators who are engaged and involved here my fear every meeting has been that I'll be the only one sitting here so thank you members for being here and being engaged and it just shows you that there's a lot of interest in the topic that we're talking about so we're going to we're gonna jump right ahead and the presentation today is really on the past what what is it and I've asked the four passes to do a presentation so that first of all we can all be on the same page to understand what is this program and then we'll open it up to some questions so if I can have my panel come forward. And I ask each of you to introduce ourselves individually if that's okay. Good afternoon madam chair members of the committee guest thank you for being here my name is Brad nine the government relations director for summit community care. And good afternoon I'm the call may and the senior director of behavioral health services with Arkansas total care glad to be here today. Good afternoon members I'm Corey **** I am with the Kerr source. Good afternoon doctor anytime from power and the vice president for care coordination and clinical integration. Thank you for choosing yourself you can go ahead with your presentation and then opened for questions thank you madam chair and and members those of you that know me know that my training is is as an attorney I'm not a clinician but somehow I was elected among my peers to run through the slide deck so I will be keeping it fairly high level but we do have the subject matter experts here that can help us go through any questions that do come up during the presentation. And I do appreciate that you All those questions till the end thank you. Okay. So. Manager thank you for the opportunity to explain the past program a little bit more detail to the committee we we do appreciate the opportunity as always to educate members around what we do this is that a program in the system that we believe strongly and we believe that it. I is the best system that Arkansas has implemented today to really do a lot of good in the Medicaid space especially around our behavioral health and R. I. D. D. D. population. so I think basically let's start by defining what is a pass and as you can see on the screen there pass stands for a provider led Arkansas shared savings entity. It is a health coverage program that serves Medicaid clients with complex behavioral health or intellectual disabilities intellectual or developmental disabilities. I do say that this is a health coverage program because as we will talk about a little bit more this afternoon I'm certain is the passes are not providers of services how we actually contract with providers that have the expertise to handle these populations and deliver services. We are actually the the pay war we are actually the care coordinators which we'll talk about more but we are not the provider. The past program is a risk based provider organization it was created in ACT seven seventy five of twenty seventeen. The way the system essentially works is the state of Arkansas pays each pass a set per member per month or eight PM PM payment to coordinate care and pay medical expenses for enrolled beneficiaries he per member per month is a payment that is set by the state of Arkansas in conjunction with their actuary. to help compensate us for the cost of care for those members in our population. so as I said it is a provider led assured stating share assured shared savings entity and provider led is a unique feature of the Arkansas program of the past program is a managed care like program but in Arkansas we do have a requirement that each of the four passes that each of the enrolled passes must be owned at least fifty one percent by Arkansas Medicaid providers. Other some additional ownership structure that is set out in ACT seven seventy five that we can go into if you would like as we get into questions but essentially there is a provider requirement in a certain type of provider requirement at a high level. I'm currently in Arkansas therefore certified passes you've met now representatives from each of us Arkansas total care summit community care and power healthcare solutions and the Kerr source pass. So the passes. As I mentioned briefly cover services for IDT and B. H. populations we cover Medicaid state plan services unless they were explicitly excluded or ACT seven seventy five there are a few services that we don't cover non emergency transportation being one it it's covered under Medicaid dental benefit is not covered because there is a separate managed care program for dental benefits I we don't cover skilled nursing long term care that sort of thing. I we do cover nineteen fifteen on a state plan services which will get into a little bit more those are essentially behavioral health type services. We cover nineteen fifteen C. waver home and community based services what we call H. C. B. S. and that's primarily for those individuals that have a developmental or intellectual disability. I have I will go through the redo the entire slide but here's an example of those nineteen fifteen I state plan services that we do cover through our providers. Additionally we do cover at the H. C. B. S. services and this is an example of those services. In addition to the services that we can get a little bit more into this if The Committee have specific questions we do offer additional wraparound services for our members and those are services that allow us to be a little more creative to pay for some things that weren't covered under traditional Medicaid the things that we might recognize in conjunction with the provider in our care coordinators that are services that would help a beneficiary that benefit a beneficiary and help them to remain in a community setting as opposed to going into a higher cost of care like institutional type setting where appropriate. So we talked about the past system basically let's talk briefly about eligibility. all enrolled Medicaid beneficiary beneficiaries must be eligible for Medicaid they must have either ADD or a B. H. diagnosis or or dual diagnosis as the case may be and they must have been assessed and deemed eligible for home and community based services. Once an individual has been determined eligible for Medicaid and has been assessed and determined to qualify for a pass the state then the signs those eligible members through a round robin proportional assignment process among the active passes so. Beneficiary a goes to pass a beneficiary be. S. B. and so on and so forth round robin. I once an individual. Is assigned to a pass and we can go into the slot it more detail of the past four contract with the state has five days to send out information to that beneficiary or member ID card information about the services offered how the program works and that individual as they're looking through the materials and has they're making that determination then have ninety days from that date coverage begins to elect to switch to a different passivation so choose. If they do not choose to switch within that ninety day period then they will remain enrolled in that specific pass until the end of the covered year there are some exceptions to that there are person for costs transitions that we will talk a bit more about it the questions arise but essentially once the persons in the past there in that pass until open enrollment kind of like with you will have with traditional insurance right open enrollment which goes from October first to October thirty first of each year. I think one of the questions that the passes were sent by the committee to address was what happens if an individual is dissatisfied with their pass. So per our contract with the state each pass is required to have a process to take and resolve member complaints. that process in contact information is available on our website as provided for members. All complaints we receive per contract as long with. I see part of the back of all complaints we receive along with how that complaint was resolved per contract must be reported back to DHS and it goes in that part of our contract metrics. individuals in the pass or their guardians whatever it may be also have the ability to contact the state of Arkansas the DHS ombudsman's office if they feel that their issues are not being properly addressed. So I mentioned previously that the past program is a managed care like program here in the state. The central component of the way the past program works in Arkansas is what is called care coordination. When the member is assigned to a pass they are assigned a care coordinator who is the primary contact we need to pass in the member. The care coordinator who works with the beneficiary the beneficiaries guardian in fisheries providers their primary care physician so on so forth together any and all information that they need to help develop what's called the person centered service plan the PCS P.. That plan identifies the members preferences goals and choices about the type of services that the overseas. The again the care corner coordinates with healthcare providers. Members have access to a care coordinator twenty four hours a day seven days a week three or sixty five days a year of the problem or to have. Care coordinator qualifications are also question that was raised I think previously so we'll we'll touch on it a. The qualifications are set by our contract with the state you know care coordinator needs to be either a registered nurse position have a bachelor's degree in social science or health related field or have at least one year experience working with this type of population. Each passed as is little bit different but for our contract we are required to have continuous education for care coordinators to make sure they meet all state and federal requirements. Including training on the PCS P. development training on cultural competency advance directive training and. Training on the full service of H. C. B. S. services that are offered to that number again to help them live a. Full life in the community. A I know. On a very high level at some it when our care coordination Kirk orders first come on board there's there's four full days of intense in person training. There is an additional three days of virtual training and there's on the job on the go trading that happens. each month and each care coordinator has a supervisor who has additional experience that has been around a little bit longer that may have seen different scenarios arise at that care corner can always reach out to you if they have questions about development the PCS P. or any other issues that may come up for a minute this year. So that is extremely high level that is our our past program in a nutshell and I think with that we'll open it up to any questions certainly if we need to get the subject matter experts at the table we can do that for. Okay we'll we'll start with representatives Springer who has a question. Good afternoon thank you madam chair thank you all for being here and thank you for this information it is very helpful to have some idea was taking place but I would like to go look there's some additional information that I think that needs to be shared with with us for instance I'm I'm written down what is the current budget for each one of your individual passes how many persons are you currently serving and what portions of the state of do you serve for each pass through and then the number of the number of individuals by race and gender and more statistical data with respect to who you're serving and what the outcomes of being and so I would like to hear more about that at this particular time sure a representative I think as to so the financial information and the demographic data that you're referencing we are required to file quarterly quarterly financials with the Arkansas insurance department in addition to the Department of Human Services and state and federal law we're also regulated by a ID so we do have financials filed with them that that would be happy to share as to specific demographic information I think we can get that to you I don't have that today. what about budgets your budget what what kind of money do you have now each I I don't I don't have that information I I again I can provide financials from the insurance department that should help I think clarify that question for you and then you're working with DDS I take it we do we we work with I DDS with the state and we work with they've Health Services Division of aging and behavior health services as it's called now we have approximately fifty thousand our Kansans enrolled in the past program. some of community care I can only speak for myself we are we are getting close to eighteen thousand members currently I think our past we have about sixty eight percent or DD ID diagnosed individual so we are very heavy in that space for the population and if the other passes wouldn't have any other information they can share I'll be happy to turn over the yes I would thank you. Share this is Nicole again from Arkansas total care and we have about sixteen thousand members our make up of our membership is behavioral health focused so about eighty nine percent of our members have a behavioral health condition and I would say probably of our total population about seventy five seventy six percent of our membership kids. This is Amy with him how are we have about nineteen thousand actually this morning nineteen thousand eighty seven members are predominantly white Arkansas total care we serve seventy percent pediatric in around thirty percent at all we also served IDT that predominantly as our kids with behavioral issues. And again I'm Corey with Kerr source we're little bitty we just started we we went live in January so accordingly we have about a thousand four hundred members we will take anybody that is assigned to us we're going to take you because at this point we're we're working to build up membership I generally you know our most of our folks here in central Arkansas but we do have folks scattered across across the state but we're we're brand new so we don't have a lot of a lot of folks yet. And just to add to that if I could so this is a statewide program so individuals in every county if they meet the criteria that we discussed would be eligible for this program and as Brad mentioned it's proportional assignment so we all have members from every county so it's it's statewide for all of us get to. I just wanted to add and clarify I think from what I understand if someone enrolls in the past brand new. They are assigned one two three four the fifth person six person seven percent eight person is that correct your assigned in a certain order. But then that person has ninety days to change if they don't like total care within that ninety days they can go to summit at cetera or wait until October as you said I just wanted to clarify that that's exactly correct okay so we are so it's not like one group is serving a certain area it's just random who you get okay. Did you have okay Representative left. Thank you ma'am Sharon thank you for having this meeting I guess because it's important I actually happen to have a cousin that is utilize an Arkansas total care so I think I need to talk to you off line I don't want to get into that right now but what is your what is each of you also orientation process for families that either have individuals who are intellectually challenged what is the orientation process for families that come on to your programs and it could just be a brief kana. So thanks for that question representative live so each member and their or their guardian gets a packet from us that tells them how to contact their care coordinator who their care coordinator is there benefits that they're entitled to and member handbook on how to access our website all those in for all those and details are sent to them via mail and then we have metrics around when the care coordinator has to outreach to those members are guardians so we have to make that initial contact with a member within fifteen days of assignment and so our care coordinator does reach out to the family within that time they go over all the details of the program answer the questions they may have and then also do you like an initial health assessment to kind of see what their needs are so they can use that information in the development of their PCS P.. It representive love that that's going to be true for all four of us that's per our agreement with the state or pass agreed or contract in its it forms part of our our metrics to show how good of a job we're doing it in the provision of of the past program okay. Thank you. Senator Hammer. Thank you Richard thank you especially for let me ask questions I appreciate very much of first question I'd have for each one of you is quickly she can talk about your case coordinators or your care coordinators the percentage of caseloads that they are carrying because one of the feedbacks that I get is there's not enough care coordinators to go around which subsequently means that the needs of the patients are not getting address Felicia which talk about are you at the minimum requirements for maximum requirements and just hit on that a little bit please. Sure the thank you senator Hammer. Per the the past agreement with the state we we are required to keep the fifty to one ratio that as the the contract standard at some and work closer to a forty to one ratio I will say that I've just because a beneficiary has a an assigned case coordinator doesn't mean that they're only able to speak to that specific. Ordinator if there is an issue with court or being out of office are busy with working with another beneficiary on vacation whatever the case may be we have backup coordinators that have access to a file that can also be of assistance in instances where there may be an immediate need for for assistance but forty to one this is the ratio that we're currently operating at fifty to one is what is required by contract. So like Brad mentioned it's a fifty to one ratio with the state during the PhD the state did allow for sixty to one ratio because as you all know very few members if any are losing coverage because of the public health emergency so just speak for Arkansas total care we are hiring on an average of eight care coordinators per month and that we do have care coordinators to support our members we also have teams so we have case managers that also helps if there's like a need that the care coordinator can address whether it be medical we have case managers that are nurses that can assist those members with those needs so we have more of a team approach of course like Brad said they have supervisors as well that have more experience so we do have like a multi disciplinary team of individuals that are staffing individual cases working with those members to make sure that there are getting the services that they need. Is to echo what Nicole was saying the public health Martian disease and sixty to one we have a kind of a unique program and power that we've created an integrated care program looking at medical and also behave or any co morbidities so we have created a a team or as you're saying there are some folks have higher needs that we've been able to establish a team where are ratios fifteen one S. R. integrated care team but that's are very high in complex numbers but on any given day it's fifty to one and triple a health emergency sixty two one we have a staff of about three hundred and forty care coordinators so we want to make sure that if that like they're saying if they can't reach their care coordinator there's also a supervisor in any high level situations and we do run all of us a twenty four seven your coordination program so we are also available meeting times on weekends and holidays for any needs that come about. In again you know you know it it's a with us being new we we continually or hiring. Ordinators we have job the advertisements that run constantly you know we're. We are a little different they were small that we're we have to live by that fifty to one just like everybody else we we are always shooting to be below that number as well so follow up manager. So if my memory serves me right I think around a hundred fifty million dollars between all four golds return through the risk corridor I may be off a little bit on that but it was a pretty significant chunk of change and we've got people that are on the waiting list and other things I'm just wondering what attributed to the money being so significant that you return that much this state which is a good thing on one side but we hear about people whose needs maybe aren't getting met or we have a waiting list that is out there I'd like to hear from y'all's perspective about a why so much money got returned and then be our the needs being under served because so much money was returned and you have any recommendations about how that money could be used to meet the population's you Sir. I think that and DHS can speak to how the rates were developed in the soundness at those rates that are paid to the passes but what I would say is with the public health emergency again individuals that tier I to tier one or maybe I'm are not eligible for Medicaid any longer and I think Medicaid price speak to it you know the public health emergency in whose continues to be eligible for Medicaid but there are several members you know that each of us have that aren't receiving services because they no longer need those services right because individuals with behavioral health diagnoses they should get better they should improve especially kids so we do see that kids get better and they don't need those services anymore that due to the public health emergency they are still on our books in so a lot of the funding that is being returned to this state is on those individuals that are not receiving the services anymore that makes sense so that is again we've been in a pandemic like two years and so it's it's a lot of the fines are related to those individuals that are on the rolls that will fall off when the public health emergency is over as far as our members getting the services that they need and I think a majority F. that members in our pass are getting the services they need I do think there's some gaps in the service continue on that we are working very collaboration of Lee with the Department online and with our provider community I talked to a provider before I came here today on and expanding services in the community so I do think there service gaps we are aware of their service gaps and we're working collaboratively with and the Department of Human Services and. I tend to address those gaps moving forwards. Can we have another group answer that question as well because you you you mostly have behavioral health so I can see perhaps with behavioral health those things improved but if you have a developmental disability you have that forever so um can that be addressed because that certainly is not the case with those situations. On the address that from the DD Addie perspective I think first on address it from the member perspective we're bound we have to serve our members according to what's in there person centered service plan that's what drives the services and what is their navigation map and we have a stellar all of our areas are seller for care coordination that we really excel in RDD an ID but you still have people that refuse services in that population that you have to find them you have to hold them accountable just like we have to be held accountable you know as individuals but we're they're all being served to that according to their PCS PC but as a whole is saying we do have people that still refuse services you know we have folks moving off the waiver coming in the summer we are prepared for them this requires a hold we have a whole specialized department that does we actually go and find our members we go to providers to ensure that they are being Sir but you still have I'm guardians you have people that refuse services just like you and behavioral health population and we do have a large majority of folks to that just don't want our services anymore that have not fallen off from the public health emergency but when we're speaking really about this here once you're looking more at those behavioral health diagnoses and folks that just. They're done they may have to say to medication management they may have just needed some outpatient therapy but they're not tearing into your tier three and what we now have coming out which is your to your for your complex care which is why we have created program to have a smaller ratio of care coordinators to those facts so that some I hope that answers your question but we're very targeted you know but we're when you Sir someone with the bill on disability you're also serving their care giver any stakeholder you know just like when you Sir child you have to involve their parents their school so it's not like an adult just telling you know I don't want somebody coming to my home we do have people that do reviews of services so you're wrapping around so does require some enhanced service modeling with our providers as well. To help then answered questions. Representative makes your next. Thank you madam chair thank you offer for being here I one of the things in your presentation that caught my attention was the. Ability for clients to call in complaints to DHS and early on as a representative I seems like on a regular basis I've received those complaints thankfully I've not had any in a while and so the question I have an and maybe also for DHS at the proper time as your clients with other compliance in me going down is that we're getting better at this the number of complaints is dropped we still have complaints were we at and in that area if you will. Representative makes thank you for that question and I'm afraid I don't have exact numbers for you you I will say that when this at the inception of this program it was a relatively new experience in Arkansas generally for us but for providers and for members and I would say that as the the program has matured and progressed yes I think there was a little bit of a learning curve that we've we've all gotten past and so. We are seeing a eight at some that we are seeing a reduction in in compliance now we we will have complaints will have sure one off it's it's going to happen sure but I think we've we've all learned together as the program is has grown up so I think that we are getting better at heading off issues before they they get to that complaint level and I know that's not the exact answer you're looking for but I hope that helps yes and I can certainly expand on that I think that mean as a parent of a child with the with complex issues and medical issues you want somebody to hear you and the members was is most important to us so we've establish a process with with the state where we have an escalation process we don't want to get to that we want most of our folks will tell their care coordinator what's going on with them but I think the processes have improved with us in the state we have an actual box that comes that we work those immediately and we want to make sure anything that keeps America from being held up and services we're addressing that and we look and check that box all day long and we ensure that recalling the gap the parent the guardian so I believe the processes in my opinion that we have improved with the with the state we have seen a reduction in those complaints but in anything we want to make sure that anything that we need to get taken care for member sometimes are not compliance said Hey I got to the pharmacy and I needed more medicine than I thought I would we want to make sure we escalate that as well we all have processes in place for escalating that because I remember in their voice comes first and just like anybody they have a right with the stars and to be able to bring this to us I believe the process is down there. And I would add that and as a past we've gotten better right and training here coordinators when we started we were hiring care coordinators just sometimes twenty and thirty a month right and that training we have really we we train all of our care coordinators as community health workers undergo three hundred hours of training when they are hired and then they have annual and monthly training so I think our training is not better I know our training is not better and so I think that helped with them and that the complaints as well as it looks like DHS nod their head that their their agreement with yourself thank you thank you madam chair. Senator Chesterfield. Thank you so much thank you so much madam chair and thank you all for being here I was interested when you said that the behavioral health services were no longer needed. What measures are we using to determine whether or not behavioral health is or is behavioral health and our behavioral health and mental health separated because mental health issues but many go on for ever and ever and ever yes I'm trying to understand now we separating the mental health of the behavioral health are we talking about one went entity rolled into one. So are providers should be doing screenings and looking at outcomes as they progress in treatment right like you said not all behavioral health and behavioral health is a combination of mental health substance use disorder and so that's just an encompassing term that are members with ADHD rights they may need to be on ET H. D. medication. For a long time maybe you know I'm going but they may just need medication management right then individual therapy and the other services that they received when they were an entity exacerbated state are no longer necessary right so they just need some medication but they have learned the coping skills that they need in the de escalation techniques I in order not to risk needs those ex you know intensive levels of services budget they have another episode that drives them back to where they were absolutely use that service available to them yes because I'm seeing well obviously we always sing around the country people who are just challenged as far as mental health is concerned and I don't think we're getting it to the folks we need to get it to you because we were we would not have these egregious acts that are taking place because I think they are all centered in mental health impressed behavioral health I'm trying to use not use them interchangeably because there is a distinct difference between them and yet the same time we have some of the same things so are we seeing any of that up to and are we making sure that it's just not medicine that they need somebody to talk to. In a lot of times they need somebody to talk to to work them through this this these grave situations on I just want that's why I was of concerning the lease and you know I'm not sure and I I know you want to say something yes I are members regardless of this year that they are tier one through tier for they can always engaging the services in our care coordinator set those up for them so they got a phone call right now and one and outpatient therapy that's our job is to coordinate that for them as set it up so regardless of whether we don't want folks to get to crisis mode we want them we want to know or care coordination we work on we will be pre crisis we want to be maintenance going to be there so they can remain stable work go to school so anything that that they need if they decide that they want to be back on medication but we do have a handful of folks that matter what we set up they don't want their they don't want you know medication so we still there still being served by care coordinator we actually have all the passes where we work with folks that do refuse services we worked as in a specialized team to make sure that we are getting them involved through motivational interviewing through you know convince the well you may need this you know it was two years ago that you did go into the hospital let's think about that because usually when of folks with mental illness when they feel good they feel good sometimes I get off the medication you know and then that's when they get into trouble so that's what our care coordinators really are they are that that person for them to talk to they going to their homes they meet them at the library and then they will help them get this therapy services if that's what they're going to they also make suggestions for them Hey you may need this you know but we're not you know we're not second I just making this suggestion who just saying based on your history of your claims you did go to therapy one time three times a week trauma therapy have you thought about that it kind of seems like you may have some behaviors as a child and I suggest that to a parent so we are pretty fully engage some of times our members as the only person I talked to secretary coordinator that's only by Senate seats and I appreciate you thank. Okay so mistaken my question thank you madam chair. I just wanna be before we get to other ones just kind of going off on on that thought right there the solution is not always medication the solution actually may not always be therapies not everybody wants to sit and talk about their problems sometimes that can make it worse. especially when we're talking about children. Putting them in a normal typical social environment is exactly what that person needs most so do the care coordinators ever say little Johnny needs to enroll in a program like bowling you know let's let's get into the bowling alley let's get him some lessons let's make sure he's going fishing let's make sure he's in the little league baseball you know program that's down there that's how most children develop their social skills is being in those environments and do you do you cover some of those costs like let's just say Little League cost fifty dollars to register do you cover those costs for families who can't afford it have we have we looked at those normal activities that children go through and help them be a part of everyday world. Yes we actually that's part of the the PCS P. development as talking about the child's hobbies what they like today we always want the member involved in the PCSB development the person centered service plan we ask them what they like to do what they want to do we actually put on a lot of our adolescent members on the phone I'm only serve with even them being in the side the contacts of civility in transitioning back home yeah we we pay for swimming lessons things are therapeutic for them because you're right children need to develop normally and that's what we want to to encourage them with their parents as well you know it's not we don't want a child to be in therapy four times a week for their whole entire life you know I'm a foster parent adoptive parent and that's just you want to talk to your kids down you want them to be like other children as much as they are in and they can be in that coming from foster care having a disability who want them to have the lives that everyone has so we do talk to the parents and to the the members about what their hobbies are and we work to to get that for them or get them to a resource that's a great thing about our care coordinators in about all of us together we have probably. Thousands and thousands of resources to connect them to to get them more involved in the community. Is that the same for all of you are you try to get the main gauge and formal social developmental programs yes okay okay representative Springer again. Yes thank you madam chair I would just like to have a follow up with respect to the waiting list of persons waiting to receive services if you that if each of you would come in as to what you believe the factors are that contribute to this waiting list this. Currently pending and I think I know that maybe somebody from DDS is here but still I would like to hear from you all is well. However that is coming operating as or what how did hi waiting list come to be come to be and what why is it in the fire there people waiting to receive the services. It representative Springer I. I hate to say it but I think that's probably a question that needs to be addressed for to the state for that institutional background it up yeah we we are excited that there are additional weight slots. Their initial slots on the ID the waiver of that has been requested of CMS more I know DDS is waiting on approval we're excited to receive those additional members were glad to see that wait list number starting to come down. I will also say that folks that are there recess at a certain need level that aren't that are on the wait list I can't get the wait list waiver services they to CBS Services still can access some services through the state plan so even those folks that are are on the waitlist are not completely out in the cold they are still getting some services last year your question about the the wait list number and and why the wait list is there I would have to defer that question at clinically all of us are folks that are waiting on the wait list and they're still involved in care coordination and they have a care coordinator so we're still serving them at the passes even on the wait list. I thank if you don't mind I'm going to add a little bit to your question do you have the capacity to take on thirty three hundred more and that's really I think more the question that we're talking about going forward here we are now going to have the money do you have the capacity to have the employees the people the service so are members already have the ones that are on the wait list are already assigned to a pass so they already have a designated care coordinator so for us as a pass we will they will keep their same care coordinator whether they're on the wait list or they move into a waiver slot. But I guess getting to more the question you said they have a care coordinator are the services there for them once they. Move off the wait list. Will they be able to get those services the employees the staff. So I do have this state has added some changes to the C. S. waiver that I believe has been submitted to CM mass to account for some of those issues like around staffing that are providers offer right so we contract with providers to provide those services to our members but I do know there are some changes around monitoring and you monitoring cared and that DHS has asked for the CS waiver and to an enabling some technology in the future as we look to serving these additional members in the community. A representative Alan. Thank you madam chair and thank you all for coming I'm going to do a little shift on you just a second of when we to we talk about the payment process would move the providers turning that claims to you all I have heard that is a difficult for them to get paid in this a talisman them sometime receives the funds for the services that they have surrendered so would you I'll briefly talk about the pay process if you don't mind. Can we start with empower. In particular. The payment process for providers. do you want to go back to the so our rate question or just kind of how we come out with our friends for providers the design treatment plans okay. Claims of. amended for over two to you guys to address that that particular question that our payments we pay by our providers with I want to make sure I understand the question because remember I clinical. we pay our providers our network and contracted with us for services and our clients payments go out usually typically is billed by units based on the code we have a certain Senate because with those come out from the State of what we cover for each of our providers did you have behavioral health services you also have as a fall under that are outside the waiver codes that fall also for IDT NDT so that's how we pay out our our providers by K. right on through the understand that point for example when someone turned a claim into a two year old your organization what happens if the wrong code is stamp because what I'm hearing is that okay sometimes when when they provide the services that give of a response from you all. Further down the road saying that the you have the wrong code and then you know yourself closed six today claims become ninety nine to become Hendren hunt twenty you say you can't pay them so we to speak to that process yes Sir we actually I can definitely speak to that process of I don't know how far you want me to go back said member okay this current in our code that you know perhaps as a code for service that. They need you know we need a modifier for to we actually have a process in place that we do contact and work with our providers to ensure that we are building out the correct code and correct units for the services that they are providing so we do have a reconciliation process and power we also have a direct contact for them Bills issue management director that works exclusively with the providers we do go back and we do take a look at you know say it was a code that normally they have utilized and then they all the sudden have built out okay that wasn't and with that you lose ation and it looks off we do have someone that spot checks that and they do call out to the provider and we work with them on that to ensure that is that what's called in and our world is really a claim claim to make sure it does drop down and it does pay them out correctly we always willing to meet with providers to for claims issues or claims projects because a lot of times what happens is we run into maybe that's occurred for quite some time and then we will and are willing to do plans projects with them it's just a matter which you know what the provider wants to do at that point but normally when that comes in we can spot check and we can we can contact providers Hey this code is really non alignment with what you have been billing and but if it requires a project that may have been going on for quite some time we will work with them like Oregon couple writers right now that when there are some code changes and they did not update their systems we're working with them in order to make a claim projects so that we can allow for that to still be accounted for for them to get paid. I hope that further answer that question I was going all the way back to the rates and the code to come out from the state one one quick follow up many of committee to provide as if I district I've seen that when they filed a claim with your organization they have a very difficult time getting a claim paid okay so the reason why the you always say when you put the wrong code email then the length of the crying out there's so many months you also wait you did meet the deadline for the to pay the claim so I would like for you to speak to that. I would wonder if there for right doing their billing out on the portal if they're faxing and how they're actually doing that doing both Korean that infects. I would encourage them to contact us and take a look at that AS in each individual provider on sometimes those claims doesn't codes do kick out but it always goes back when your provider and you go in you bill for service is going to come back to you if it was denied and wine with like a denial code or what's going on in your in so I would need to see from a research effective what they're getting on their end to bring it back so that we can research it and work with them individually because it could be that they have exhausted their units are it could be that they are not billing the right code with that service there's a number of different reasons that claims don't pay but we would love to meet with them and talk through that so that they can we can work through them getting paid out we do have certain every pass and you know every insurance company has some certain amount on the claims have to be filed that doesn't mean that we don't want to talk are providers individually to see what happened because I know being a clinician like I said earlier I was going back to your rates and because the whole nine yards I've learned enough being a commission in the managed care feel that I know also being a private provider that sometimes you don't know your clinician Arkansas is trying to your on billing so we would love to take a look at that from the perspective of what are they getting what are they getting back with messages they're receiving are the and the timely filing status and if they're not it doesn't mean that can't be overridden it just means we need to talk with them individually and take a look at what happened from start to finish but as we don't want anybody to not serve our members because they ran into a problem with claims are. I think it's important that if they provide the service they should be paid yes Sir thank you I would love you have any of those those providers names contact information thank you I'll give you my card for them to contact us and we we looking claims all the time because we want to make sure that is not something that will happen again as well on there in our thank you for your willingness to yes. Senator Hammer. Thank you measure on follow up represented thousands line of questioning do you know or do you have the ability to know of the money that was returned to the states through the risk corridor how much of that would be identified as claims that were not paid because of denial to the provider. Senator Hammer I can take that back and look and usually if we. Don't have a claim then we don't know about it. So as far as denied claims we have very few claims that are actually denied that are counter acceptance rate is ninety eight percent with the state and so we have the claims that we've had most of them have been paid but I can go back and look to see if there's any outstanding claims that would have impacted that risk corridor payments but if we do I wouldn't think it's at a huge number. And men sure no not a member of the committee I appreciate led to but I would go ahead make a request to the chair if that's permissible I thank you would be good to know working with DHS of that total money that was returned how much would have been paid to providers had it not been for denied claims status for whatever reason because I'm thinking down the road if that got fixed that money would shrink or you have a and I have providers to contact me with the same issue that representative Allen said in that is if they should have got the money they should get the money shall collect and what that total number is we can get that please and could I have a follow up please manager yes you may I'm just going to add because you're you're asking a question about Denials and things like that I have I have a question from a friend can the passes make available to their members the clinical guidelines or criteria they use to decide if they requested service is medically necessary if the member has received notice that a requested services being denied because is not not medically necessary has that member in a position to know if the decision was correct or if an appeal is warranted so how how do they know that. If you have any answer. So our inner qualquer I Terry I believe is posted on the website I have to go back and confirm that but we use in our wall cracked area for medical necessity decisions I know you can request the criteria if it's not posted online but I'll have to check and see if it is online he in addition to that there is at a reconsideration and an appeals process and that is dictated in our contract around and the Medicaid fairness act and that that state fair hearing process and our internal appeals process and that information is in there denial letter for I denial of services it will tell them how to how to request either a state fair hearing or an appeal with the actual insurance that pass. To the Committee one of the challenges that every health care providers facing is staffing right now and take for example the the I. D. D. population that shall serve or somebody else serve and with the difficulty in hiring direct support professionals in those areas yet you get paid per member per month per you know allotment I'm just curious about your abilities to meet the needs of the say the IDT population so a reference that a while ago given the critical shortage of finding personnel but yet you continue to get that money whether you're staffed up or not and I'd like to you to speak to that issue and thank you will care can like to get the guys on this one and get some if if the chair would allow you to get to a summit Brad and Corey to speak to that please. I certainly take a stab at center up. So so again I think just. Just to be clear for the for the committee as a whole we don't directly hire direct service professionals at the past week we employee care coordinators that coordinate the care we then in turn contract with our providers who are then responsible for hiring their own staff for the provisions services. And we do receive a a capitated payment of per member per month to address the needs of a beneficiary and and that amount can vary a little bit depending on what rate so that person is I. E. how intensive their. Level of care is but that that rate is calculated with the state and with Milliman based off of and and there's a lot more that goes into it but based off of historical spend historical claims a lot of other. Other information so that PM PM that we get that global payment doesn't always necessarily I think account for things like a minimum wage increase has certainly or a sudden increase inflation that's thing. And so we. So there's that on the on the provider side of things you know. We are a any willing provider state and so we work with our providers we contract with our providers and go **** rates with them providers are always able to come in at any point in the in the process to visit with us and to express a need for us if they think that a increased provider rate might help them attract and and keep direct service per professionals they can bring that to us and we're happy to to address that that issue. I think part of what we're hearing from. In Arkansas and in the community is it's not necessarily a pay issue it's just a lack of work force issue. A lot of our ID DD direct service professionals aren't licensed credentialed professionals these are lay people that are hired on in trade up to take your job it can be a tough job and so it can become very difficult for us to become very difficult for the provider I think with that specific subset of their employee to attract and keep good talent when there are honestly probably. Easier jobs that pay comparable money available and this is this is been a problem that's existed. In Arkansas and I think it all Medicaid programs for for thirty plus years you know you you've identified something that is a systemic issue it's something that the state acknowledges the passing knowledge the passes we acknowledge and I think the providers of knowledge and we continue to work collaboratively with them to try to figure out ways to address those those kinds of concerns that you that you bring up senator Hammer but I don't know that there's a a civil will it cut and dry answer that that really gets there and and I guess what I'm struggling with in my mind is the and and trust me the conservative side is very happy we return that much money even though it's ended up in the Medicaid trust fund and that thing is building up pretty heavily I understand that that's another issue. Yes same time if we're having trouble getting work force. With that amount of money being returned why would you not to go she ate or what limit you from negotiating better rates with your provider so that they can pay the staff because if you're if we're operating under staffed. And those needs are not being met what where's the break down that we've got that much money going back that subsequently ended up as a Medicaid trust fund but we're having trouble hiring staff because we're not paying them enough when we have that much money returned and that's what I'm trying to get my head around is that doesn't balanced me so can you help me balance that. Store was anybody. I selected that turned off senator you know me well enough to know that I know enough just to be dangerous. The. You know we will you're talking about the rates. You're talking about what we were paying out so much of that is is based on actuarial studies it has to be I believe under CMS guidelines or have to be studies done of that DHS that show that this is actuarially sound you yeah we could I guess just go through and give everybody all the money they wanted that you know in the end we're regulated industry and if if we are putting more money that we're taking in to the point where we can't pay claims then a ID's gonna start your problem because they're gonna come over and start telling us we got to do something different you know we we're limited State law on on the amount of profit that we can make I think it's what three percent is that correct so you know there there's it's not like you know there's. I mean I'm I'm not gonna sit here and say that it's it's we're not making a profit profit so that profits of a good day it's it's what allows us to do some of the more innovative things that we do but you know there's a limited on the money that we get because we're limited by law and then then you have you know we have a tax that we pay I think it's two percent that goes back to to reduce the duty wait list of there's just different things in there that make it more difficult to say well everybody all in all a rising tide lifts all ships the. We we have to look at it and you know take a we a lot of times from DHS again we're bringing I can only say that every time I speak we are we're we're brand name and you know part of our problem obviously is that our network we've we've hit the matrix that we need to hit with DHS for for the network but we don't have near the network that a lot of the. That the other three have and we're trying to build that network in that we're negotiating with them and we're talking to them and they're telling us what they want any to give and take so it's You know it's I don't know that I can give you a. A simple answer to I can tell you that you know of. From the standpoint of. What's going on with the money that's going back into the into the this state we we don't know what happens to want to of course we haven't paid again because winning thank you but I don't think we any of us know what happens to the money the same this really savings because we're we're not turning the money and they're keeping an eye out to pay for yeah we're paying for so I don't know if that helps at all. I'm not too smart. And senator I think you know you specifically asked about the money that the we pay back into the state every year and yeah I think there's there's more that goes into that then anyone at the table can really speak to that it may be an appropriate question to ask the state but Cortes nonprofit so I just wanted you know for the member's benefit just to kind of. Walk through ACT seven seventy five and kind of how that works. That the state sets for us what's called the medical loss ratio which essentially means the amount of money that we are required to spend for direct services actually helping people in the state here has said that at ninety two point five percent which is a very high threshold which is a good thing but industry standard across the countries closer to eighty five percent so we're already spending quite a bit more money for direct services than what other states do it for the same. The same type of population the premium tax which was part of ACT seven seventy five to help reduce that DD ID wait list is two point five percent that we pay back in a week we do get a two percent administrative fee which covers just the cost of salaries you myself included and then if there's any money left over and that depends on a lot of different factors you know under the statute we can keep up to three percent S. as profit for managing the program up so there there there seems to be a thought that. The passes have a pool of money that we can access. To kind of address all of these ill all these ills or talking about that that's really not true we are we are somewhat limited in how we spend the money or was required to pay some of this back into the state so. We were doing what we can and certainly we are happy to work with our provider partners I mean they're the ones providing the services on the ground I am probably more than they need us so we're always willing to have them come in and talk to us you Corey's point it's it's capitalism we negotiate these rates a provider that goes to Cory there may be more of a need for Corey so he might give them a hundred and three percent of the Medicaid fee schedule you know they might be given only negotiate hundred one percent for us that's fine that's how the program is supposed to work but it's your deeper questions I'm afraid we'll have to defer to the state well and I know that's a manager that you I know that money is not like a check is written back that its future its pull back from future reimbursements I did wanna bring clarity to that edge but none the less it's gonna be money that's recruit down the road we've got a track it to make sure don't get lost in DHS budget somewhere but thank you measure. I don't know if five someone from DHS might want to come up and just clarify anything if there's any questions specifically on this and bread something else that I just wash is coming up just kind of filling in and I know representative fry has a question to But you mentioned something about staffing and and this committee with kind of talked about credentialing you know it's hard to retain the employees but if there's a ladder of success there's better training of you know when we had nurses years ago there was a nurse now we have C. N. H. U. an LPN to an R. and you know all the way up and and is that a potential solution to some of this is well just feedback while they're still getting settled. So for me I just wanna make sure I understand the question correctly so like a career ladder by okay so that is something we have talked about originally with this program and then a pandemic happened so we're not opposed to looking at some sort of career ladder FOR a staff you know you get this much training and there's this match and then you get this much training and there's at a higher rate we're not opposed to looking at something like that it just takes meeting with some stakeholders around what that looks like. It just. Piggy backing on that the same kind of a concept you looking at innovative ways to do things. You know another thing that we look at what our providers to as is value based reimbursement so we we provide in our contract with our provider a set of metrics and if they show outcomes with our members that meet those metrics and they may see a payback accordingly which I think is a it's a good way to. It's a good way to bring our provider partners to the table to and helping us meet the state's goal which is improving the quality of life for these populations so that that that's just something else that they were looking as well. We'll go ahead and let you all share if you would follow up with senator hammers question if you have any other details you want to add reach their. Sorry. Thank you. Thanks guys. Background. I am thanks at Melissa whether ten at director for development disabilities. Paul stone I'm with the Arkansas Medicaid or the Division of Medical Services the DHS. Many of you guys I remember Paula designed and the past program for the state I was her psychic back then we have the same last name. An Senator Hammer is happy that I've changed mine this is very confusing. And with them just like the opportunity Paul and I both would to kind of if if we if you allow it to set the scene for what we're working on it DHS in in terms of and bettering the past program and and more of a strategic plan we have around and the program itself you know I think it's important for by term member of that on our one year anniversary pollen about ourselves and coffee caps that said and we made it through twenty nineteen because we lost the house not knowing a pandemic was about that. I'm in on the one year anniversary of past once the governor announced the school closings so M. any kind of managed care program takes years to build so I feel like we have been and we have this whole in time where we stopped. The process of what we had in mind to where we'd be today and it's and we just now I within the last few months been in a place where we have the opportunity to start the second phase that we planned on starting in twenty twenty which was nineteen was let's build the processes let's teach providers how to bill let's set up the policy in the programmatic structure in in your to let's focus on program gap service gaps outcome based results for the members which is how the program is designed so I would say that that's what we're focusing on now rates as part of that and training is definitely part of that but I think we're looking at at at a much broader and look and in particular because we have so many clients right now some significant behavioral health needs both on IDT and I'm B. H. but IT is shocking the amount of clients that need significant behavior support in how we build out those programs I think everybody but we were surprised when we start looking at numbers of the large amount of children in the past program right so a lot more than than what I think we anticipated going and so forty thousand of our fifty four thousand members in the past for children so really catering services to children with behavioral health needs both ID D. and children just with the mental health issues so M.. We are trying to come up and and formalize a more strategic plans to lay out this vision so that we can talk about this in various committee meetings but I think we're touching on pieces of it in different committees but we're not laying out the full picture very well and that's on ice but we definitely see some at one of our biggest issues and challenges right now it's a major service gaps and and programmatic holes and those were there prior to pass they've been exasperated exasperated since the pandemic but we by no means blame the passes for not having certain services in place we did feel like that is on us to drive policy in terms of setting up programs and provider types so Do you want to talk about what you're working on if you might. I know there was a lot of allusion to what was called home and community based services and so no M. and and my background is is a clinician I'm an LCSW so I've been providing started out of fighting counseling services to very young children and then work for community mental health and and worked in other states before came back home to Arkansas. So you know really in thinking about the services that need to be offered to both Children and Youth in in even adult to some degree with a mental health diagnoses or those with intellectual disability that have symptoms of a mental health condition so acting out and we talked about behavioral health acting out behaviors aggression and those kinds of things is what we really know that's needed is a beyond counseling services Is those true home and community based services that are delivered with both professionals and para professionals and delivered in people's homes we can't put everyone in an institution for the behavioral health population you only stay an institution for a short amount of time and and I've got to say with with children and youth sometimes the the things that happen in the behaviors they learn an institution that they didn't go in with they come out and I may have a different set of behaviors and so we we really want to be be careful about that but but we're really talking about is providing the services. In those settings I'm particularly in the cities in which those behaviors occur and then I think as a passes are coming and looking at how the services can be delivered to support families because families are the are the core of of those those activities that happen and so I think that with that you know we have a provider community one that before the past we really have providers that we're providing services to intellectually disabled people and providers are providing services to people with one mental health diagnosis and we set out those two can't cross and I worked in Medicaid and we told everybody those two can't process to different populations you can't do that one of the reasons for that is as a therapist we provide a lot of therapy like cognitive behavioral therapy is the names of everyone of them and they don't work well for everyone so we really want to make sure the services work but the home and community based services really do have an approach that can work across populations so aligning those providers. In saying we really need at one provider type that can address people's behaviors provide those services in home and community settings where the behaviors are occurring provide enough support to families and foster families and whoever's taking care of people that they can feel comfortable in managing those behaviors and then getting people to a place where. They don't need that level of intensive service and we can do things like enriching activities how people get jobs to supported employment help people graduate from high school in in and she's career path so I think that's really what we're driving at and and the passes would be able to then pay those providers in a very different way so with Medicaid we paid people per service you click the box you provided in our counseling you get paid for in our accounts and services you got paid for an hour of her professional services you in in the school. You check on the kid you got paid for that so really what we're looking towards is instead of paying for that in that way is the passes would have that ability to pay for and services that are led by team members so that professional could lead a team of people that are going to go in and wrap around that family right around that community and really provide those services so as not less of a stating we need to really come in and make sure we got our provider type and all of that together. We've got to make sure that we have that set up where the passes can pay for the services this combination of services in a different way I and then what they'll be able to do is then pay for outcomes some said of us coming to say Hey we we paid for a service that it really work what we're saying aye the passes can go and I talked some about what they called value based purchasing. But what really what we would want to see as this team of people providing services in home and community settings and and not using a medical model really using this humming community based model and then they would come in and say did you keep that person to the hospital to keep that person out of institution and that's your measure for success and if you did then we want to know exactly how you did that in the common combination of services and we want to make sure that you get paid by what you produce not paid for an hour because you click off an hour. Of services so that's really what we're driving well and just to clarify so that the past model was never set up to be what it is at this moment meaning we were always envisioning I think all of the passes and the State envisioning getting to this. Bundle the your payments based on outcomes it'll a bill improve the providers because we have a whole bunch of providers that are dropping people off at ER's and not coming back and picking them up they're calling police and they're sitting in jails and they're not going back and picking them up. And there's nothing at this point that we've had any way of managing it or enforcing or forcing them to go back and so until we get to a point where the payment for providers is based on an outcome based measures that then we can see a valid improvement because we think all of the members in the past can improvement have a better life right I mean all of their outcomes will be person centred of course because everybody's going to be different but we think everyone we should be able to see that everyone is having a better quality of life and getting a better outcome so I think we're having these right discussions what is important to us is that the town of we never expected people to continue to build on a fifteen minute unit for supported living you know we didn't we thought we'd be in a different place right now then we are but we you know have that time work rate means you tell time differently now right pre pandemic imposed so but we are looking forward to the opportunity that we have been able to re engage and and start building it like we envisioned it and I think the pass and this and that but I lastly and I'll stop talking I need to clarify on the actuary comments. Yes under managed care regulations we have to have our rates are per member per month rate that we pay and managed care entity approved by the centers for Medicare and Cade Medicare and Medicaid and we have to use a certain type of actuary to do that work that has a stamp of approval from CMS. We are we cannot go back at this point in us to increase our PM PM when we continue to receive funding back from the passes in the rest court or. The risk corridor works both ways it is a safety net not only for the passes but for the state of Arkansas that if we give them too much money they give it back if we don't give them enough money we true up at the end and it's not like there's a some cash sitting in a statement the Medicaid trust fund rate we don't ever draw it down from that bed it's almost if we if they give it back to us at the end of the true up it's almost like it my mind I think of as a credit right there's no there's no. Cash engaged with this. Send right so we're not am I don't think we're at risk of a miss placing it or losing it is just going to the next month of per member per month but we don't set rates we don't set supported living rates we don't set therapy rates the way that managed care rates are stacked is based on historical utilization and large categories of service so D. D. rate is set as a package Aditi services so I just want to be very clear that that you know I think there's a lot of that you know we talk about well we're not giving enough and the PM PM so therefore they can't pay more on this and that and I think it just pulls down and I think they degree it's just a difference in opinion they would like us to raise rates up front. And then if we give them too much they give it back to us and what we're always saying aye go on out there and spend it and if we don't give you enough will give you more at the end so it's just the difference on who gets the money up front if that makes sense but the record or works both ways so I just think that that's important to remember what we're having this discussion. Okay that's good information of this circle in so many so many things anyway I I stayed there I know representative Johnny rise had a question for a while I have a feeling it was probably for the passes but will will continue with some other questions so representative Friday yes thank you thank you madam chair lane ladies and gentleman outside of the realm of of the care itself with the nurses and all of that therapy and all those things I'm sure that sitemizde within the building but let's just say that you do have that child as a little girl this and drama a little boy that was to play baseball and let's just say that that fifty dollar fee is put in there for baseball in order to pay the fees on it does that payment did come through the provider or does that payment come directly to the parent that pays. For that. So. Under federal and state law Medicaid funding can only go to Medicaid enrolled providers so if the M. and there is a mechanism where the passes can pay for the services but we have to do it in a way where it's passed through a Medicaid enrolled provider at this point but they can pay for swim lessons drama classes and gym memberships camps just can't account as a medical service right it would not come out of there right Medical Center so it would come through the provider. It would the past with pay the provider for that state yes okay thank. Right representive Springer. Thank you madam chair good afternoon good to see you again I wanted to follow up I think the last time you were here we were discussing about that little list that you have all those thousands of persons on the waiting list and have you develop that plan yet the monitoring. So as to help give you will move those persons off of that list. At. We use a company called the long wait a DHS to build all of our I. T. dashboards and so they are finalizing production on that the waiver has not been approved yet we received a very large amount of public comments that are actually printed in my purse I was going through some of them in together but we are inserting all of that is we have to send those to see a mass as part of the submission said the waivers to be sent this week and and so we're just waiting their approval okay all right looking forward and I'll get it to you as soon as it's nice thank you. I think that might have been the question represent a senator Hammer you were asking about time timeline did you want to ask anything else. Are there any waivers that your working on that you have not submitted to CMS because we have had conversations about therapeutic communities of assisted living there's negotiations I understand they're going on between the passes and some of the provider groups to try to ban dated over because based on when we get those. Approvals back we we may see some providers not be able to hang on if the passes can't negotiate with some of those provider groups that need to meet those essential needs so as of today have all the waivers been submitted to CMS or which ones have not been submitted that were were waiting to get finished up. So I was checking because you know there's lots of waivers that DHS so I just wanna make sure but I will talk about the C. S. waiver has not been formally submitted I'm not allowed to formally submit it until the public comment was ever in all those comments are entered so I should have it formally submitted by the end of the week a draft was sent to them a month ago to start their informal review M. as for the other parents waivers that I was approved that has the behavioral health plans was approved back in March. Works okay at the once the work the B. was approved in March and I is being amended right now. Any other member have any questions. Really. Okay. Any final comments from any of you. Again madam chair members of the committee thank you for the opportunity to to come in and visit with you I hope this is been helpful of course how many of you know us here at the table if you have any follow up questions anything comes to mind please feel free to reach out to us. One of the representatives would like your card so if each one of the passes leave a card on the table so that I may share it with her thank you. Okay I'm sorry before you leave representative hawk has a question. Yes. Ninety. Thank you I just wondered how do you ensure that one at a person complains about their service they are not being dropped by that provider. Do you all make sure that how do you manage that process of we talked about complaints early on but I'm just wondering how clients can. Ensure that they're getting the help they need even though they may be difficult to work with and are in the complaint category how do we ensure they're not being dropped by a provider. So I think I think that's more of our question only because we okay so the way that it's set up we certify the providers meaning we certify B. H. providers CS when providers so we kinda have the authority to say your meeting or not meeting your certification requirements and I'll if you are hearing complaints about clients their intellectual this disabled with their waiver provider which I to hear those complaints if that's what we're referring to the same thing. We are about to go back in to the certification manual and say when you send that when you send in a letter that says I'm unable to serve this client anymore waiver provider for explained C. we used to have a provision that said but you're going to keep serving them into you transition to another provider so there's no disruption in service yes that was pulled out when we once the pass for several reasons not strategically you know we were scurrying on a lot of issues and that it needs to be put back in and so when CMS approves this waiver I'll immediately be bringing before the legislature a corresponding certification manual will you will see that language reinserted and because we are having an issue thank you I appreciate that welcome. Any final questions anybody. Okay well thank you all presheaf the information and the dialogue and keep in mind that ultimately we're just trying to provide the best services to the people who need it most in our state and I appreciate everyone being willing to converse and talk and hear each other out so thank you and thank you members the number of people who keep coming to these meetings is just really mind blowing and I just personally just wanna thank you for being here and being engaged in I'm willing to sit through you know long meetings and and be a part of the discussion so thank you okay meeting adjourned at thank you.