Health and Human Services/Urban Affairs Committees - Room 1023

I'm Senator brian hardin. I represent the banner cumulative and scottsbluff counties of the 48th legislative district in western Nebraska. I serve as chair of the health and human services Committee. And I'll start by having members of the hhs Committee introduce themselves, starting on my far left with Senator riepe. Thank you, chairman murphy riepe. I represent omaha at district 12. I feel like I almost need to stand up. Most of our hearing rooms don't have this little lift, if you will. So I feel like I'm a little guy hiding down here behind me. I apologize for that. But we're glad to have such a big crowd here today. And thank you very much. Thank you gentlemen. Good morning. Beau ballard from district 21 in northwest lincoln and northern lancaster county. Dan quick, district 35, grand island. Senator, class Senator. Stanton from district 37, which is in buffalo county. Kearney shelton and gibbon. And we have just one on the urban affairs Committee. And we have one member. Good morning, Senator victor rountree, district three representing bellevue and papillion urban affairs Committee. It's good to see everyone this morning. And I screwed up because dan quick is on both of these schedules. Okay. He does double duty assisting the Committee today. To my left is our research analyst, bryson bartels, and our Committee clerk, corey beerbaum. Joel, would you introduce yourself? My name is joel. I'm from lincoln. Awesome. Thank you. Today's hearing will be invited testimony only. If you've been invited to testify, please fill out a green testifier sheet located at the side of the room and hand it to the page when you come up to testify. Written material may be distributed to the Committee members as exhibits only while testimony is being offered. Please have at least 12 copies. Hand them to the page for distribution when you come up to testify. We do not accept oversize exhibits, cds, thumb drives, or other electronic exhibits as they cannot be transcribed. To better facilitate today's hearing, I ask that you abide by the following procedures. Please silence your cell phones. When you come to testify, please state and spell your first and last name for the record before you testify. We'll be using a three minute light system. When you begin, the light on the table will be green. Yellow will mean you have one minute remaining. The red means you need to wrap up your final thought and stop. Questions from the Committee may follow, but do not count against your time. With that, we will open with me. This is for the LB 737 olmstead hearing pursuant to Nebraska revised statute section 81-6122, subsection four, subsection a from the newly passed LB 737, the health and human services Committee and the urban affairs Committee are required to hold a joint hearing to assess the progress of the olmstead plan and potential legislative solutions. Today's first hearing will focus on LB 737.

The 2024 evaluation informed the development of the current plan, which extends through 2032. As a result, the 2027 evaluation will serve primarily as a mid-point assessment of the current plan, rather than a development of an entirely new three year plan. The 2024 evaluation provides a useful baseline for understanding where Nebraska is today. Liz gebhart morgan, the principal investigator with with partners for insightful evaluation, will be presenting after me, and she can provide much of the detail into the plan and the progress that the plan has made thus far. Looking ahead, the department will focus on implementing the current plan through 2032, continuing to engage stakeholders, improve our outcome measures, strengthening interagency coordination and preparing for the 2027 independent evaluation. We'll continue working with the olmstead Committee to assist in the review and development of any subsequent updates to the plan. The Committee continues to meet quarterly and has several workgroups that are focused on specific areas of the plan. The participation of individuals with disabilities, families, advocates, providers, state agencies, and other stakeholders is an important strength of the Nebraska's approach to olmstead planning. At the same time, while the advisory Committee and its work groups provide advice, expertise and recommendations, ownership of the plan and responsibility for its implementation rests with the state. The Committee is an advisory body. It does not replace the state's responsibility to establish priorities, allocate resources, implement programs and continue advancing the goals of olmstead to serve and support individuals in their homes and communities. Nebraska is committed to community integration. We've established a planning process and advisory structure, and independent evaluation and legislative oversight. We've also made meaningful progress, including eliminating the developmental disability registry wait list in 2025. We will continue to build on that progress. Be honest about where the system still falls short, and use olmsted plan the olmstead plan as a practical tool for incremental improvements to the outcomes for nebraskans with disabilities. I thank you for your time, and I'd be happy to answer any questions for this hearing. Thank you, director greene. Questions from the Committee. Senator riepe. Thank you, chairman, and thank you for being here, mr. Greene. My question would be, this is the next formal review from the external consultant is in 2027. Given the issues at hand, I'm concerned about expanding this up to six years instead of the three. And we did. Was there consideration given to the idea, given the issues to back us up to 26? Because, you know, I was trying to speed read this thing, but it looked to me like it could be two years as well, 2 to 3 years to take a look at it in at this time as opposed to waiting. Time is of the essence, it seems. And so can you respond to that, please? Yeah, I sure can.

And I probably should know this, but are there any federal requirements that we stay within or is each state get to decide how their their plan works? There there is not. In fact, it's not necessarily even a requirement that states have an official olmstead plan. Many do as ways to. To show their efforts to comply with the. The ruling from 1999. But it's not a mandate or. There isn't any set structure to how that has to happen. So we just follow whatever we have it in statute. So we have to follow what's in there. And then. Yeah, so our our statute in Nebraska requires the creation of a plan. The statute also directs the frequency of the evaluation that that independent evaluation is every three years. And those would be the two things in statute that are more clearly defined. Okay. All right. Thank you. Senator rountree. Thank you so much. Thank you, mr. Green, for our opening and testimony regarding the housing. One of the questions that I had on the previous time with you in previous briefing, looking at the slides as part of urban affairs and working with our olmsted members regarding housing, we were trying to determine how much housing we have available for our disabled community. How do you track that and how do you determine what's available? Do you work with builders through this commission to determine that we need more? Well, what we have is sufficient. How do you track that to get to the number needed? Yeah, I think that that's a great question. And you've pointed out a significant challenge for our state in really trying to identify what is that number. And, and it often sometimes is, is tricky in the definitions, right? Affordable to one is not affordable to, to another. And so, and even accessibility, right. Can can vary widely. And so that has been a challenge that the Committee as well as the work groups who are kind of focusing on housing, have been challenged with. We do not today that I'm aware of, have a like an inventory county by county or by state that says, here's what we do have available in affordable housing. But I know it's something the Committee is working on trying to establish. So it's a vibrant living document. As issues arise, you're able to resolve those and take care of those without waiting for us to get to maybe december 27th. We just kind of handles as we as we get to those. Is that correct? When I say that it's living and it's vibrant and alive. If an issue arises today, something that the Committee identifies, you can implement today to fix those and continue to provide good life. Yes. So those committees meet regularly to tackle kind of their part of the plan.

And that might look different for somebody else with a disability that maybe wouldn't be drawing social security, but still needs access to that accessible and affordable housing. So I don't know if I've answered your question directly, but I think it it is a challenge that the committees tackle in trying to take all of the data and the input that they have from stakeholders and create those strategies that will help move some of those larger goals that are identified in the plan. Other questions for director green. Seeing none. Thank you. Thank you sir. Liz. Gephardt. Morgan. Welcome. Good morning. Good morning, chairman harmon. Members of the hhs Committee and urban affairs Committee. I'm liz gephardt, morgan, lizgebhart hyphen morgan. I work at partners for insightful evaluation and was the primary author of the olmstead plan evaluation report submitted to the Legislature in december of 2024. And I really appreciate the opportunity to be here to talk to you today about that. As you know, Nebraska statute requires an independent evaluation of the olmstead plan every three years, really to assess progress and identify opportunities for potential revision. Pi was responsible for evaluating the 2023 to 2025 olmstead plan, primarily focused on fiscal year 23 and 24. So looking primarily at july 2022 through june of 2024, just given the nature of the timelines, through our evaluation, we explored the progress that was made on the plan, any observed impacts and improvements, facilitators and barriers to that progress, and then opportunities for strengthening the plan. And we looked at this through a variety of data sources, including interviews. We conducted a survey for individuals with disabilities and their families, a survey with partners and advocates, and then also focus groups. Another aspect of our evaluation was actually doing a review of olmstead plans or related documents from 22 states and the district of columbia. There's additional information about those data sources in ththe handout. For more context, as part of our review of the olmstead plan, there were seven goals that we were looking into, and among those seven goals, there were 41 outcomes. Those are monitored by dhhs on an annual basis through benchmarks based on that data. The fiscal year 23 data indicated that 71% of those annual benchmarks had been achieved. The next fiscal year, 56% of those annual benchmarks had been achieved. It varied based on the topic area about the level of progress and the accomplishments seen, and there's qualitative context provided in the evaluation report and subsequent summaries that were provided to each of the workgroups, so they could dive into the data a little bit more fully. We we identified many different facilitators and successes we consistently heard across the board, no matter what topic area that limited funding, workforce shortages, and also just limited information and awareness about the olmstead plan really prevented some of that progress.

You know, on the on your handout, one of the handouts when you and you talked about it a little bit, but the 71% benchmarks in 2023 dropped to 56. And is that because maybe you accomplished some of those in 2023? Or what was the reasons for the drop? Part of it, we treat it as a living document. Very much so. And so what was challenging is that, and one of the goal areas, we actually lost funding. And so the initiatives connected to some of the outcomes and benchmarks couldn't be accomplished. And so when funding changes or the political climate changes, it just makes it tricky to follow through on goal earmarked. Things I should know. But how does the funding is that for the state then, or is that funding from. How does that work? It's through various departments, so I'd have to double check on which federal agency it was specifically for. Oh, it's federal funds, probably. Okay. All right. Thank you. Is there a riepe. Thank you. Chairman. I guess I want to build. Trust in your organization such. And so I'd like to know a little bit. Did. How long is your organization your independent of dhhs. Is that correct? Okay. And how long have you been serving in this. I'll call it a consulting role. Yeah. I've been with partners for insightful evaluation since 2020. And then before that was an evaluator with dhhs and then was in the state of missouri. Okay. And do you have agreements with other states outside of Nebraska? Yes, we do not specifically for olmstead, but we also have agreements with the state of maine, the state of colorado. And I think we had one in north carolina. I want to say I'd have to double check on that with my. Okay. That's helpful to establish this credibility for me. Thank you. Chairman. Any other questions, Senator ramsey? Thank you, chairman, and thank you so much for your testimony. As you have been evaluating and producing reports. One of the questions or one of the oppositions to the bill that brought us here was that we get the reports and nothing's ever done. There's no outcome from the reports. And I said our desire was that once we got the report and this update, if there are any shortfalls or areas that are missing that we can address legislatively, that would be a desired outcome. So as you have been evaluating and producing reports, has there been any viable legislation that has been brought forth based upon what you've determined? That would be a really good area to explore as part of our next evaluation of the olmstead plan. Off the top of my head, I can't think of any legislative solutions that would help modify that, but I think it's definitely worth noting to explore in our next evaluation. Thank you. And second question, paul, we talked about limited funding.

We did a sampling of individuals who are currently receiving supported employment services or previously received services, who we interviewed and were given the opportunity to provide feedback on levels of satisfaction, meaningful services and also areas of improvement. The workgroup also shared resources and trainings throughout the year to gain increased understanding of evidence based practices. Under goal two, the employment workgroup generated a list of metrics to be studied in order to better understand timeliness and engagement of services and quality outcomes. As a result, we are created a supported employment data snapshot and the workgroup studied the data together, asked questions and offered recommendations. And finally, under goal three, the workgroup discussed and shared existing resources for students, families and teachers, highlighting the benefits of employment and available supports. There was time dedicated in between meetings and also as part of the monthly agenda. To learn more about business outreach and to brainstorm more coordinated ways to support businesses. In closing, the employment workgroup is a dedicated network with a focus on advancing the goals and activities outlined in Nebraska's olmstead plan. Some members serve on the olmstead advisory Committee, while others attend because they share a passion for ensuring all individuals have access to employment. This workgroup has advanced into a center of accountability and sharing. In order to maintain a momentum and drive impact, we must continue to discover new ways of engaging key partners. Some of these key partners are already identified and listed in the olmstead plan. Others will be realized as the priorities evolve. This isn't work. Any one agency, office, provider, or individual can do alone. The power of our plan is leveraging the collective interest, resources and determination to make things better for those impacted most by Nebraska's olmstead plan. Thank you for the opportunity to testify today. Thank you. You bet. Questions? Senator. Thank you so much, chairman. Thank you, ma'am, for the testimony and giving me some insight onto this particular part of the plan. Just a couple of questions. We talked about tg supportive services. However, were people into the workforce and also bringing new partners on board. I know that it's kind of spread across the board, but are we seeing new partners come on board where we have place to place our members for employment and budgetarily? Have you seen a decrease in availability of funding for providing those supportive workforce opportunities? I guess, has anybody had to come out of the workforce because of funding? Okay. I'm not aware of anyone coming out of the workforce due to funding, so I'll start there. I will also mention that specific even to Nebraska vr, we have dedicated business services staff who are constantly doing outreach to communities across the state to talk about businesses or talk to businesses about the benefits of hiring people with disabilities. We speak to hundreds of businesses, and we have partnerships with them in order to help support that.

We're meeting with individuals one on one to talk about employment. Thank you, Senator. Thank you. Senator, a question, and you just kind of alluded to that. Do you have any vr desserts, so to speak, across the state, or do you have areas that are significantly understaffed to provide those services? We are actually fully staffed right now, so it isn't a matter of staffing. We do travel, so we're out on the road trying to make sure that our areas have the appropriate coverage. I think maybe to part of your question, we see more referrals to employment services in some areas rather than others. And so we do track that data. So we have a better understanding where we could be doing more outreach to those communities to increase the number of people served across the state and in those particular counties. Thank you. Questions. Thank you. Thank you. Tobias orr. Good morning. Thank you for having me. My name is tobias orr. That's tobias last name or orr. So I'm the director of the Nebraska assistive technology partnership, also known as atp. We are Nebraska state assistive technology act program, and we're located within Nebraska vr and the department of education. Our mission is to help nebraskans with disabilities learn about and obtain the assistive technology they need to live, work and participate fully in their community. Since 2016, I've had the privilege of serving on the advisory Committee, and for the past several years, I've chaired the housing work group. Today, I'm here to provide an update on the work of the housing work group and the progress we have made towards the Nebraska homestead housing goals. The housing work group brings together representatives from state agencies, agencies including dhhs, department of economic development, Nebraska investment finance authority, along with advocates, housing providers, individuals with lived experience. The group met monthly over the past several years and recently transitioned to a quarterly meeting schedule. As our work has matured, our primary responsibility is to monitor and advance the four housing goals identified in Nebraska's olmstead plan. Over the past year, we've had significant progress in goals one, two, and four, with work on goal three to begin next spring. Under goal one, cross listed resources to enhance access to affordable and accessible housing for individuals with disabilities. We're continuing to expand the use of Nebraska dot find help.com as a centralized housing resource. All low income housing tax credit properties and developments. Receiving department of economic development funding are now listed on the platform. Also, accessibility information was enhanced by updating property surveys to include sensory and mobility accessibility features. These improvements make it easier for individuals with disabilities and service providers to identify housing options that meet their needs. To ensure the platform is widely used. Training has been provided by nifa to state agency staff, regional housing coordinators, housing authorities, property managers, educators and social workers.

We had 850 searches per month on that. $4,850 000. Okay. So that's quick. So I missed 4000. Okay on that. So that does provide a lot of good opportunity or information back to those that are searching to find homes and have those needed. Okay. So then we talked about the mental health illness and awareness training. Can you just hit just one more time for me? So as far as for finley.com or, or the. For the yes.com and also for members to be able to provide services or homes. So as far as.com. So it's an ipo that heads that up. And they've been doing trainings and presentations everywhere. I've run into john turner consistently at every event talking about finley.com. And just to clarify, findout.com is a has various resources on it for individuals, from housing to food to everything needed for living. We focus on the housing part. That's why they gave you the numbers that 65% of the searches on find help for Nebraska are housing related housing. As far as the serious mental illness, I know they've been doing training to regional behavioral health coordinators and other divisions, specifically pointing towards find health.com. And then I think just some other of the barriers that they identified in their review, they're doing training to kind of overcome some of those. Okay. Thank you. What about those hud funding vouchers? Yes. Those again. As much as I can. Yes. As much as you can. So yeah. So Nebraska was awarded the 811 housing vouchers. And I know 35 of the 140, I believe it was have been issued just this month, I think might have made that decision. So those will be attached to, I think it was how many projects it was. Find it real quick. Maybe 60. I don't have the number of the exact amount of projects, but they are moving forward. So these will be new new builds, apartment complexes with housing vouchers attached to specific units. Okay. Outstanding. And lastly, on the go forward, we had like 12 new contractors with eight more on board. Yes. To help address the housing need. So specifically that's atp. So we do home modifications or assessment modifications for all the waivers in Nebraska as well as we work with Nebraska vr some private foundations. One of our biggest challenges is contractor recruitment. Specifically when we're using waiver dollars, those contractors must be medicaid providers, no different than a nurse or a doctor. And anybody that knows, contractor knows they don't like paperwork. We also have background checks and things like that. So it is it is difficult to recruit contractors. We put a lot of effort and resources towards making that process as streamlined and easy as possible. And then just the marketing, the outreach to get them to come on. Thank you so much. I appreciate it. Thank you. Senator, quick. Yeah. Thank you chairman.

So you're receiving an executive summary from doctor lisa mills, who we contracted with in our past state plan to look at ways we could improve employment for those with intellectual developmental disabilities. And her work in 2015 came up with this really great report. So the executive summary is there. And then in addition, we hired her for an additional year. She helped us facilitate a supported employment work summit and then create a coordinated, supported employment work plan. And as a result of that, we hired an in state subject matter expert to continue that work plan. And we've made a lot of progress, and we're really happy that some elements of the work of doctor mills recommendations and the olmstead or the work plan have been incorporated into the new olmstead employment goals. So here's just a few things I want to stress the importance to keep the movement going, we need to prioritize meaningful employment and data sharing. Clear data communicates what Nebraska values, and Nebraska vr has really made strong improvements in that area by releasing some of the outcomes specific to disability groups. The next thing I want to stress is that we need to ensure that dhhs and Nebraska vr share data on waiver participants who are referred to and ultimately receive services from vr. Both agencies must collect and share the data on the number of transition age youth, those that are leaving high school and are they deciding to use vr services, or are they going into waiver de services, which really is more expensive in the end? Miss larsen, over three minutes. Okay, I do, I might, yes, and there's additional recommendations. You can see that. But bottom line, I think it's been alluded to that every work group needs to have the key agency partners there. And without key agency partners, it's really hard to make progress on. And we need a more detailed plan to ensure that we're making meeting deadlines and not missing deadlines and that sort of thing. Thank you. So I know it's a lot. I'm sorry. I try to get it under three minutes and but. Thank you so much, chair, and thank you so much for this testimony. I put the spreadsheet here as we look at the sharing, collecting and sharing of data. Has there been any difficulty in getting data back and forth or. No, actually, well it hasn't, it was a little delayed, but I'm very pleased that Nebraska vr has been able to share that data, and they've been able to break it out into specific disability groups. So we've been able to see the data of how many people they're serving who have intellectual developmental disabilities, traumatic brain injury, autism, mental health, serious mental health issues. So that's helpful really.

And then but those folks stay with the schools, with the high schools, with transition programs, they're not necessarily going to be the ones that help them out into the community. So I think there's just some systemic issues there that we don't quite have that it's just it it'd be easier if I know I'm working with my job coach here, and that job coach is going to continue working with me as I go into adult services. But the system is just not in Nebraska. It's not set up that way. We have hired a contractor or a sub recipient recipient, sean roy from transcend. He's been doing a lot of work with us. You can see on our website. And he actually visited with me and he said, you know, it'd be one of the ideas is if this vr could hire the supported employment providers that they ultimately use when, when folks are through transition to work with them in the schools instead of the vr pre ed staff doing that job coaching work, if they could hire the supported employment staff that are going to do the work anyway, as they then they can follow them along and it's a more seamless process. I should ask you, I visited like our goodwill in grand island, and they do a lot of work with people with disabilities and actually do some job training there. Is that just an added resource, or is that something that through. That. That I my understanding is that goodwill of greater industries, they are a supported employment provider. So they get re there's a payment system that's set up with Nebraska vr, and they're very passionate about meeting those demand or helping people work. The. The concern systematically is that when people start working, there's this milestone. And once they are employed, like for 90 days or something like that, once they reach successful employment, then the vr job coach will step back. But as we all know, employment can change. We can have a new manager, we can have the economy, can have some struggles. We can have covid. I mean, we would they need that coach to come in not all the time, but there needs to there needs to be a process for long term supports. And our system right now doesn't have that set up really well. Those supports really should be coming from the dd waiver system. And it's just because funding is so tight, budgets are tight. It's we haven't figured out a better way to address that so that, that it's supporting people and keeping their jobs because what happens, they lose their job. And you know what? They have to go back to vr, have another referral, and they have to restart that process all over again. So the cycle starts over again. And that's that doesn't make sense.

So while the current federal administration has chosen to take a narrower view that does not eliminate the responsibility and nebraskans had recognized the importance of supporting people with disabilities, disabilities and families. And since 1981, nine years before the first americans with disabilities act was passed. The unicameral past LB 389, the disabled persons act and family support act funding in that bill, described the state's commitment to supporting disabled people, strengthen families, and promoting independent living. What's important. To realize is that disability does not discriminate any person from any income, ethnicity or location can enter this minority group at any time. A prime example is me. I was 27 years old, a practicing registered nurse, a wife of an individual on the air force, and the mother of a two year old son, and we were living in madrid, spain. I developed new symptoms. However, they didn't improve, but the end of a week I was in the hospital. They did multiple tests, couldn't find out what was wrong with me. I continued. I was moved to the intensive care unit. I probably shared by my first clue. Anyway, I went to bed one night and I woke up two weeks later and I was paralyzed from the neck down and on a ventilator. So that's why I'm so adamant about olmstead, why I am a second class citizen overnight, essentially overnight for me. I spent two years in a hospital and in nursing homes. Then food is being put to bed at 4:00 at night or in the afternoon. However you want to look at it. I on their schedule and yeah, everything was done to meet the staffing needs, not to meet my needs. Thankfully, my family remained intact and I have. I have benefits and resources that allowed me to continue living at home, but not everybody is as lucky as I am. Recently, disability rights and I conducted a survey that went out to people with disability, family members, friends and allies asking people how they thought Nebraska was doing on olmsted. I have sent the full 98 page copy of the survey and all the responses to each of you and. But you did receive today. Highlighted version that we developed of just some of the responses, because I thought it was so important. I thought one of the survey responses. Buried my. Is that I need to focus on the needs to invest in community based services in a way that makes true choice and community integration possible. It is not enough to say that individuals have a choice to live in the community. If the services workforce funding housing, transportation, and other supports needed to make this possible, I'm not available. This response reflects a broader concern. Nebraska has invested substantial resources and institutions. Wheelock failing to provide supports and services necessary for a strong home and community based system. This includes a lack of oversight into what dhhs does.

If you don't have your own van or whatever. In 2025, LR 251 was introduced to look at the state transportation system. Excuse me. However, this was introduced into the body a but the chair of the telecommunication and transportation Committee refused to have a hearing on it. Nebraska has a responsibility to make sure our state is constantly working to provide home and community based services to our citizens, to those that currently have disability, and to those that may not have yet, because the national average said one out of four people will become disabled in this country. According to the developmental disability that. Disability is a normal part of the human experience. No one should have to leave their home or community just to get service or get stuck in a nursing home or hospital with no way out. I have gone through four government governor's terms trying to get homes and interiors because in most states, the governors are the ones that push this forward. But john. Hansen. Hendrix. And governor palin will not do it. So I want to thank the unicameral for eventually seeing the light and introducing the bill and passing the bill. Eric, this valley should not be political. It's a bipartisan issue. And I call on the legislation to prove that people with disabilities matter. And if they're any questions, I'd be glad to answer them. Thank you, mrs. Holt. Questions. Thank you, mr. Chairman. And thank you, ma'am, for this really inspiring testimony. But it tells life like it is, and I appreciate that. And that's what I tried to do, is to focus on what people are really facing out there versus all the pretty words that you're getting from everybody else. Yes. And we are. We're just one breath away from dying. We're just one step away from being disabled ourselves. And that is something that we can never forego is the compassion and the understanding. Our society is only as strong as the effort that we put into taking care of our weakest citizens, and all of us together, taking care of one another definitely can make this state a better state and better place for all of our citizens. And you missed it, I did, thank you. Yes you did. Yes you did. But I sorry, I see you and I have a conversation, so I appreciate that. But this is good information. Hearing about the $700 to get from omaha to lincoln and then not getting picked up. These are the realities of what we deal with. And sometimes if you have everything that you need, we tend to forget about those who may have lack or not have a need. So we want to keep our focus on that. So I thank you for what you've shared.

My name is jodi thomas. I want to thank you, chairman and members of the urban affairs and health and human services Committee. My name is jodi thomas jay omithomas, and I am the chair of the community sports workgroup for the Nebraska olmstead plan. I'll be direct. Community supports is not making the progress it should. And it's not for lack of trying. It is because the people with the authority and responsibility to move this work forward are not at our table. The housing work group has john turner, as you heard earlier, who is. Professional responsibilities align with many of that workgroup's goals. Transportation has providers and. Jodi gibson from the Nebraska department of transportation employment has, as you heard, lindy foley. And they're doing a great job. Community supports does not have regular participation from the key partners named in the olmstead plan. I did hand out our portion of the olmstead goal. So you didn't have to read all the whole thing if you just wanted to know about us. But and on that, our goal one, you can see that our key partners are mainly state state departments, the department of behavioral health, the department of medicaid, long term care, various things like that, certified community behavioral health clinics, cbcs are one of our community partners, but they're located throughout Nebraska and have a range of services. Are we expected to contact every one of them to try and find a person that can represent them? The managed care organizations are also named as our key partners. I have personally asked two of them more than once to send a representative. No one has attended or responded. I have repeatedly asked for the names of people responsible for these areas. I have sent emails and received no response. Some state contacts respond only when I include another olmstead Committee chair with mine. I'm a volunteer chair that should. That should not be how this works, but community support goals are broad. They include transitions between health care and adult services, access to home and community based services coordinator. Thank you. My printer printed on both sides. State systems. The direct support workforce, data collection, communication, access and self-advocacy. We cannot address goals that broad without the state agencies and other organizations responsible for those systems to participate in the work. I am asking these committees to hold dhs this Committee. Sorry to hold dhhs accountable for implementing the community supports portion of the olmstead plan. Require the agencies divisions. Other key partners named in the plan to attend our meetings regularly. Identify who is responsible for each activity, respond to our questions, and report measurable progress until the reasonable partners are at the table. The responsible partners. This workgroup cannot do the job Nebraska has asked it to do. Thank you, and I are happy to answer any of your questions. Thank you. Questions. Senator ramsey. Thank you so much, gentlemen.

I have to admit, I wasn't great about getting about doing minutes for a while, but we have kind of gotten into a system. But there's probably. 6 to 10 that come regularly. You know, people that they see that we're not accomplishing anything. They don't want to take an hour out of their day to just come and find out. We don't know anything more than we did before. That's also why we went to a quarterly meeting. And did the meetings. Are they in one location like in. We're all virtual. It's the same. We're the third wednesday of every month at 11 a.m. Okay, so really, there's no reason people can't attend if it's a zoom meeting, right? Yeah. Yeah. Well, you know, I mean, they all have jobs too, so but yeah, but we make it pretty easy. Yeah. Yeah. Well, I think the input from everybody is important, like you say, to, to complete the goals that you wanted to write. And do you have bylaws or something that regulates your. No. Okay. All right. We do have a lot of individuals with lived experience on our Committee because it's community support. So, you know, it brings a lot of people, but we don't have the representation from the state departments that we need. Okay. And then once you're like for your meetings and does that go back to the full Committee, then eventually. We yeah, all of the Committee chairs report at the advisory council. Yeah. Is that something that comes up though? I'm guessing maybe that happens with other committees. Oh, I bring it up every time. Okay. Yeah. All right. Yes. Thank you. Any other questions, Senator campbell? Thank you. Chairman, thanks for being here. You mentioned that you don't get a response from the state agencies unless you cc another Committee chair does. Kirsten larsen? Yes. Are they then participating in some of these other committees and just not. Kathy's on our Committee? Kristen is on our Committee when she when she can. I mean, the folks who you're not getting participation from. Oh. No, they're not participating in other committees. Oh, wait, I'm sorry. Ask me that again. I'm just. So the folks who are not participating that you would like to get participating in community supports, are they participating in some of the other committees? Well, and I have to say, voc rehab does come to our community supports. Lindy was great about finding someone who could come to all of our meetings, and they come and they report to us what happens at the employment Committee. That's the only one we have somebody from the education Committee. So we have from other work groups, but they're not the people that can give me the answers. They're not the people that can bring us information. I see and do.

It affirmed the right of people with disabilities to live and thrive in their communities, instead of being hidden away, warehoused in massive cindy institutions. As is so much the history and mistreatment of people with disabilities throughout throughout history, I want to. I also want to thank Senator rountree and unicameral for calling this hearing as this right is under attack in june of 26, the us department of justice issued a public opinion warning that the department did not believe in the integration mandate and did not interpret olmstead in the way that it has been for over 30 some years. And in july, it announced that it would not be enforcing this right. The department's slip, opinion and memorandum, as cathy had said earlier, are not legally binding. However, it is a clear and dangerous signal that the administration will not enforce the integration mandate or support programs that are essential to community living. In the wake of Congress's enactment of h.r. One, home and community based services are already in the crosshairs in every state. As a result, people with disabilities will be faced fewer services, reduced independence, and increased institutionalization. Combined with the presidential executive order 14321 call for institutionalizing people who are homeless because it is assumed that they all have a serious and persistent mental illness. The unsuccessful proposal to reduce compensated hours for caregiving under the Nebraska medicaid waivers, recent statements, recent statements by folks that say Nebraska will still advocate for hcbs services but will not hesitate to promote institutions. The importance of Nebraska's commitment to fulfill the obligation and promise of olmstead and its decision, and to enable Nebraska disabilities to actualize their right to live in the community, has never been more precarious or urgent. I sense more and more the responsibility to ensure this right will increasingly be left to the states to handle. One of my mentors many years ago had a saying that that is pertinent to this discussion today, and that is rights have responsibilities. In order to exercise your rights, there is a responsibility for the state or the administration to provide the means, methods and mechanisms to exercise these rights. The message from the us department of justice's decision to erase the established right of people with disabilities, to live in their communities, and to be free from being institutionalized unnecessarily or against their will, leaves disabled nebraskans with a civil right, but nothing to enforce that right. Essentially the same thing as not having the right at all, thus having a robust, comprehensive and collaborative olmstead plan will be critical for Nebraska policymakers to maintain their focus, direction, momentum, and fidelity to the spirit of olmstead. Having a right to live where one chooses is fundamental, with the same gravitas as freedom of speech, due process rights and equal protection, state leadership and commitments to provide sufficient resources to implement Nebraska's olmstead plan will be instrumental.

So I think the olmstead plan, in conjunction with the road to housing will play, will be a synergistic effect and will be instrumental in in developing those affordable, accessible housing. And then lastly, and the last legislation, I proposed a bill dealing with our disability housing a 5% for physical disabilities and a 2% for visual hearing impaired. Do you think that's reasonable? Does it put other restrictions out? Should there be more? Should be less. I mean, you're dealing with multi multiple units. Well you know I don't I don't know. I don't have a specific number for a percentage. But but I do believe that would be a good start. The 5% as we as you had introduced originally your bill, you know, and I think that I think that that this funding, if we can get stakeholders on the table and develop a package to apply for and receive these funds will go will go very far in, in creating those affordable and accessible houses that people with disabilities need. It's a it's a severe shortage. And I remember my friend vince, who has a disability and he was homeless for a while and he, he literally had to hide behind dumpsters in the alley so he wouldn't get mugged on streets of lincoln, Nebraska. I think ketv did a story on him and and followed him around and trying to find the dumpster that they can he can hide behind so he can get some sleep in his chair overnight. It was, it was it was a hair raising story. And what they said back then was that, you know, homeless shelters are not usually accessible to persons who have a mobility impairment or disability. So there he couldn't go to the homeless shelters and he couldn't have he'd never have have housing. So he's basically living on the streets for a while until he could get finally get some affordable, affordable and accessible housing, which took a while. Right. Thank you so much. I appreciate that. Other questions. Seeing none. Thank you. Sure. Mary phillips. Hello. Good morning. Good morning senators. My name is mary phillips. That's maryphillips. I am here to testify as the co-chair of the education work group from the olmstead advisory Committee to share the progress of our education workgroup. The education workgroup is composed of both members and nonmembers of the olmstead Committee. The membership roster is attached to my testimony today. I represent the arc of Nebraska on the advisory council, and I am also a retired director of special education for an educational service unit. Esu six, by the way, and most importantly, I'm a parent with lived experience having a 38 year old daughter with developmental disabilities. The vision of the education workgroup is that nebraskans with disabilities have equitable access to high quality educational opportunities that prepare them for meaningful participation in their communities.

We just very recently received the complete list that we needed of all the esu, all the esu special ed directors that we were inviting to our workforce roundtable and a listing of all of the state college deans. We just recently received that. We've been asking for it for several, several weeks, a couple of months now. So another barrier that we have is that obviously there's no funding for olmsted. And so we're planning a round table with $0. So we're thankful for having partners like monroe meyer, who are who are able to help us out with locations and, and with supporting this endeavor. We know that bringing highly qualified stakeholders together will help contribute to a plan to really help us with recruitment, with training, with retention, to meet these workforce strategies that we're facing in Nebraska. And it is it's not a singular issue in a certain part of the state. It is across Nebraska. We're these workforce shortages, and we're not just talking special ed teachers either. We're also talking about related services staff, paraeducators, ots, pt speech pathologists, nurses, all the folks that support these students to have meaningful educational opportunities. So I'm open to questions. Thank you for inviting me. Questions. Senator. Thank you. Senator. I have a few questions. Esu six. Where is that? Milford. Milford. Okay. And then when we talk about these shortages, is it salaries? Is it the work? Because it's it's. So that's really what the roundtable's job is to do is to help us determine why are we not getting candidates, teacher candidates coming into these colleges? What, where, what retention strategies are being implemented right now? Where are we finding shortfalls? We don't know the answers to these. So in light of not being able to have a robust Committee meeting on a regular basis, we thought bringing people together in a round table might help us understand some of these barriers. So what type of funding are you looking for from where new and all those things. Oh, well, you know where I'm looking for need to increase the the amount of money that comes into special education rates. We, I mean, we can start talking about that, but I, I personally think it would my professional opinion here would be it would be helpful to have some type of program for teachers or for students coming into the teaching field, whether it's student loan forgiveness or whether it's some kind of a incentive pay stipend, something. And I, I know we're in a tight budget year, but teachers in Nebraska are 45th paid lowest in the country. And yet we have some of the highest outcomes for graduations and and that kind of thing. But my focus truly is on special education.

So we do have a strong partner with the department of ed, but we we would like to see more partnerships with the higher ed community. We would like to see more partnerships even with the esu. And those are areas where it's just hard to get them to come because they're already working, you know, long jobs. Thank you. Yeah. Any other questions, Senator catherine? Thank you chair. Thanks for being here. Follow up on Senator. Quick question about. So in terms of getting folks to attend, you said they don't have they're not set up to be released to come. Does that mean they have to, like, take time off to come as opposed to getting paid to go? I'm sure they're paid to come. If they came, right, this would be underneath under their umbrella of, of work experience. But it's more of we, we don't have any stipend to come. We don't offer any mileage to come. So they would have, they would be at the mercy of their place of employment if they did come. But as jodi said, our meetings are virtual anyway, so we're not asking people to come to us except for the roundtable. But we also will offer that virtual. Thank you. Yes. Other questions? Yes, Senator. Thank you. Chairman. Thank you so much for your testimony and your lived experience and professional experience. And you said that as an equities and resources that are urban and rural areas. And I know that's pretty broad. How do we get those resources? The the better resources out to the minimal areas and so forth. Those areas want those resources. Is there any push back on certain things as far as resources are concerned? The resources are many of the resources come directly from the school districts themselves, and some of those school districts just don't have the funds. I've had superintendents tell me, yes, I know I need a mental health specialist in my district, but second grade classroom desks are 20 years old, you know, or my cinder track needs replaced. I hear those things. And then that tells me the priorities for that community are not a mental health professional in the school system. Thank you. That clarifies. Yeah, that's just reality. It is. Thank you. Yes. Another question. Seeing none. Thank you. We appreciate you. You're very welcome. Before I go, I just would like to also recognize and thank my spouse, major dorn phillips, for attending. This is his first hearing and he came today to be my biggest cheerleader. Thank you. So this is this has. Been atypical. This hearing has been atypical for the for the Legislature. We don't normally have two committees come together, whether it's during the session or during the interim. And so this has been an enjoyable thing, I think, for us to be a part of. So I was just going to ask you, vic, would you mind just.

I'm Senator brian hardin. I represent legislative district 48 and serve as chair of the Committee. I'll start by having members of the Committee introduce themselves, starting with way over here with Senator ballard. Beau ballard, district 21, northwest lincoln and northern lancaster county. Dan quick, district 35, grand island. Senator merv riepe is here and he will be back shortly. So assisting the Committee today is our research analyst, bryson bartels, as well as Committee clerks corey bierbaum and rebecca bartunek. And, joel, you're still here. You decided to stay. That's good. We keep trying to discourage these young people, but they stay in there for more. Today's hearing will be invited testimony only if you've been invited to testify, please fill out a green testifier sheet located at the side of the room and that to the page when you come up to testify, written material may be distributed to the Committee members as exhibits only while testimony is being offered. Please have at least a dozen copies. Hand them to the page for distribution when you come up to testify. We do not accept oversize exhibits, cds, thumb drives, or other electronic exhibits as they cannot be transcribed. To better facilitate today's hearing, I ask that you abide by the following procedures. Please silence your cell phone and when you come to testify, please state and spell your first and last name for the record. Before you testify, we'll be using a three minute light system. Or will we be using a three minute light system? We'll be. We'll be using a verbal system. So you'll just have to trust us on that one. Hey, we want a system, he tells us. Okay, so we're we're all friends here. But I might say, help us out, help us out. And so questions from the Committee may follow. And with that, Senator rountree. Good morning, chair hardin and members of the health and human services Committee. My name is victor rountree. Victorrountree, and I represent district three, which is made up of bellevue and papillion. Today I'm here to introduce LR 404 to study the changes that have been implemented by dhhs to the various home and community based services waivers in our state, as well as other issues facing the disability community. LR 404 has a broad reach, which is important to fully encompass the different stresses on our hcbs system. The resolution lists eligibility requirements and caps placed on waivers. Assessment tools used by the department to determine needs of those with developmental disabilities. Entering into a 1634 agreement with social security, and the use of algorithm based assessments as topics for research. Each of these topics could be a separate hearing on their own, so I ask that we take the time we need today to discuss the serious impacts families in our state are facing, and consider how we can help them move forward.

The hcbs waives included the aged and disabled waiver, the development of disability, adult day waiver, the comprehensive development of disabilities waiver, the traumatic brain injury waiver, and the family support waiver. These waivers serve 17,644 people in 2025. July 1st. This year, the department implemented amendments to three of the waivers change in service limits, billing practices and coverage services. I've included copies of a memo from our amazing legislative research office that describes these changes and death. I'll briefly cover the changes, but again would encourage you to ask questions of the subject matter experts behind me for more specific information. First, the department ended its contract with the league of human dignity, which calls the shift in service coordination and case management. Dhhs has assigned service coordinators to cases that were formerly managed by the league. These changes were done as a cost saving measure, but causes concerns about reduced hours for patient and overworking department staff. Next, the department established limits on the amount waiver services that can be authorized for participants of the a d waiver. The limit is 150% of the average annual cost of nursing facility care, or a threshold of $138,657. If an individual's needs exceed this amount, they can apply for an exception to the limit. The department has also made changes to billing and reimbursement methods for ad waiver providers. Dhhs replaced negotiated reimbursements for a number of ad and tbi waiver services with a maximum reimbursement rates. Dhhs claims this is part of compliance with federal medicaid payment transparency requirements. Individuals behind me may be able to explain from a service provider perspective what the changes in reimbursement mean for their businesses and for patient care. In regards to the development of disability waivers, it is important to remember that the state in recent years underwent the process of ending the waitlist for services. In 2024, there were 2704 individuals on the waitlist for developmental disability services. As of 2025, there was officially no longer waitlist through expanding access through other waivers. This process in and of itself has large impacts for what services look like for families. Effective july 1st, the department restructured dd waiver services, splitting residential habilitation into separate services and adding other services. The department also implemented the electronic visit verification process in 2025, which has caused issues for service providers. I've heard stories of service providers who are working with a patient but cannot do certain activities due to the complications of the system. For instance, a family home may be recognized as the location for the app, but the family barn nearby cannot be registered for the building. Verification or service provider would have to change the plan activities for the day and take the client to a store or other space that has not was not originally planned. They are unable to register those hours in the system again.

It looks like they are going to wait and then make it hard for you later. That would be fine. Thank you. Sir. I appreciate it. You will be sticking around. I'm here for the day. Yes. Thank you. Director tony green. Welcome back. Good morning, chairman and members of the health and human services Committee. My name is tony green, tonygreen, and I am the director for the division of disability and aging in the department of health and human services. I appreciate the opportunity to discuss the department's use of the interrai assessment and the transition from the inventory for client and agency planning, more commonly known as the icap. I want to emphasize the dhhs supports the continued use of the nri assessment as the foundation for assessing the needs of participants on our dd waivers. The transition to interrai represents an important modernization of Nebraska's assessment process, and provides the department with better information to understand an individual's needs, strengths, risks and available supports. The interrai system is more comprehensive and validated. Assessment approach. It was developed specifically to provide a broader, more holistic understanding of an individual's functioning health strengths. Risk preferences available available support and support needs. Rather than looking primarily at isolated functional limitations, interrai considers the individual in the context of their overall health and daily life. That distinction is important when the department is making decisions about the intensity of services and support an individual may need. The goal is not simply to replace one assessment with a with another. The goal is to gain a better, more complete understanding of the people we serve, so that services and resources can be aligned with the actual assessed needs while considering all available resources. Without unlimited funds. An approach such as this is fiscally responsible, necessary and complies with Nebraska statute requiring an objective assessment process. You'll remember when we launched the elimination of the waitlist initiative, we indicated a new approach was necessary. That was that was more needs based, fair and equitable for all the old way of just waiting and getting services or getting access to all services after a waiting period of 6 to 7 years via the comprehensive waiver without regard to need, is no longer sustainable. Implementation of new processes and a system can bring about challenges. You will likely hear about some of those from testifiers after me. Obviously, we strive for thorough and accurate assessments as a result of some of the challenges in this area. We have implemented early and ongoing enhancements to the system that include and are not limited to, activities such as increased training for all staff and supervisors, conducting interviews, and implementation of a mandatory 100% supervisory review of all injuries completed. A secondary review whenever an appeal is filed. A staffing review when errors were noted with supporting documentation. Appeal preparation reviews, some resulting in withdrawals and dismissals. Creating the Nebraska interrai manual.

And so there isn't really any true savings going on when you don't maximize that full budget amount. That's really just an indicator for the state to say, this is what it could cost you. If they had no other supports, and they had to rely fully on the system for group home and day supports. And we have a mixture of folks. There are some folks, some folks in our system that are in that situation, and they do expend the full amount. And then we have many who are not and that are still living at home with with family members who that are still living at home with with family members who are who are taking care of them and providing that residential support and perhaps only accessing day services. And so they use just a smaller piece of their budgets. Okay. Thank you. You're welcome. Questions? Senator riepe. Thank you, chairman. Director green, thank you for being here. I want to note that you have a long tenure, a very respected position, and very someone that's approachable. And I hope that that's been the case. I know it's it's a tough situation that you're in and we're all in my one of my questions would be, and I have a couple here would be, is Nebraska the only state that's having these issues at this time? And that relates a little bit to the source of the formula, is that that's not exclusively for Nebraska. Other states are using this across the country too. Yes. So there are many other states that currently use the interrai. And in fact, Nebraska had been using it for five years prior on our aging and disabled waiver already. So it was only new to the developmental disability waivers in july of last year. And again, we had been using it for five years on the aged and disabled waiver only to determine level of care. So we only had that tool putting giving us one output, which is do you qualify for a nursing home? And that was the decision we used the tool for when we rolled out the interrai in in Nebraska on the dd waiver side in july of 25. We also built it to do the level of care, meaning do you qualify to live at the intermediate care facility, which is sdc? But we also added other outputs for the assessment to include service planning to include which type, which waiver of the three would be most appropriate to meet your needs, a residential component of what kind of residential services would you need? And then also the budgeting tier. There are many states. I think last I knew around 25. They're using the interrai today in some one of those capacities. And so it is a widely used tool across the country, but it is also used for many different purposes. Right.

So on our nursing home waivers, which is the 80 waiver and the traumatic brain injury waiver, those are all folks who qualify to live at a nursing home. And then there's three waivers that you heard the family support the day and the comp. Those have a separate tool still in array, and they have to meet intermediate care facility level of care. There has been growth in both populations, probably more significant growth in aged and disabled waiver. Dd obviously we've had growth with the elimination of the waitlist. But but statistics over the last several years on our developmental disability side of the house are still in line with what the data has been showing for many years, that we generally add about 600 new folks with developmental disabilities into the waiver program every year as, as as newly eligible new net new. Yep. Net new folks. And right now, because we've eliminated the waitlist, that growth is primarily and expected in it's coming in our children because you can come in and get services immediately upon eligible eligibility being determined. We've we've gotten all of the adults into services. So really your adults that kind of are new to the system would be people that maybe weren't accessing the system at all for many years that finally come forward or folks that would move here. But the primary growth and the dd waivers has been in children. I'd like to ask you to respond to this. There was serving on this Committee at the time when we introduced managed care for medicaid. And when we did that, it it changed the system because before. That fundamentally is we provide the service, we send the state the bill you pay. All of a sudden it was someone in between who's saying, no, we have scales and standards that this is what we pay for x and y, and it created a lot of grief at the time. And I don't know whether that's all gone away or not, but is that a comparable thing that we also moved to something that was more of a structured. Discipline, if you will, and not just a quote unquote cost plus kind of a model? Yeah. It is way off. No, you're not way off, Senator. It it is a very, very different tool from what we had before. It's much more comprehensive. If you if you look at the icap in the old assessment that we were using for folks, it really only focused on two areas problem behaviors and kind of your activities of daily living. It didn't look at anything else. It didn't look at what your living environment was, what your childhood looked like. Whether you're in the home, whether you're out of the home. And so we only focused on that and said, based on these behaviors and based on these activities of daily living, here's how much money you need.

But that the scoring process isn't something that that's something that the individual fills out or the family member, right? It's not something that the the department is talking to that person or visiting the home. Is that or are they visiting the home to see exactly what those people are experiencing? Yeah. I mean, the inner eye is done in person with the participant. And then whoever else is a part of that generally provider, staff or families, depending on each person's kind of who makes up that support team for them. The site can vary, right? Sometimes it's in a residential setting, sometimes it might be at a day setting where the participants at. But, but it is in person with the participant is the expectation of the assessment. Because I have family, I've talked to families who are there providing round the clock care. They can't that the person that they're taking care of cannot be left alone. They have to have someone there. And every being reduced in services. Yeah. And so either they have to go get a job and leave their child alone or pay for other services. Does the state their child alone or pay for other services. Does the state pay for those services? Then if you have to bring in outside services. Yes. If they if they were eligible for out of home services through the assessment process and they were available in the waiver, that is a service that that would be available to a person on the comprehensive waiver at a greater cost. Yes. Yeah. I'm sorry, I'm a little I'm a little upset about all of this because I have families reaching out to me and it's, and they're, and it's having adverse effects for them. And. If we're going to look at evaluating this, I mean, is there any way we could pause this until we figure out what is happening here? Because it's it's really being it's devastating for some of these families. Yeah. I think, you know, the, the request that that has come to pause the assessment is challenging and tricky and perhaps runs contrary to statute. That requires us to have an objective assessment process in how we allocate resources. So again, I would point out, I certainly am empathetic and I to have here have heard from families who have seen the decrease, but I also in more quiet arenas and not public meetings, have many conversations with families who are saying, this is working and it gave the right decision. Right. Pausing somebody who's at a lower tier who should be going up to a higher tier could also be detrimental to their needs. And so it's, it's a it's a fine line of how that pause would look. And so we are at this point continuing to move into year two.

I hope we can get work through some of that, especially for people who have been maybe reduced that need to be reassessed and have that, you know, that they can at least, you know, find out that they can still provide that care for their for their person in their home or. Well, and I didn't mention that there still is also a secondary process that if, if the interrai has been complete and teams to include families would feel that that is not sufficient to meet their needs. We have always had what we call an exception funding process, where that team can fill out a request to our clinical team that is staffed with our psychologist, our nurses and our behavior support specialists that make decisions on whether they can receive what we call exception funding, which is they would get higher tiers of funding based on identified need that is unmet. Still, even in the current structure. And we have several folks that are on approved exception funding request. I just have one more question, if I could, and that has to do with staffing. I know in other areas we've especially in behavioral health, qualified staff, people finding people to work in, you know, in nursing homes, finding people to work in substance abuse disorder, those type of things. And psychologists and counselors, I mean, do you find it hard to find qualified staff? And then once you have hired someone, having them being able to train them so that they can do the assessment properly and, and not push them through, through too quickly. Yeah. I mean, we have we do experience turnover in this unit. It is probably more for, you know, entry level kind of, of wage position in the system. And so it, it does lend itself for people moving up, either getting supervisory roles or moving, kind of advancing their careers, that, that it is often kind of a stepping stone position, if you will, for folks. So turnover is there. And, and we do have vacancies. This team for a while was running generally. Around 6 to 7 vacancies on a consistent basis. Out of the 40. I'm sure that's a challenge. Very much so. All right. Thank you Senator. Thank you. Thank you chair. Thank you, director, for being here. You mentioned a little bit about the process. Can you unpack the appeal? Can you can you unpack the appeal process a little bit more? I guess my concern is the transparency of this process. Can you touch on that a little bit and how families can go through the appeal process if they disagree with the tools assessment? Yeah. So the appeals that we that folks are referring to, these have been in place for many years. These this is the standard appeal process under the administrative procedures act that you go through for medicaid denials, waiver denials, funding, you know, changes all of that. And so.

And there were four of those. So the 189 that are withdrawn and dismissed, that is largely a group of folks that filed the appeal. And then upon I mentioned earlier, one of those enhancements we made to the system where we do that pre pre-hearing kind of review, like, did we get this right? Right. Because we want to go to the hearing, making sure we have 100% accurate tool and the families might contact us or we might discover it in our own review. But if, if prior to the hearing, we are aware that there are discrepancies in the tool, we will correct those and we will rescore them. And in many of those cases, then that tier went back to where the original issue was, and they withdrew their appeal. So you could look at many of those as though the families were successful in their appeal. They just never got to the hearing because we were able to resolve it internally with that internal review prior to the actual hearing date being established or occurring. Does that help? Yeah it does. Thank you. Okay. Yeah. I'm going to do a strange thing. Director. Yeah. Not that you're not used to me doing strange things, but anyway, I'm going to ask a question and then I'm going to leave the room because I have to go to a national security briefing. Okay. Senator riepe is going to take over for me, but I'd like to get your answer on the record. If we could just would you speak to the entire budget, the total budget of what we're looking at here? Maybe. What did it look like before? Compare it to how things are working under the inter I. And so anyway, if if I could get that answer, that would be wonderful. And so I just wanted to explain what I'm about to do. Ask. There's nothing like asking a question and then running away, but it's all being recorded and so forth. So when we're done here, kathy, you're up next. All right. Thank you. Thanks. So obviously our budgets both on, on the ad, tbi waiver side of our house, which again, nursing facility waivers as well as our dd waivers have increased I think in total right now, the division as a have increased I think in total right now, the division as a whole, which most of this comes out of waiver services. But we're we're now sitting at about 1.1 billion in our division for all of the services and supports that will include esdc. That will include all five of the waivers. And then many of you know, we have other units of, of smaller programs for, for folks, but predominantly, most of that money is within those five waivers is total budget. And it continues to increase in both waivers. We've had population growth. And on, on the dd side expected. Right.

My name is kathy martinez. I'm the president of the autism family network and the mother of jacob, my adult son with profound autism. Jake is 23 years old and attends a day service site 35 hours per week. Jake's high level of need requires a one on one at all times. He cannot speak, he cannot toilet nor bathe independently. Has an iq in the low 40s and he is an elopement risk exhibits aggressive behavior and his sleep disorder, often waking in the middle of the night to pull food from the refrigerator and dump on the floor. Taking care of jake is a full time job, and we do it out of love for our son and to protect him. Our family has been advocating for him for over two decades in the schools, in our community, with insurance companies, with dhhs, and within this very legislative body, we will continue to speak out against injustices for vulnerable disabled people like those occurring right now in Nebraska. I'm here today to provide information about the current problems within the disability waivers, most specifically the interrai assessment tool being utilized by dhhs. While dhhs will tell you that 25 other states use the interrai, it is important to note that in those states, it is mostly used for geriatric level of care for nursing home, not the d d I'd. Community arkansas previously used it, but a court case stopped the state's ability to use it any longer. Nebraska dhhs decided to give it a try, despite what happened in arkansas. The interrai is inaccurate and meant to be a budgetary tool. There is no longer person centered planning, nor is it a needs assessment. If a person's budget can be reduced solely upon who their caregiver might be, I believe this punishment of budget reduction based on having a family caregiver is also a violation of the olmstead act, which allows a person with a disability to choose where they would like to reside without punitive result. We all heard the previous assessment tool, the the inventory for client and agency planning, otherwise known as the icap, was outdated. Well, that may be it was more accurate. An average year of icap yielded approximately 100 appeals per year. The first year of the interrai has produced 584 appeals. The case mix index score, or the cmai from the interrai assessment does not factor in doctor's documentation, therapy notes or functional behavior assessments. I have provided this Committee with my sons just for reference of what is being ignored by professionals. How can dhhs ignore psychological evaluations and expect an accurate assessment? The cmai score from the interrai is the only determination of an individual's funding tier and level of need. Furthermore, there are only a few questions from the inner eye that factor into the cmai score. It is a waste of taxpayer money to do annual assessments on a stable population of people with developmental disabilities.

Since director green refuses to pause the use of the inaccurate interrai, what they are indicating is that the supports intensity scale or the sis assessment is now being used in 17 states with accurate results. I provided handouts to this Committee with information on that assessment. There also are issues with the other waivers. But that's what I'm going to cut for you, sir. And I just like to to finish with if we can't get the governor or dhhs to fix this, we are employing our legislators to intervene. Helping the disabled has never been a partizan issue and never should be. This is a pro-life issue. This is a human dignity issue. Please help protect our most vulnerable nebraskans. Okay. Thank you very much. I have two comments. One is this, I think a typical situation where when you've seen one, you've seen one and no two cases are even close to being identical. Number two families are in a not a very strong negotiating position when you're trying to determine what you can or cannot receive, you don't have a lot of options. But thank you for being here. Are there questions from the committees Committee? Yes, sir. Senator quick. Yeah. Thank you chairman. I know for paragraphs. I know I won't, but, you know, I don't have the lived experience at all of you have had. But I hear from families and I think it's it's I appreciate that you're here fighting for your and advocating for your your loved ones. On your like a day to day thing for you, for your with your child, I mean. Do you have day services in two or is it or how does that work for. He does have day service. He attends 35 hours a week. But with the reduction of the budget that the department is suggesting that he go to, that may be in question, because the day service site will not be able to serve him with that budget. They're trying to reduce him to an intermediate budget, which is the equivalent of $18.89 an hour reimbursement for a day service site, and the one on one staff that they have to provide to keep him safe, and the others in the day service site safe would not even cover the dsp, let alone administration costs of the agency. Okay, I think that kind of helps you because I have someone in grand island who has a ten year old who goes to day services, and I was trying to figure out how I haven't been able to speak with him yet, but I was just made aware of it. It is putting that in danger. A lot of people, like my husband and I, both work and we have to work, and we wouldn't be able to work and support the rest of our household and our family.

So I'm not I'm a little confused why we're doing another one if this one's still in effect, because while you're in the appeal process, they can't reduce your funding level. Burt. So now we're doing another one. So I'm questioning, am I going to have to hire an attorney for the second assessment and, and spend another $5,000 for a retainer fee, and then we'll have two appeals in place at once. The whole, the whole process is a bit confusing. Okay. Thank you. Ballard. Thank you. Any other questions from the Committee? Seeing none. Mr. Martinez, thank you very much. Our next testifier will be stacy pfeiffer. Is that correct? Welcome. If you will state your name, spell your name, and then proceed with your presentation. Thank you, Senator riepe and members of the Committee. My name is stacy pfeiffer, stacypfeifer. Today I'm going to speak about the economic and socio socioeconomic impact that these changes are having on our state. As the saying goes, you cannot cut your way to prosperity. There are far reaching effects that these cuts will and are causing. The waiver program touches every district in Nebraska. Changes that dhhs are making are cutting already thin margins that service providers are working with. Many are dangerously close to closing. Many are not able to offer the same services to clients with the new budgets they're given to work with. As kathy just attested to, they're already having staffing difficulties, and now their staff are asked to do more with less. And this is resulting in lower quality of care. The instability of these jobs is discouraging people from even applying. So there are several service providers across the state who can't even get people to apply for these jobs that they have a shortage of already. And some other changes that dhhs is making on the back end is making the overhead higher for these these companies. These changes will force some of them out of business. And in many rural areas where there's limited options, there could be no option if a family has to stay home to care for their loved ones, they may have to quit their job. This would lower taxable income, you know, and and these businesses closing would would lower tax income and people losing their jobs. You know, there's already been lots of jobs lost across the state. So this would only increase that. It could take years and maybe even decades to recover from what is being undone through this process. You know, if a if a service provider closes, it's not like one's just going to pop up a week later and take their place. You know, that can take a long time for them to build back up and get back to the place where they're where they are. Additionally, a families are losing their income because they no longer have the waivers to cover their care. They could lose their home.

Some people are are having sort of an opposite problem where if their budget was increased and there's a service provider in the rural area who can't offer those services that their increased budget requires, they're saying, well, we can't serve you with that. So, so those people don't actually want that increased budget. They want to stay where they are. So even even though normally you would think an increased budget would be a good thing, that's not always the case. Okay. And then you were talking about the number of beds that someone had to move someone to a facility because they couldn't continue in home care. And there's only 12 beds. I mean, what do people do if there's no available beds for the. Exactly. That's that's the big question. That's the question everybody's asking, what are we going to what are we supposed to do? You know, there are people now who are trying to find alternatives and aren't having any luck at that. So they're they're saying, what do we do? Yeah. Okay. All right. Thank you, thank you. Seeing nothing else, thank you very much for being here. We appreciate it. Miss bradford and the next testifier is mr. Brad murman. Is that did I tear that down? Yes. Oh, I think he did. He step out? Yeah. Okay. Then we move on to mr. Craig. Is that it? I'm going to mess with people's names here, I apologize, you'll set us straight when you get up here. Orr set me straight. Thank you for being here. If you would state your name, spell it and for the record. And then proceed with your presentation. Thank you. My name is craig, craigcasados. Okay. Thank you. Good afternoon. Chair and Committee. As I said before, my name is craig. I'm the executive director of the Nebraska association of service providers. Our members support nebraskans with intellectual and developmental disabilities in their homes, jobs, communities, group homes. In 1981, this Legislature declared that nebraskans with developmental disabilities disabilities are entitled to live and work in their communities. Olmstead and the ada made it a federal obligation. That promise is coming apart, and the people holding it together family members, providers, direct support professionals are being asked to do more for less, to fix a budget deficit that they did not create. In the last three years, providers have received one rate increase 2% in july of 2024. Well, every other cost around in roads. Nothing this year. Not looking to have anything next year. Dhhs is own workforce, report says the median direct support professional earns $18 an hour, $3 below a living wage. For providers, turnover is at 51%. Nearly half of our workforce has been on the job for less than a year. What does that look like? It looks like somebody new coming into your house every six months.

And maybe you can talk about some of the other issues some of the providers are facing. I know you talked about, of course, you know, the reduction in reimbursement challenges. I everything rolls around the services that somebody gets. And then when you add things like nri, that seems to be decreasing a lot more, it means funding on there. And then with providers. Not really getting increases in their waivers means that they're getting increases in their waivers means that they're having to do the same thing that they've had over years. But the cost of everything else in the world, including all the trainings that they have to get their staff on, things of that nature, everything is increasing for them. Whether or not they're not getting rebated back. Has there been increased requirements from the state to for. To have certain type of staff or to have requirements for staff to meet certain qualifications, have those increased over the years or. Requirements that the staff need. For training and certification? Yes, and some of that is, is some of the issues to where the state is mandated. Certain training programs, okay, that all the providers have to use, and where that becomes difficult for providers is whether we'll just pick on matt, which is the crisis intervention training that's needed once it's mandated in the state. Matt can charge the providers what they want because they have no choice on there. And so it's been reported to me as recently as two weeks ago that to get two trainers trained to train all of their staff, it cost them $7,000. Okay. All right. Thank you. Yep. Are there other questions from the Committee? Okay. Thank you very much. Thank you, thank you. And our. Mr. Brandt murman, you're in the room. We would invite you to come forward. We did receive, as a Committee a handout from miss martinez. I initially thought it was a master's degree. That would give us something to keep us up, keep us out of trouble in reading, I guess. Thank you very much. Okay, sir, if you would. Again, I know you've been here the last hearing, but if you would state your name and spell it for the record, please, and then proceed forward and see if you can keep it within the three minutes. I know that's tough. Yeah. It's tough, especially especially. For me. But we'll give it. Auctioneer voice. You know. You don't want to hear that. That's not good. Well good afternoon, Senator hardin and members of the Committee. My name is brad narins. Bradmeurrens, and I am the public policy director at disability disability rights, Nebraska. I thank you for the opportunity for the opportunity to you today about Nebraska medicaid waivers, the aged and disabled waiver and waivers play an important role in the lives of disabled nebraskans.

But go ahead and proceed in the interest of time, hopefully within the three minutes close. Very close. I my name is philip gray. Philipheray. They say a picture is worth a thousand words. I don't have a picture, but I do have a thousand words and I'm out. We don't allow props anyway, so. I'm currently the president and vice president of the arc of Nebraska. I'm also a volunteer on the governor's advisory Committee and on the state medicaid advisory Committee. I also work for the social security administration for almost 40 years and have some technical knowledge about what I'm talking about. The current process to determine medicaid eligibility for individuals on ssi is constructed in such a way that it. It adds barriers and roadblocks to a smooth transition and causes errors in making those determinations. The question I'm addressing here is, would Nebraska be better off served by moving to section 1634? Under section 1634, a state can enter into an agreement with the social security administration so that ssi applications can also serve as a medicaid application, potentially reducing Nebraska's administrative costs and possibly barriers for Nebraska's disabled individuals to qualify. Ssi is a federal program for individuals that are blind, disabled, or over the age of 65 and meet restrictive income and resource requirements. Ssi eligible individuals are categorically eligible for medicaid and therefore are entitled to medicaid automatically once they are found eligible for ssi. There are roughly 28,000 ssi individuals in the state of Nebraska, and I handed out some material with that information on it. The Committee looked at this issue in 2024 under LB 1007. At that time, the department determined moving to 1634 would not be beneficial. The fiscal note from dhhs said Nebraska would have to pay half of the applicable administrative cost, but it also said the average rate was unknown. It identified implementation and computer system costs that were also unknown. Their decision clearly was not based on actual numbers or deep analysis of how the transitioning would impact Nebraska's medicaid community, or the management by department of health and human services. 1634 agreement says ssa can only charge the states one half the additional cost to social security for providing data to the states, and cannot charge any program related costs. Nebraska already pays a fee for this service, and it is unknown if there would actually be additional costs by transitioning to 1634. Of the 42 states currently eligible for the program, 34 have elected to sign up. Such numbers indicate Nebraska should conduct another review, but this time based on actual numbers and experience of current at 1634 states. Nebraska's current process also can result in errors for the ssi eligible individuals, causing disruptions for the individual and unnecessary administrative work for the state. I believe they have reduced their error rate, but I don't know if they have. As the numbers are not tracked.

One of the reasons for that is most of these folks on ssi came out of institutional care. That the ssi program is 75 was the means for individuals to transition out of amherst. 83 minutes is. Okay. And just to finish this, if we remove their entitlement to medicaid under those circumstances, they would probably have more. There would be a more difficult time staying in the community. Okay. All right. Thank you. Okay. Thank you very much. Hearing or seeing no others. Thank you very much for your testimony. Thank you for your time. Thank you. Our next testifier is catherine rohloff. Cathy. Is that. Oh, no. Sorry. My apologies. Role rall. Okay. Okay. I promise. As Senator reid, before you remind me of my three minutes. I am asking for an accommodation under the americans with disabilities act because of my disability. Well, I think we have a lot of disabilities here, so I'm not. I will make that judgment call at the end of the three minutes. I'm not going to grant it in advance because we all have time concerns, and we're interested in hearing what you have to say. And so I will ask you to state your name and spell it. That's fine. But also I that I can contact the lawyer and I, and I'm willing to do that because. If you find that necessary, then that's what you should do. I'm not I'm not going to be intimidated by that. So please proceed. Okay. My name is kathy hall. Hkathyhell. And I am the co-chair of the olmsted advisory Committee. But I am here to discuss how the the modifications to both the dd waivers and the disabled and the use of the interrai assessment processes will have negative impact on olmsted. When you go to the olmsted page. On the harm and the health and human services website, you see a statement that Nebraska's olmsted plan is a roadmap to a strong state where we can all live and work in our communities. The olmsted vision is people with disabilities, living, learning, working and enjoying life in the most integrated setting. The olmsted decision. That states have a legal obligation for providing services to people with disabilities in the community. This is a civil rights. I feel. I fear that the current process. Nebraska is implementing is pushing people to institutional settings. The integrator is a starting point to assess an individual's needs. It should not be the end point. The centers for medicare and medicaid services have had repeatedly indicated that person-centered planning is a core requirement. Only community services. That means Nebraska must comply with person-centered planning requirement, or we risk being out of compliance with seeing that if someone's budget has moved from advanced to. Intermediate or basic year, how is the state assessing if that decision is person centered? If there's any consideration of the individual's.

My son jacob is 15 years old. He has profound autism, is functionally nonverbal, and is completely dependent on others for his adls and his iadls. He has significant medical, behavioral, and safety needs that require constant supervision. Jacob has historically been in the advanced funding tier, which dhhs described previously earlier this year as serving individuals with high supervision and support needs and behavioral and or medical complexities. I have six affidavits from medical providers and one affidavit from the school district documenting his need for this 24 hour care and supervision. One provider states. Without 1 to 1 support, jacob could be at immediate risk of serious harm, hospitalization, or institutionalization. His safety plan, which I've provided you a copy of, has nearly 50 medical, environmental, behavioral and legal risks that he is subject to. These are not theoretical risks. In the testimony I provided to you, I've given you examples out of protecting my son's dignity. I'm not going to tell you, but they involve issues of fire setting, elopement, and inappropriate sexual behavior in the community. Even the interrai assessment agrees with us on the on the scales that kick out of the inter ray he has on the aggressive behavior scale. In a 0 to 12 range, he scored ten, meaning more severe aggression on the distractibility hyperactivity scale 0 to 16. He's a 16. He's off the charts. When you look at risk of injury to others on a 0 to 6 range, he's a four on a risk of harm to himself. He's a five. Please keep in mind that these scales don't accurately show my son's deficits, because I'm still in appeal, and I can't get the questions answered correctly because of changes that dhhs has made to the inter ray manual, and they're not following the way it was intended by its authors. So let's enter into the case mix index. In 2025, dhhs implemented this assessment inter aria assessment tool. They chose to use the case mix index as the funding algorithm. We need to bifurcate those two concepts because they are two different things. According to the medical journal that the case mix index was based upon. It is not to be used for funding decisions. My son's needs did not change, but the scoring mechanism used to determine his level of disability did. And this placed him in an inaccurate funding level, which places his health and safety at risk. The problem is that the funding algorithm that was used, the case mix index, fails to account for the functional needs of the persons with the disability. Last legislative term LB 958 was passed at a 47 to 0 vote in there, and also comparing to dhhs own regulations regarding funding, these determinations need to be based on functional need. The case mix index is not doing that.

Thank you so much for being here and I really appreciate your comments, your, you know, your advocacy for your for your son. Thank you for letting me come. Any other questions? Okay. Thank you very much for being here. Our next person is tony sorensen. Oh. I'm sorry. Okay. If you'd be kind enough to please state your name and spell it. You've you've been here for a while, so. Welcome and free to please. Tory sorensen, torisorensen. And out of abundance of transparency. I want to tell you, Senator, that I am a people pleaser. So I'm going to walk you through what I have here. Instead of giving a written comment. Thank you. I am a physical therapist. I've been working on figuring out this nri for 7 or 8 months. I figured out what the state isn't willing to tell you. So page one in your packet. Some research terms. What is reliability, validity, and generalization? What the nri case mix index is measuring is not what they're explicitly stating. It's not measuring the functional needs of an individual. It is taking into account if they have family at home. That is what tony referred to as available supports. And this tool is only looking to fund the unmet needs of individuals. That's why we have a problem here. So I gave you two participants children and adult. You can read through that and see how two very different individuals can come up with the same funding tier to get us all on the same page. This is pronounced interrai. I've listed some information on there about the case mix indexes. Why appeals aren't working. This is what dhhs isn't willing to share with you. These are the six questions that determine funding for children. I have a child in my home right now who is advanced funding because two questions determined that his age and that he has no supportive relationship with his family. A couple pages down, you'll see the adult one, and I'm going to show you that in in four years, when he is retested, he's going to go down to intermediate based on the research. It's not measuring the same thing. I've read the research for you and provided you quotes from the research, and highlighted the ones that I feel are most important. Dhhs has taken apart their descriptions of funding tiers. It no longer means anything. It doesn't say that an advanced individual needs this level of care. It says an advanced individual meets the definition of a case mix index of whatever. So they're taking that apart. Case mix index for adults. As I said, the child that I have in my home at 18, he's going to go to intermediate because he left home before the age of five. That is what's going to determine his funding tier getting slashed in half. Some quotes from the adults.

I'd like to talk about the service need assessment that has been implemented by the division starting in july 1st of this year for the aged and disabled waiver. I'd also like to talk about informal supports and paid supports, and a little bit of the difference with that. You'll notice as you go through there that I like a good chart. So I made some charts for you. Page one. I've had families, I've spoken with many families across the state, and families have graciously shared some of their information with me on the condition that I heavily redact the information. So the first two pages of the handout are notice of decisions that families have received after their family, their loved one have gone through the service needs assessment. The top one, the first one, their personal care hours were reduced to 21.75 hours per week. From the initial 144 hours. This is an over 80% cut in their in their hours that they were approved of, the next individual had their hours cut to 44.75 hours cut per week. I also have a. An example of the service needs assessment that is being completed that the division is using to come up with those. 21.7544.75 numbers. To give you an idea of how this is being broken down. So for example, you have x amount of numbers to give and help an individual with a shower or helping them shave. Estimated time may be for oral care. You can have a few minutes to help your loved one brush their teeth. Medications that doesn't even factor in because that is assumed that they're living with their family. Family is going to take care of that. So that isn't factored in. There's even time allotted for wheelchair maneuvering, so I do not use a wheelchair. I don't know how much time, but hopefully nothing breaks down because I'm sure you're probably go over your allotted minutes there. Meal preparation, money management, all of these services that you can see in the service need assessment are given a minute total. So you can go through that and see exactly how the state is looking at things, breaking it down, and in essence, nickel and diming our families. We are in essence, throwing grandma off the couch so we can shake the couch cushions for coins. 44.75 hours 21.75 hours. You cannot go over ten minutes to help your loved one shower. This is what we have become. This leads me to the informal supports as I have two children, one of whom has severe intellectual disability. He has severe autism. He has epilepsy, he has gerd. He has a slew of other medical health conditions, which of course were not entered into his inter hour assessment because it honestly did not matter.

I mean taking apart an existing framework piece by piece and replacing the programs and structures on which the framework was built. And I'm increasingly concerned that may be what we're seeing. Now, I want to be very careful about what I'm saying here. I three minutes, three minutes. Wow. Okay. Well, I got to get this out. I'm not telling you that I know there's some master plan inside dhhs to dismantle Nebraska's current disability framework and replace it with something else. I don't know that. What I'm saying is that after watching this for three and a half years, I think this Legislature needs to find out, because there has always been another question sitting beneath this. And that's money. And today, we don't have to look very hard to hear and hear lots of discussions about states budgets. We did ask about money. We were repeatedly told as far back as 2024, these changes weren't being driven by money. And to be fair, the state could point to several million dollars initially of new investment. But at the same time, Nebraska was talking about bringing in several thousand additional new people into services. Some of us kept asking the basic question, how do you dramatically expand the number of people being served without increasing the cost of the system? Senator vargas essentially asked that question of director green before the appropriations Committee in 2024. I don't think we ever received a complete answer. And I know the developmental disabilities advisory Committee has not. So that's why I hope LR 404 goes beyond merely looking at the nri and some of the other terms. Investigate a lot of other things. The the only last comment I'll make here, chairman, is. Look what's happening to funding tiers looks. What's happening to risk tiers and exception funding. Look at budget caps. Look at the changes in the aged and disabled waiver. Look at regulations and statutory changes. But most importantly look at the budget assumptions behind all of this. And when those assumptions were made, when today, the program for 24, which is the budget line, the developmental disability age approved budget is a mere 1.7%, net of the total Nebraska fiscal 27 budget. Certainly a lot of change. We're into the second three minutes here. Yeah, certainly a lot of change for a small part of the budget. Thank you. Okay. Thank you. I'll take any questions. I'm going to see if we have any questions. Senator quick, do you have any questions, Senator? Yes. Thank you, mr. Brown. And I missed your testimony. Did you did your sons move tears in the recent. Or were they were they at the assessment system? Were they moved? They originally they fell two ratings. They fell from advance funding down to intermediate. And then through what they call a redetermination. They were moved up to high. But they are. My sons are incontinent.

In fact, we've gone from the institutional era to the one size fits all era, and we need to move rapidly into a more expanded era where we serve different populations in different ways. And that's what we had committed to do. And this blew it up. I'm not certain if we don't get the funding right, that we can even maintain the agency and we run it. It's a nonprofit. We take no money out of it. It all goes to serving the people. And that serving the dsps or the professionals that work in that, so that we're on a we are on a cliff's edge, to be very frank. And one of the things that I think if you can get. Director green back at some point and talk to him about. We know that there's another 5% cut coming to his budget. I mean, he was very clear about that in our last meeting, and it's what I call the trinity. It's going to affect eligibility. It's going to affect program cuts, and it's going to affect funding. And those are absolutely straightforward out there. They're working on it. They'll be telling us the first of the year, and I give him credit. He told us 100%, this is going to happen. We're not exempt, but we're already collapsing. And I think you've all heard that today. And by the way, many of the people here are professional doctorate level, master's level. They know what they're talking about. This is a absolute we're on the cliff edge, just straightforward and being blunt. And for three and a half years, I've seen this and I don't know where we're going and nobody knows where we're going. Certainly the Legislature should know where we're going. Any other questions? Thank you. Questions. Thank you. Thank you very much. Sad stories today. Thank you very much for being here. And we were all we would invite Senator rountree to join us and sort of. Give us a wrap up, if you will, or whatever you feel comfortable with. Thank you so much, mr. Chair. And I, first of all, thank all of our testifiers for coming and testifying today. We've heard a tremendous amount. We recognize that it's a lot of work to be done. I would state that I believe what our families are looking for is open, honest, transparent communication, knowing how decisions are made and not hiding anything behind the curtain, but putting everything out front. And we can make good decisions with good information. So we recognize it. That changes that we've talked about today and the waiver services that are not just small tweaks. You've heard the greatest. We've heard the middle part the least, but yet they are live and they are impacting families right now as we speak. What I would ask of dhhs, I know that mr. Greene testified.