Commission on Medicaid [Aug 05, 2026]

Hello, everybody. We are going to get started. The Commission on Medicaid will come to order. Mr. Shadun, please call the ball.

Bridges. So excited.

Gilchrist. Excused.

We'll say excuse for the moment.

Sirota. Excused.

Brown. Here.

Okay, so we have a very small and compact agenda. We should be out of here in about 45 minutes.

Yeah, not true. We have a very long agenda, and we got sent a whole bunch of material, and I assume people had some time to look over some of it in any case, but we are going to go through a lot of it today, and it sounds like we have breakout groups and all kinds of exciting stuff to get through. So I think at the end we will also try to figure out, make sure we're all in alignment on the next meetings and what we're going to be covering. And I do want to say thank you to healthcare policy and financing for putting together what looks like a very heavy lift of crosswalking things and breaking things out of the normal way that we see them. And it's really helpful. So thank you for that. And so we'll try to keep things moving along and also try to keep things, you know, positive to the extent possible given some pretty negative things that we're looking at. So with that, I will hand it over. Well, first of all, I will say that Senator Kirkmeyer is present. We knew that, and yet we're going to acknowledge it twice. and I'll turn it over to Summer Gatherkel.

Never let that stop you.

So, yes, we have a lot that we want to do today. So what I want to do is kind of share with you first what we've heard from stakeholders so far, because I know this is something that's been important to many of you. We've had a number of different ways for people to engage. I will share that we've learned a little bit already along the way around what's working and what's not working. So what we have received so far is we have the public input survey, which I shared with all of you last week. We've also shared with interested folks who are on the list, both that I have and the staff have. So we're trying to get the survey out. I know that there are some groups that have already sent it out to their membership loud and clear, wide and far. So definitely appreciate that. We expect to see this number of responses increase significantly over the next couple of weeks. We have the short form, which is really kind of you don't want to take the time to go through the long survey, but you just want to share here's your experience. We have just a couple of responses to that so far. There are a few more that came in this morning, so that form is circulating. We've had office hours both in the last two days, which we, again, learned a lot about. So we'll be rethinking that, and I'll talk a little bit more about that. And we did ask for people. We have all the ways for people to give back information is anonymous. Some have agreed, many have agreed to be kind of quoted anonymously, but for right now we're keeping it pretty open and vague. You can see here who's responded to the survey so far. Obviously our biggest, the biggest respondents are the paid family caregiver at 56.1%. That is really, I think, reflective of the groups who have sent this out, right? So, again, we know that there's more work to do to make sure that we get this out to more providers, advocates, more individuals, the counties, and so forth. So, there's some work that we know that we need to do that we're planning to do this week, but wanted to at least share some of the initial things that we're seeing. We did, one of the big questions on the survey was what do respondents say to protect? As you can see here, the one that they want most protected is the home and community-based care services. So that is something that has jumped to the top. And at the bottom there, you see protect behavioral health and substance use disorder services. Again, this is more reflective of who has responded to the survey thus far, right? So I think it's just one thing. We wanted to give you an update on what we're seeing, but again, expect that this will change in the coming weeks and we'll continue to provide these updates to you. What we heard was working, because it's just as important to understand what's working in addition to where we need to do additional work. Family members being paid to provide care was high up there. The waiver services, the inpatient residential SUD waiver benefit. I'm not going to read through all this for you one by one, so you have it there, but again, I think it's just helpful to understand, you know, what we're hearing to protect and what we are hearing that is working well, because we do want to make sure that we understand that in order to be able to better grow those services What respondents have reported I just going to interrupt for one second I think we have Rep Gilchrist on Zoom Okay and then Senator Mullica has joined us

Good morning. Okay, what respondents reported experiencing? So, again, these are reported. They're not verified. It's what people are sharing is their experiences. 84% have had a service benefit or approved hours or payment rate cut or capped in the last year or so. There are 60% on a waiting list. 57% expect the new federal law to affect them. And 52 are average score of 100 on getting straight answers and respect. I will also share, having done recently a community needs assessment for the city of Denver, this is not an unusual number, right? So we are seeing that there's a significant need across the social service industry to make sure that we are treating people with respect and dignity regardless of their circumstances. And it was something that we heard from people with lived experience in that scenario as well. Hardest things to do, reach a person who could answer the question, get through enrollment or renewal, get help at home. So, again, lots of challenges there. And then we can see where there were some reported effects on a cut or a cap. So, more stress to the family, saving time spent working on calls or setting up meetings, missed work or lost income. So, we have a good sense on the first slide of kind of here's what's working, here's maybe what we want to do more of. And then we have some understanding here around what respondents are experiencing and where there's opportunities for improvement. Again, keeping in mind that most of the respondents thus far are the paid family caregivers as the majority of survey respondents. This is just a quick example. Again, I'm not going to read through all this since you have it in your packet, but what people wrote their survey open responses in the short forms on the left side there, you've got their written responses. the most the thing that most people are focused on the phased family phased paid family caregiver hour cap you know making sure that that is addressed the exception process is described as unusual unusable there were several reports of people learning about things from social media or the news as opposed to directly from the department or provider multi-year waiting lists I mean so So you can see the list goes on here, things that I think we can continue to look at and dig into and learn a little bit more so we can understand where there's opportunities for improvement. The short form, there's just a couple of bullets here. I know that some of you have asked for those raw responses. We're going to wait to provide those when we have a few more responses since four is such a low number. We want to make sure that we are providing that anonymity to the people who requested it. And then office hours. So for those people who participated in office hours this week, I will share that it was a learning experience. We are going to structure it and do it differently. We did in-person office hours on Monday, and we did virtual office hours yesterday. On Monday, we had a full two hours' worth of meetings. What we found is that people wanted more structure, more one-on-one conversations. So we have as of this morning identified some preliminary dates for office hours We put those out on the webpage hopefully by the end of this week and there will be time slots so people can sign up for a specific time slot And then virtual we still exploring the best way to do that And Senator Mowale, I know you dropped in yesterday. I would love to get your input on that at some point. That was more of an open conversation with various individuals jumping in and kind of sharing their experience, sharing their expertise, and making recommendations or suggestions for consideration. So the kind of big themes that we heard across both sets of office hours, the basic operational data is not attainable. So we heard a lot about, you know, wanting to ask, asking for data, wanting data, being told it wasn't available or they couldn't, it couldn't be given out. Lots of requests for additional stakeholder input from, especially from the department. So really making sure that the stakeholders and especially people with lived experience have the opportunity to engage, especially when new rules and regulations are coming out. Policy scored in the long bill are reportedly changing shape during rulemaking. So really, again, kind of some lack of communication there and perhaps not reaching what was thought to be the original intent of some of the funding. And then no mechanism for the legislature to verify whether promised savings materialized. So I think this comes back to, again, kind of data collection, what do we have, what do we know, and how can we learn if what we're doing is working going forward. A couple of the other things that were raised as themes, conflicting communications from the different agencies that you see listed here, some duplication across the different agencies as well, and of course those work requirements and six-month renewals that are coming up were a big concern for everybody. What was working and worth protecting. So again, I think it's just as important to weigh the good with opportunities for improvement. The provider stabilization fund is working as intended. The paid family caregiving is definitely cheaper than the hospital or more affordable than the hospital. Community providers are taking on the gaps that maybe the state can't currently cover. So they are really stepping in. So many thanks to all of them who are doing that. and certainly hearing that the current leadership at HCPOF is more open to collaboration and working towards trying to be as more transparent as transparent as possible.

Correct. Yeah. Okay. To be clear, this was from somebody who came to the office hours. Yeah.

Yeah, absolutely. Absolutely. So just one office hours, as I said earlier, we have just as of this morning identified Additional dates for in-person, we'll try to get those posted on the Commission webpage by the end of the week as well as virtual office hours as well. We'll have time slots there so that we can continue to give opportunities for people to provide input. Those will also go on your calendars as optional so you're always welcome to drop in, listen if you want, just want to make sure that you are aware of when they're happening. Last week I know and we can recirculate again to all of you this week, We sent all of you the stakeholder survey and the short form for people to share their experience. I want to just continue to ask all of you to share that with the groups that you're meeting, with your constituents and so forth so that we can get this out far and wide.

Yeah, thank you for the question. We did not turn anyone away. I think we went, the office hours were from 11 to 1. I think I stayed a few minutes past one, but I would have stayed longer. I'd put extra hold time on my calendar if needed. I think what we're looking at is going to be 15 minute increments for people to sign up going forward for those office hours.

And certainly if you're hearing other feedback, open to figure out how to do it differently.

Sure. Okay. All right. So just wanted to kind of remind us and ground us in, not that you all don't know all the work that we need to do, but we have a lot of things that we are working on and lots of different data that we're trying to make sure that we get to you, again, in a timely fashion. we've got of course what's laid out in the legislation what you've asked for, what people across Colorado are asking for so we're trying to be reworking the schedule I feel like multiple times to figure out how do we make the most use of the time that we do have and being very intentional around it. So just want to kind of assure you that we are aware of all of these asks. I think Senator Mamale you spoke well to it yesterday in office hours when someone said, well, what's the goal here, right? Like, we want to make sure that we get to our December 11th, or December report with, here's some very actionable, tangible things and recommendations that can be done. And there's probably going to be a list of things that are still going to need to be explored or considered. So I think keeping that balance in mind going forward will be really important. Just so you know that we are very aware of the schedule. We've got a couple of working sessions left where we're going to do some deep dives. I know that today is work like a dog day. I can tell you that all of our meetings going forward will also be work like a dog day and will probably be longer than the ones that we have scheduled so far. So I would expect that we will likely go into the evenings for some of these to make sure they able to get through all the data and information that we need SO I WANT TO KIND OF SET THAT EXPECTATION NOW SO THAT we have some time lots of time for synthesis discussion options and recommendations to pull together across November October and November. So just wanting to set that expectation now. All right. Any questions on that before we move into our next session. All right. We are, one of the things that we have learned and what you already all know is that there's a lot of nuances that are involved with everything that's going on at HICPUF. So we're going to gauge your current understanding and we're going to have a little friendly competition. So bear with me. This is something new I know for all of you. We are going to put you into small groups. You're going to have nine statements that you're given. Your group is going to decide if it's true, if it's true with a caveat, or if it's false. And then we'll see who ends up at the leaderboard at the end. Just to make it a little bit more fun, there is a gift bag for the winning team. So get ready to be a little... It's $3 socks from Target, so I think we're okay. So, what I'm going to ask is that you all move to get into your teams and hopefully we'll be able to get Representative Gilchrist to participate as much as possible. Maybe we can use the chat box. And if I can ask my colleagues from HICPF to come on up so we can talk to you about Truths and falsehoods?

Thank you.

Nope. You're going to be just looking at the screen. Yep. Yep. You actually can't look ahead, so don't worry. I'm just having trouble sharing my Yes yes I do If I can get do you have any I trying to figure out how Yeah is it not coming through Yeah so it this Shoot now where I go And then can you pull up the... Yeah. Is it a file that you're trying to save? Yeah, it was something on the internet. Okay, let me... Just like a webpage? Yeah. Are you able to download it? I'm not, yeah, because it's online. While you all are waiting, pick a team name. If this doesn't work, I might have you disconnect and rejoin the meeting. Okay. I can see if this comes through. I don't know. I'm not sure I'm not. Let's try this again. Oh, there it is. Okay. There we go. Okay. Okay. Thanks for your patience. So one person on each team, if you can use your phone to pull up the QR codes and put your team name in. One person on each team, use a QR code to pull up the quiz and put Put in your team name.

Everybody got their team name in? So here's what you can, here's what's going to happen. You're going to see a statement pop up on the screen. You're going to have two minutes to talk about it with your team to determine if it's true If it's false, if it's true with a caveat, and then we will, we only have one team joined so far. Okay. Awesome Sauce, Kyle Majority, and Medicaid Avengers. All right. I like it. All right. So here's what's going to happen. There's going to be a statement that pops up on the screen. You have two minutes to talk about it with your team. You choose your answer. So your team captain chooses the answer. Once all the answers are submitted, we're going to have a discussion around whether or not it's true. Everybody ready? All right. Hospital care is the largest area of Colorado Medicaid spending. spending, true, false, or false with a caveat? Talk amongst yourselves you got 110 seconds You have one minute. Don't forget to submit your answer. All right, you have 20 seconds. Oh, everybody submitted their answers. All right. We are all across the board here. It's what you all submitted. Great question. . . All right. False with a caveat. So, Director Hammer, set us straight. What do we need to know?

Could be someone from...

All right. Oh, awesome sauce. Top of the leaderboard. Oh, here we go. The QR code, yeah. All right. So I'm going to ask if we can kind of keep it, try to keep it to the legislators to make sure going forward. Fair, fair. Okay. Most of what Colorado Medicaid spends is on people who could work but do not. . Thank you. Okay, you have 30 seconds. Don't forget to submit your answer. Okay. All right, here we go. True with a caveat and false.

Yes, Rep Chaggart.

Yeah, we had some outside folks sign up, so it's skewing the results.

I can't take them off right now.

So hopefully it's, yeah, again, just keep it to the legislators responding if we can. All right, next one. Behavioral health spending is included in the 14 billion medical services premiums line. True, true with a caveat, or false? Correct. Thank you Thank you. Okay, 30 seconds. Have you all submitted your answers? Everyone submitted? Across the board. Director Hammer, tell us more.

in the medical services line?

Okay. Let's keep going. Most of the department's 10 offices were created without express statutory authority. Oh, yep. Thank you. Before we move on, I just want to call to your attention that there is a line item in what you presented to us called Inpatient Mental Hospital Fee for Service. To the tune of what used to be $5.4 million is now $556,000. So there is some in there still. So your statement of false is false. The funding, even though it is paid through fee for service,

Okay. We will take it back and explain, but when we get to the details,

Okay.

I don think that true I don think you can create an office without statutory affiliation Well, it was in the stuff that sent us, I just don't remember where it was. Most of the departments have ten offices. It's in the office. He could, but he's got to get funding. And if you're going to get funding, if you're going to fund it, oops, this is all.

It is false. So the statute that authorizes the Department of Healthcare Policy and Financing establishes that the executive director may create divisions and units within the department. So eight of our ten offices were established under that authority of the executive director. The Office of Community Living, however, is described in statute, in its own statute, as is the executive director's office. So nearly every office has an authority, but for eight of them, it's a general delegation rather than a specific legislative decision. I'm sorry, that means that they were created by HickPuff administratively, not through legislation.

I mean, like, I guess, like, the legislation says you do what you want, and I guess that means it's created with legislative authority. but it wasn't created, like, it's not, I think the key here is express statutory authority, meaning the legislature created that particular office. I think we interpret it as the question was, were there offices created outside of statutory authority?

and then you do anything you want.

I'm going to let Summer be the arbiter of the points.

Okay Okay Okay Okay Okay Okay Okay Okay Okay Okay Okay And the executive director office

Does that have to be true of all of them? I think that's actually what express statutory authority means.

So I'm going to jump in and just, yes, I'm going to keep us going. And I think the part of what we want to have with this discussion is to understand how hard and nuanced some of this is, you know, and I have heard definitely in conversations a lot of different types of assumptions being made and trying to get us all on the same page to understand and use the same definitions is going to be really important. So that is a little bit of what we're driving home here. So what I'm, yeah, thank you.

Absolutely. And that's a great point. And one of the things we're going to continue to talk about today because we all have those different definitions and perspectives. Now, so just because the executive director is given statutory authority to create offices doesn't mean that there is express statutory authority to create that office. So it's true. Okay, I can't change the leaderboard manually, but we are noted, yes. Awesome Sauce is two out of four, just for clarity. Okay, here we go. Stately spending. The programs with no federal match has grown across the board over five years. Yes. Across the board. Thank you. . Have you all submitted your answers?

It is True. The total rose from $24.5 million in fiscal year 21-22 to $115 million appropriated in the 26-27 budget. Most of the 10 programs are flat. senior dental and Canadian drug importation, family support services, state-supported living, and state case management sort of move within a narrow band. As I think was referenced in one of the team's deliberations, the two programs that have grown most are two that were created in the last number of years, both cover all Coloradans and abortion care.

Fifteen.

Correct.

we do not describe those as Medicaid programs. They are programs within the Department of Health Care Policy and Financing that we administer, but so they are not part of the Medicaid program. We don't consider them to be Medicaid programs or state-only programs.

Thank you for the question. I don't know the answer, and I wouldn't want to provide a wrong answer, but we can follow up and make sure we get you that information.

Yes, ma'am. I would imagine we are. I just don't know the mechanism by which we're tracking it, and so I didn't want to provide an answer that wasn't complete and clear.

And we'll get you more details as a follow-up.

it's true with a caveat. Give us a scoop. It is true with a caveat, and this is deep Medicaid policy complexity. And so as I tried to say, there are a number of programs that we administer that are not considered Medicaid programs that are state-funded only. There is one, however, that is considered a state Medicaid program, but also is only state-funded, and that's the state contribution for Medicare Part D, which is state only and is currently $270 million.

We pay the Medicare. In this very specific case. The individuals are duly enrolled, and the state pays their Medicare Part D premium on their behalf.

Yes. But not as part of the HickPuff dollars that are state only spending that was part of the previous question that has increased over the last five years. Correct.

To be clear, the department didn't create the questions. Summer did. and two, I think the goal was to expose the nuance of the financing, and so that's why we answered the question.

No, we don't pay the match.

No. We pay the premium for the Medicare Part D,

It's an artifact of the Medicare.

So they are both Medicaid-enrolled and Medicare-enrolled. They're low-income seniors that are enrolled in both programs, and the state uses state-only funds to pay their Medicare Part D premium.

I don't know the extent of the buy-in engagement, but we can certainly follow up on that.

Not the Part D part.

It's an artifact of the Medicare modernization that was created in Part D.

States used to pay for some sort of prescription drugs to these folks. And when they passed that and created the Medicaid program, they basically made us continue to pay for it. Mr. Curtis has done the same thing for it.

I'm happy to provide more information.

So Colorado is significantly exposed but is not the worst hit group. RAND, which is a national research firm, identifies Arizona, Iowa, and Nevada as expansion states losing more than 15% of Medicaid funds, driven by their heavy reliance on state-directed payments and provider taxes.

So there is some nuance here because claims payment can be made up to a year after the service is provided, and so this represents when the claim was paid by the department. There are, in addition to primary and specialty and preventive services, which you can see totals about $1.7 billion, there's also inpatient and outpatient hospital. The other thing that we tried to do is we've been asked a number of times which services are optional, which are the optional services per federal statute, per the federal law. Those that are the gray shade are services that are among those optional benefit categories. So, for example, you'll see in the primary specialty and preventive services, podiatry, outpatient services. Speech therapy for adults is optional. And so we tried to give you a secondary glance at the optional services using that coding. A few of them are mixed. And so if we need to dig into specific service areas more deeply and come back to you all with additional information, we're willing to do that and happy to do that. We were just trying to answer the request that you all have better visibility into actually how dollars appropriated to the department are paid out to health care providers for Medicaid members that access services. So the second major area is inpatient and outpatient hospitalization. You'll see there, for example, we do cover services that are provided in ambulatory surgical centers, places that can be not a full hospital experience but an ambulatory surgical center for things like colonoscopies and other services that are safe to be done outside of the physical hospital setting. So that is an optional area that we cover. And you can see, for example, 24,000 individuals last year received a service in an ambulatory surgical center. Our behavioral health services, again, fee for service and then the capitated program, again, looking at what was paid in fiscal year 2018-19 compared to what was paid in fiscal year 24-25. And you can see there has been significant growth. We have a presentation about the different areas of growth with the policy pieces that underline some of that growth that we can help to dig into. The next area of category is the home and community-based services. Again, Colorado has had a proud history of supporting home and community-based services as part of our commitment to inclusive communities and community-based living. Also within that, however, there are services like hospice, technically, again, a optional service from a federal statutory perspective, but one that we do cover here in the state of Colorado. Similarly, nursing facility care, which is a required federal service. And you can see there, nursing facility care is provided to nearly 13,000 Coloradans. And you can see that number is actually lower than it was in 2018, 2019. Private duty nursing and then PACE, the PACE program, which is the program for all inclusive care for the elderly, as well as pediatric personal care. Then there are a series that are sort of unclassified. And so we put them in this order for you all. And that is including of our managed care programs that we have across the department. And then pharmacy. Pharmacy has technically, again, is an optional federal benefit. I think most health care programs include it. Yes, please.

Do you guys have that?

The Medicaid spend by member experience categories is the top. It's blue. Sorry to have missed that direction there that that's the one I was working off of. My apologies. So you can see pharmacy spending, and then others include things that would typically probably find their place in another area, but for the purposes of the way our claims payments come in, we have them broken out. So those include anesthesia, imaging, transportation, et cetera. So this again was was really designed to help answer some of your initial questions about where where do the dollars go and how might when I think we spoke with Senator Amabile she like can you frame it like a normal person would experience the health care system as opposed to necessarily a state budget document? So that was our attempt to do that, certainly willing to take another crack at that if we need to. I'll stop there and see if there are questions.

Thank you, Summer, and thank you.

Director Hammer, this information is really good, but I guess I would ask for a deep dive

Sure.

For instance, dental under primary specialty and preventative. IN A SITUATION WHERE THE ACTUAL UTILIZERS IS GOING DOWN, THE ACTUAL DOLLARS THAT WE'RE SPENDING HAVEN'T QUITE DOUBLED, BUT THEY'RE GETTING CLOSE TO DOUBLED. THEY'RE UP AT LEAST 80%. AND SO WITH SOME OF THOSE LARGE ONES WHERE YOU HAVE EITHER A STATIC GROUP OF UTILIZERS or a reduction and a significant increase, I know it would help me to know what's different here. Is it benefits?

And then somewhat different, but still to give an example, and we go down to HCBS, children's extensive supports.

And I've asked this question before to your predecessor. or when we have a shrinking growth in children that we're seeing in our school system, this is a situation where the number of children that are qualifying for that waiver have more than doubled. And we're also seeing that in PBT. So again, I don't mean to do it in 20 or 30, but there are some examples here in both of those cases that need some explanation as to what's happening here.

Thank you, Summer.

No, these are just direct services. These are just direct services?

Thanks to the, like, Ray payments or whatever else, or what else is missing, I guess. Yep. Director Block will talk Josh Block I the committee I the department chief financial Officer So rate payments are on there They under the unclassified stuff on page two managed care ACC physical health capitations. That's where we're paying the PMPM to the raise for care and case management. Page two of these guys. Managed care. Medical spend by member experience category on the second page. First line of the managed care section.

That amount is just for the managed care or for the physical health capitation, for the per member per month payments for doing primary care case management and other supports that are provided from the raise. The behavioral health capitation is captured in the behavioral health services line.

It does.

Again, happy to do that. But for the behavioral health services, I can provide a little context now if you'd like me to, or we can dig into it a little bit later.

Okay. So for the behavioral health services, one of the things we tried to catalog as we were also preparing this information is sort of what have been the policy decisions that have been made that have added to some of the growth. And so some of that is the addition of the 1115 waiver demonstration, which is allowing us to cover substance use disorder services beginning in 2021. So that inpatient substance use disorder was prohibited until the first Trump administration found a different pathway and allowed states to apply for inpatient substance use disorder treatment through an 1115 waiver process The state has taken that option and beginning in 2021 In addition there also been continuous coverage for children the second amendment to that some re-entry services, and then treatment in other places. In addition, there was the addition of the recovery support services organizations, RSSOs, as peer-run or peer-led organizations. There was also the removal of the prior authorization for outpatient psychotherapy services via Senate Bill 22-156. New safety net providers, I don't want to read this whole thing to you, but there were a series of investments made by the General Assembly to both expand services, in addition, things like the Colorado System of Care for High Acuity Youth that have added to that growth line. I think teasing out, I think if the question back is, can we tease out those particular additions and services in a deeper dive, we certainly can. But there are a series of policy decisions that have been made across this time period that added to some of the growth. In addition, when I've been out talking to community members in particular, there has been, I think, a general discussion about the acuity of behavioral health needs. I think when I was over in Grand Junction meeting with Health Solutions West, You know, they really talked about the complexity of some of the Medicaid members that they're serving and the acuity of those services. So the co-occurrence of a meth addiction and other underlying behavioral health needs. I asked that with some other providers, and I think in general we are seeing higher acuity needs among behavioral health services, and our data shows that too. So higher intensity of services even among a similar population or a standard population. So those are the kinds of things we're seeing in our data. And again, if there's more information you want us to dig into, we're happy to.

Thank you for the question. Yes, the primary care case management component is per member per month for all members in a service area for a RAE because the goal is to have all of them have the supports to be connected to primary care. What's reflected in the behavioral health service line is actually behavioral health encounters by an individual who accessed behavioral health services. So that is an encounter. So 279,000 people last year utilized behavioral health services paid for directly by the RAE. But the RAE gets the per member per month on the behavioral health side for everybody.

Senator Mable, that's correct. And I think the context here is that the payment that we make to the REI takes that into account. So if you imagine you have somebody who is receiving services, maybe they need $1,000, $1,500 worth of services for that year. For that person, we're probably paying $150, $200. And so the payment that we make for every – even though we make a payment for every single person, it takes into account a utilization rate. In theory, we could pay only for the utilizers and not pay for people that aren't, but we don't know that in advance. Capitated programs are designed to be done in the future. And so everything that we calculate assumes that not everybody is going to use it. So the individual payment we make for any person is actually much smaller than what it would be for somebody who's utilizing it. And that's the fundamental nature of managed care.

Just the one. So we have to add them together to see what the Ray is getting in total.

Senator Kirkemeyer? Yes, and I appreciate your comments with regard to the high acuity in the system of care.

Because there's been several lawsuits over the years.

But has the department done a trend analysis or an analysis forecast on what that's going to actually cost? Because I think the original costs were pretty low, you know, with regard to the last lawsuit that you spoke to. And I think we should be expecting that there's going to be additional costs, and it's because of those lawsuits. And that the individuals that we were supposed to be serving weren't getting the care that they were supposed to be receiving.

Senator Melka and then Rep Taggart. Thank you. I guess my question is, I appreciate this because I think this is really valuable information, Director.

hey, is this out of whack? Because we're obviously, as a commission, going to be starting to dig in on these numbers, figuring out, I think, I don't know how you get through what we're trying to do without cuts. This is going to be information that we need to make policy decisions. But also, I think it's going to be important that we have that information from the department if there's issues, if something is out of whack. Why is a program having less people served but significant costs increase? And so I just wanted to know, is that ongoing? Is that something that's planned? because if it is, I personally think it should be, but if it is, I think that's pertinent information for us as well. Thank you very much, Senator.

And real quick, not to interrupt, because I want to hear your response too, sir, but that's not the only area where I think there's some wonkiness. And so I just want to be clear. That's just kind of one that kind of shines at you. There is some out-of-whack numbers in here still.

Can I interrupt, Taggart, and then rep Brown?

I do want to correct one statement. We did lower the dental cap this year in the JVC. So please, we did it, and it was tough. And so you kind of left it hanging out there that we raised it, and we did not raise it. I may have raised it in years past, but this year we had to bring it back. I don't want to overcomplicate this situation, But one of the things I think that at least would help me and our JBC analysts do this for us is a good number of these would completely fall away from analyzing them in detail if we put the inflationary factors on for these five years. and then it comes down to a list that is more manageable where it's either based on a benefit increase or something else kind of situation. But I know for me, my eyes, I appreciate this, but I would bet if we put inflationary factors, this list would probably cut down to half of what's here. So it would make it easier to really drill down into the ones that we need to be looking at.

Can I confirm, is that something we can do?

I trust your folks' judgment on that. I think you know what I'm trying to do is get to a manageable group that we really need to dig into as compared to a group that, whether it's because of rate increases or whether it's because of inflationary situation, it's kind of a norm.

Understood. Rep. Brown and then Senator Kermar.

Senator Kirkmeyer?

Yes, I think that that's right, Senator Kirkmeyer. And I think that's part of the pressure that we know our provider community is feeling, that the inflationary pressures for them to run their practice or run their business have been either at general inflation or at medical inflation, and our rates have not kept up and, in fact, have sometimes, unfortunately, needed to be reduced. And so that is the crunch. I've asked Dr. Rothgary, our chief medical officer, to help put together a sort of access monitoring strategy to see where, given the changes both in the last couple of budgets that have required rate reductions as well as upcoming changes in HR1, how will we be actively monitoring whether or not those two things have come together in such a way that access is compromised? and so that is one of the current areas that we're trying to do that. I think the other goal is to have the conversation here with you all, that this was the kind of information you all thought you needed to understand and seeing it in a different way, and so we'll continue to provide it in any way that helps to inform the shared conversation that we need to have around the services that are in shaded, that are optional services and whether or not the robustness of the program can continue, and then how, if at all, we would change those together. So I think that's the exact set of questions that we want to explore as we go through this process with you all.

Okay.

Yes.

But as you walk down this entire list, that answer differs for every single service category. A good example here is pharmacy. Pharmacy is something that does increase every single year because the pricing statistic is tied, based on something in federal law, to providers' actual acquisition cost of those things. And so even though I think on just trying to look through the number here, the number of total utilizers has actually decreased. The spend on pharmacy, this is the gross spend without drug rebate, has increased significantly. So as we unpack this, and as Director Hammer said, we'll look for ways here to provide what are the rate increases, What are the utilization increases? I think it's important that this committee understands that there is no single number that answers this question. It differs for every single one of these categories.

So Senator Kirchmeyer, you picked behavioral health here and a few months ago Gretchen went through, Director Hammer went through some of the policy changes that there and you correctly identified it, right? Is that some of its policy changes. When it comes to behavioral health, that is probably the area that is most likely to have kept up with inflation because of cost-based rates. So I bring this up because, again, we are trying to put together information that helps illuminate those things because it is the most important question here, right? what are the isolated effects of these individual policies? What are the things within the General Assembly's control? What are the things within the Department of Health Care Policy and Financing's control? But I don't want to sit here and promise you that I'm going to be able to provide a perfectly clear explanation from these things because there are so many factors that are moving into it, and each one of them requires a detail here. We're going to do everything we can to provide as many, like as much explanation as we can for all of them.

sorry i jumped in yeah and and not to i guess to to tack on a little bit to what senator kirkmeyer is saying is i i also am curious of how you do this what inflationary factor are you using um how is how is that going to be determined when we're getting this information but i want to go back to a little bit what i spoke about before as well is that like when i look at NEMT here out of whack. We know it's been in the news. We've gotten presentations that there's fraud, waste, and abuse. We are being tasked with a monumental thing that we have to do here to try to solve a huge problem for our state with this Medicaid program. And what I need from the department is where are you finding out where that fraud, waste, and abuse, where are you finding out where things are out of whack so that that can be addressed so that we can actually do our work. Because if we paying an EMT million and that million too much well that million that we may not have to figure out how to cut and make a really difficult decision And so I guess that's what I want on the record, and I want to task with you all is that for us to do our job, we have to have that information. And this is not fun. It's not going to be great, but we need that help. And I think that I'll just leave it there. We need that help.

Reptiger. Thank you, Madam Chair. I feel like I made this overly complicated. And from an inflationary factor, I just want to come back to the fact that I think we're all saying we want to narrow in on the issues. How the most serious issues, and dental has shown up in that area. Certainly NEMT shows up in that area. I guess I just want to, again, put it back to you folks. When you look at this, because you're the experts, you can probably pick, and I would imagine you've already done it to a certain extent, you could probably pick 20 or 25 line items on this report that just from a mathematical standpoint don't make sense. And you've got to dig in. We've got to dig into them and find out what's at the core of that problem. And so I trust your judgment, but I, and I appreciate this, but we can't tackle every one of these. We've got to tackle the most important.

If I can just add real quickly, because I think what we also want in the analysis is what are the factors that take into consideration the assumptions that are being made. So I think those are some of those details that are going to be important to kind of highlight so that there's a full understanding. And quite frankly, if the answer is we can't figure it out, then like, I think we can be frank and candid about that too. Yeah, if I could just add, Madam Chair, I would also just historically, I would like to be included where areas where historically we have seen higher cases of fraud, waste and abuse. I think that that's something that we need to be heavily focused on. And so even though it may not seem out of whack, if there is an area that historically we've had those issues, I would like those included.

That's correct.

Sort of.

It depends. When we do the budget for medical services premiums, we don't budget for every single service category individually. No, I'm not talking about the budget.

So it's the over or underutilized part of the question that makes this difficult. Because when you say over or underutilized, the answer is compared to what? So when we talk about...

So for example, we spend a bunch of money on inpatient hospital expenditure, fee for service. Somebody shows up at a hospital, we pay a claim, there's a utilizer. There is nothing in our forecast that says we are projecting this many number of people to go to a hospital this year. That actually has rolled up in a higher component. So while I can tell you what the utilization is and I can show you how utilization grows year over year, there's no point to compare to against this is what we expected for that. There are other points of comparison in the budget, right? So, for example, I can tell you what I expected to spend on acute care versus what I actually spent on acute care. But the more granular you get, whether it's inpatient hospital or pharmacy or FQHC or some of those factors, then I don't have projections to compare against. However, finance answer, I'll give a program answer. There is the source of truth that is the financial accounting, and we do report that to you all monthly, our spend against the appropriation. So that comes over in the premium and caseload expenditure report that is posted on our website and sent to you all under legislative request for information. There is also, though, a data team and a benefits management team that is in other parts of the department, and they look at those trends of utilization from a data perspective. So, for example, I'll use an example for when I had the opportunity to serve as Medicaid director. Josh was the budget director at the time and we saw a growth in NICU expenditures that we couldn't explain and so we did a little digging and accompanied with that was an increase in emergency medical transportation and we figured out that there had been a number of children who had been born in the metro and gone back up to the mountain areas and their concern was there and then they were flown back to the metro area. So it gave us some insight into how we could better improve transitions of care. So those kinds of data are being looked at by our program and policy team every month through our data analytics shop, which is in the clinical quality and improvement office. So we have both lenses. We have our expenditure, and then we have utilization and quality measures that we're looking at monthly.

Can we move on?

Okay. So I think we're moving on to this ender. We're still talking about where the money goes, right? Yes. Okay. So we're moving on to the... We have a question from Rep. Taggart.

We can clarify.

I don't know what that means either. We don't know what that means either, sir. We'll get back to you and clarify. Although, Representative Taggart, I think as you look through this, even if the chart is incomplete, the important thing to remember is that everything on here gets at least a 50% percent match as services. So for example, the first one on this list that says no proxy available for adult glasses after surgery, the estimated federal match on that should be 50 percent. Now, it gets weird, right, because it depends on the actual population, right? The service itself gets a base federal match rate of 50 percent, but if you are part of the expansion population, it gets 90 percent. If you're part of the breast and cervical cancer prevention and treatment program, it gets 65 percent, and that's where things are. But I think you can assume for the sake of looking at this, everything gets at least 50%.

Well, I just want to move on to the next thing. And I was guessing that it might be about this

I don't know that I have it at my fingertips. Can we take a five-minute break?

We need to recollect some things.

Sorry to interrupt.

Okay, thanks. So I'm wondering, the number, like on the first one, $389 million,

That's correct.

That is correct.

It is the entirety of the contract over multiple years.

And when did that contract start?

With Deloitte 15 years ago.

I believe that it is after each new procurement cycle.

But for example, for CBMS, it's procured, and then over the contract period, I think we can do between five and seven years.

I mean, I think there are some really big numbers in here, and so I guess on some of them anyway, I'd like to understand how long is that?

And also like are other departments kicking in and this is just the number that HICPF is paying?

So this number is just for HICPF?

So maybe Senator Mable, given what we learned with the first set of data that we tried to present to you,

Okay. My other question was, well, I mean, I had flagged a few of them.

also and I'd just like to try to understand what that is because my understanding is HICPF

are in each of the departments that are doing some of these things and then also paying a

So actually this is how much, and I get maybe it doesn't break out that way into each different

But you know on the care and case management, we're spending $111 million in addition to

the care coordination that happens with the providers.

I would love to know how much money in the Medicaid system is spent on care coordination and how much that adds up to per member because it just looks big

and then some of them have, they have no match, I think,

And again, I don't know what that means.

And then on the pharmacy benefit management system,

So is there some corresponding number that is the savings?

Those are my questions about that.

I mean, it just seems like an awful lot of money on top of other money,

Well, it pays the claims from the pharmacies.

and then the claim is paid.

Okay.

like how much is that per prescription or per claim that gets filled

Okay.

Just because for me that just looks like a giant number.

and you spent a bunch of money to get the system set up,

and the cost of doing that should go down over time.

because, again, I don't know what amount per year.

So, you know, we've done a number of budget requests over the years

and they always start exactly in the way that you think.

and then the costs go down in terms of maintenance.

And that, you know, is much less than the development cost, but it counts for things like the staff that are working on it, the power that's used to do it, the physical locations of the servers and things like that.

The cost does go down after the initial implementation phase.

this is again that this is the total contract amount so we can as you asked break it down by the annual expenditure I will say you were asking a question

So I think our team inside the department is 17 FTE

Okay.

I have a very basic question. All of these numbers are inclusive of federal funding.

That's correct.

So the match rate you're showing us is 90% of that or 75% or 50% or whatever the match rate is, of that number is being covered by the federal government?

Okay.

Rep Taggart.

I've raised this concern before, and that is when I look at the software side of things here,

In business, that is no longer the case.

Oracle is one of the companies that has major platforms.

I guess I realize there are only 50 states that participate in Medicaid, but do we ever have a conversation, a consortium of states that say, let's get behind one platform or another, and then you do some customization of a base?

but it's almost impossible to update without huge expenses.

has in fact and I know we're working on a replacement thank God for CBMS so let's not

to, but what's our strategy here?

Thank you, Representative Taggart.

I hear what you're saying, but at the same time with your background working nationally, we do have components.

And to me, that provides a base that you can build off of that you don't have to build.

and it just, I have a bias because proprietary software sounds good at first

but down the road it is an absolute nightmare

Representative Taggart, I'd add just a couple things here.

Senator Kirkmeyer.

I don't know if anybody asked this or not already, and I apologize if you did, but I wasn't here.

And so is there a report on what they've actually found through program integrity

Because even if it's including the federal match, I steal my taxpayer dollars.

Great.

Senator Frizzell?

I just, where on this list is the RAC audit auditor?

Thank you.

We'll get back to you.

Being honest, I don't want to tell you the wrong thing.

There are lots more.

But for specifics, we can absolutely get you those numbers.

Is that how we decided the selection?

I think it's more about being illustrative here.

Okay.

I mean, I ask because the RAC audit process was something that was heavily scrutinized in recent years by both the Joint Budget Committee and the Legislative Audit Committee, and I think that those are important numbers.

Supposedly, things have improved.

Sure.

Are these are all of these materials available online for our folks for folks to follow at home We missing two documents that are being uploaded The two that are in the Google Sheets Okay

So it sounds like they will be added very, very shortly.

And then, Representative Brown, we were talking about this during the break.

so sometimes you've got to go into the fact sheet and find them.

But you may have to – folks listening online may need to dig a little deeper.

So I appreciate the department's diligence there.

I, again, will not go through all of them, but we also tried to tie sort of who's in that office and what are the structures within it, who have the FTE, and then what is the function, and are there any additional things of note. For example, the Rural Health Transformation Program Division, those positions are all grant-funded and term-limited. They will not, since there are no state dollars going to that, they are in structured term-limited positions as FTE. So that is the overview of the department's structure that helps us to administer. we at the front of the program level budget crosswalk tried to then tie those offices to the benefits that they oversee. So both in the very large spreadsheet that is the legal size as well as in the high-level fact sheet, tried to recognize that, for example, that service category of acute care is $6.9 billion, dollars and there are really three offices that support that acute care, the health policy office, the pharmacy office, and then that undergirding through the Medicaid operations office. So again, we're not going to go through each of these, but we recognized, as you said, Rep. Brown, it's hard to keep track of all of the things we're trying to help send over to explain the structure of the department. And so I wanted to provide just a high-level overview of those and then happy to take questions. All of this is also getting a match? Yes. And does that also vary, or is there one match? It varies by staff. Thank you for the question, Senator Mable. The caveat, because, right, everything is true with the caveat, it appears today. The caveat is, for example, those rural health transformation programs, it's not necessarily a match. Those positions are federally funded. And so that piece does not have a match. But, yes, across the offices, some of our core functions and administrative functions are, the bulk of them are 50-50. And then some of our technology supporting staff who do work on some of those 90-10 technology-related contracts, their salary is matched at 90-10. Senator Kirkmire. Thank you.

Six.

I think as I understand it, and you may know better as a member of the Joint Budget Committee, we do have divisions in our office, in our department. They are under our offices, though. I think in many other state agencies, I think the way we describe an office would be considered a division. The unique part about our office, or the way we are structured, is we really administer one sort of structured program or set of programs. So I think unlike perhaps Department of Public Safety, where Colorado State Patrol is quite different than the Division of Fire Prevention and Control, right? So those two perform different functions on behalf of the state. The way we are organized and while we use a division structure, I think it's different than the way other state agencies do. Our divisions are underneath our offices and help us to break the work down further.

Yes.

Deputy executive, executive deputy directors. We have in eight of our offices, I think it's eight or nine, I can get back to you with the exact number. We have a designated deputy for that work, but they are an acting policy and manager member. They sort of continue. It's just an organizational structure so that, for example, when Adela Flores Brennan is out, Kristen Bates can serve as the interim Medicaid director during her time of leave.

No, they were additive.

Yes. The Cost Control and Quality Improvement Office, the Medicaid and CHIP Operations Office, and pharmacy had been... So part of... To explain the history, so maybe three, excuse me, I got it wrong. The pharmacy office was previously in a clinical office that was led by our chief medical officer. It included data and analytics and pharmacy under the direction of our CMO. Director Bim Steffer changed that structure and pulled pharmacy out as its own office, given the high expenditure and the sort of unique nature of that benefit, I think as Josh was describing earlier, and made it its own office. So it had been an embedded division within a clinical quality office, and it became similarly the executive director's office, the Human Resources Department and Learning and Development used to be in the Policy and Communications Office, and it was moved to the Executive Director's Office. So some of the reorganization that was done was taking current operating divisions and groups of staff and moving them to different offices as part of her vision for the way the office would operate.

Behavioral Health is a new one as well. That's correct. Yes.

Cost control, quality improvement, and the Medicaid and CHIP operations office.

Mm-hmm. Okay. Again, though, just as another illustrative example, so the eligibility division when I was here the first time was in the health information office because of the interaction with CBMS and others. So it was a choice to move it to a more operational frame, and that's what became the Medicaid and CHIP operations office. Similarly with provider enrollment, that was also in the health information office and was moved to the Medicaid and CHIP operations office.

Yes. Thank you for the question. They are in term limited positions and it was advertised as such. So they do not become certified state employees. They are in a term limited position. We have a number, not just the rural health transformation. And so our human resources department tracks that. And at the end of the federal grant, their employment with the state will end.

Other than the 19. I would have to count. And they term limit at different times. We tried to provide that in the notes section. we can certainly come back to you with a number and look at when those terms end.

Yes, Senator, thank you for the question. I think one of the things that is difficult to describe is also the complexity of the program has changed, not just the numbers served. So, for example, when the 1115 waiver was contemplated by the legislature, a number of FTE were associated with that to help implement that new program. So while those are additional services, they may not be to new enrollees. So tracking FTE to enrollee is one proxy. I'm not at all suggesting it's not something we pay attention to, but also the appropriations of program staff as the department adds new programs is another component of that. I think that the 10 office structure is not the most efficient way the department could be operating as someone who is new to the work and, again, trying to separate out the historic way that I understood the department to be operating when I was there. I think these buckets, if you go left to right, Director Birch used to say I was a soccer player, so I see things laterally. But left to right, I think this notion of an administrative set of functions, a constellation of staff that are organized to deliver the program, and then a constellation of staff that are responsible for core operations those in some way make sense I would maybe move a few things around but that highest level I actually was looking the Department of Early Education, I think, has a similar structure. They may have pulled out financing, but they have financing, administration, and program. So I think at that highest level, those kinds of things make sense. So I do see an opportunity to bring back together some of the program areas that have been separated out into offices to increase the ability for the staff to be aware of what is happening with each other and to be aligned and collaborate. One of the things I have done, since I haven't necessarily had the runway to actually reorg, is we have reorganized the way we meet as a department. So I've changed the senior executive team meetings to be inclusive of the offices that do have a deputy. They now come to our senior executive team twice a month, hopefully broadening the number of people that we have the opportunity to hear from and partner with. And then our executive leadership team is all of those division directors across. And we've changed the format of that to really be focused on enterprise-wide projects. So we have identified 10 to 12 bodies of work that we would call enterprise-wide projects. Examples, HR1. Nearly every single part of the department has a component in making HR1 go. Similarly, the rural health transformation and others. So the county redesign. So those enterprise-wide now have been put into a portfolio, and we do updates on each of those, every executive leadership team, which is twice a month now. So while I haven't necessarily made changes to the structure, I've tried to help improve the way we're communicating with each other across the department to help to make sure we have connectivity across each of them. We also stand up ad hoc work teams and those kinds of things, but I do see an opportunity for perhaps a different structure that could be a little more efficient. Thank you. Yeah, so, I mean, not to reiterate what you just told us, Director Hammer, but it seems to me like the previous executive director kind of took things and made the organization more flat, right? And what you're talking about is sort of putting groups together in a different way that might be more efficient at some point. But, of course, it seems like you're, you know, maybe we're a little ways from that. I mean, do you have plans for reorganizing things at this point, or are you sort of waiting a bit? In my professional experience, both when I was here before and as a consultant, rushing to reorg is not an effective strategy. And so given that I serve under Governor Polis and Governor Polis's term will end in January, I don't feel it's responsible to start a reorg that I would not have full responsibility for across. That is not to say that ideas can't be explored. I think Senator Mable, you had mentioned maybe a recommendation from the commission. I think certainly conversations. But given the time that I have known availability in this position, I feel it would be irresponsible to start a reorganization of the offices. Yeah, I mean, the only thing that I would say is it puts a lot of the way this structure plays. And obviously, I believe that the structure of the department is ultimately at the discretion of the leadership of the department, right? that you supposed to design your department in a way that effectively executes the programs and the directives that you get from the legislature But it puts a lot of pressure on the executive director because you seem to be the only person who kind of can see the entire chessboard And I think that's the structure that has been put in place here. You know, if you had a little bit more vertical structure, you might have some deputies that were a little closer that had a little broader view of what's going on in the department. So I'm sure that's probably what you're weighing at this point. So anyway, I appreciate that conversation. Yeah, and I would just say, because I think it's really important to say, one of the things that is very clear is that there is no turf or tension between these office directors. This is my senior executive team. We come together every Tuesday morning, adding legal, our chief medical officer and our human resources director. And we are working really hard to act like a team and to put the structures in place to support that team-based thinking. And so I just think it's important. I, too, have gotten feedback about how it can be a little difficult to navigate the department. But I have not ever gotten feedback that there is tension or turf between the two offices. I just worry and believe in my heart of hearts that we administer Medicaid and CHIP as a department. And doing that in silos is not the most effective way to do that. Rep Taggart. Thank you, Summer. And I appreciate your statement that reorganization is not something you want to do by snapping your fingers and that it probably couldn't take place between now and January. However, I do think the principles surrounding an organization structure can be spelled out. For instance, when I look at this, you have some divisions which I would consider, from the words that I use, that we use in business, that are somewhat decentralized, and that's programs. And then you have the centralization of services that are provided to each one of the programs. In our business, it would be a product division supported by finance, supported by operation, supported by IT, et cetera, et cetera. And I see some of that concept here, although there's some conflicting ones. For instance, health policy, just reading what you've written here, does not seem like a program. It seems like more of a centralized set of policies. But I don't want to digress there as much as I think encouraging putting together the principles, not necessarily us, but I suppose we could, the principles of what this organization should be going forward, I think is an important thought process. Because I would agree with you, some of the makings in the far left make sense to me, because, again, it's decentralization versus centralization. and I agree with that. It's just that there's some stuff within it that doesn't match up with that and then the one two that I noticed there's health policy is is one of them and cost control and quality. If it was me, I would put that within within the program side of things so but I would just encourage you to take it forward and make a recommendation. Thank you. Senator Kirkbier.

I don't know the answer to that. I did, to Representative Taggart's maybe just point, I moved Dr. Roth-Gary and our part-time clinical, other clinician out of the cost control and quality improvement office and up into the executive director's office. That is one change that I made starting July 1st. In an attempt to try and see that perhaps maybe what you were mentioning, Representative Taggart, that we need a medical point of view on our senior executive team and we need clinical insights into all the decisions we're making. And so moving that to the Executive Director's Office positions Dr. Roth-Gerry as opposed to being down in one part of the organization to be further to the left in this picture and able to provide oversight across the different areas in the department.

Okay, I was curious on that because I know there's one requirement in the Department of Public Health. So I have a couple of questions and then a comment for you. So I'd like to know which office is focusing in on the error rate issue and which office focuses in on the CBMS stuff. And then there was an article in the paper just recently, Colorado Politics, and it stated that of the 200 million, this had to do with the Rural Health Transformation Grant, Bates said 160 million would go directly to providers, and the rest was allocated to training and technical assistance for 19 new staff who will assist in operating the program within the cholera Department of Health and Environment. I think there's a bunch of errors in that paragraph, and I would suggest maybe you get that cleared up, because I had several text messages this morning and said, what the hell is the department doing that they're using $40 million for 19 people and it's over in the Department of Public Health and Environment. So I said I don't think that's exactly what was said. You might want to clean that up. But just back to my other two comments, where is the error rate and the CBMS, where are those issues being handled, which office?

Any other questions on the structure before we move into programs? Okay. What additional things did you want me to say about the programs?

Any other questions from HICPF? They'll be around, but we're going to move into exercise unless there's other questions that you all had.

Well, we have the time put aside so that for the things that we aren't diving into, if you have questions around those materials that were sent, let's dive into them.

Yeah.

We can definitely add that to the calendar, and I can definitely see how that would be a strong recommendation coming out of this commission related to the next administration. administration, what does that look like and how can there be some more efficiencies? Are there other questions about the materials that you all received that we had not had a chance to dive into yet? Understanding that you received a lot of information.

We can give you full packets going forward. I think we'll have enough time now to be able to do that.

Sorry, Kirchmeyer.

It is in the Policy Communications and Administrative Office because it includes the legal component of actual rulemaking Our chief legal officer, our in-house general counsel, Rachel Enterkin, and her staff do the technical component. And then Adela Flores-Brennan is the senior executive team member that attends MSB and represents the department.

Because we had some issues about a year ago. So, Senator Kirkmeyer, the Chase Board reports through my special financing division in the Finance Office because it is related to a lot of the technical components of the provider fee operations. And so in terms of recommendations, I think we'll, we will get back to you on that one.

That actually went through your office? The staff who work on it work for me. I think that the point is that it's not that I am the sole person interfacing with the Chase Board or my staff. It is that my staff manage the operations. They manage the logistical support. They set up the meetings. They get the agendas out. They manage the websites. The information coming from the Chase Board, the policy associated with it, flows through the entire department. It goes up to the executive director so the decisions about policy related to Chase happens at a department-wide level. It involves the Medicaid director, et cetera.

Senator Kirkmeyer, yes, there has. that is a conversation that is very much ongoing.

Senator Kirkmeyer, we'll get back to you on that one.

It does not. It's the sort of question that requires me to coordinate with the governor's office. The November 1 budget has some complexity associated, right, because everything needs approval from the governor. so there are interesting moments prior to November 1st where we're allowed to talk about what's going to show up there but it is not my call or the department's call to tell you when we can give you a sneak preview I would caveat that though if I might if it's after November 1st it won't be a sneak preview I appreciate Josh has the responsibility to answer the question in a technical way I have had the chance to talk to many of you independently. And I think, as I understand it, part of what we needed was this kind of time to think together collaboratively. I think given where we started the conversation today about wanting for you all to have a better understanding of our expenditures and how those expenditures match with our benefits and services to individuals, we have these large structural financing challenges ahead of us. And I think it would be my hope that we could do some modeling exercises as you all could request from us. Could we model what would happen under these conditions or in this situation? That doesn't, I don't believe, violate the sort of budget process. And I will say, and I have said that I think it would not serve us well to not be able to have some conversations about potential scenarios in the future and how collectively as a state we're going to rise up and meet those challenges that we all face together. So I hope we do get to have those conversations prior to the formal release of the governor's budget, which is one component of a longer-term question around the sustainability of the Medicaid program.

Thank you. And thank you for that, Gretchen. And I do want to echo Senator Kirkmeyer a little bit, though, and appreciate you, Gretchen, on the modeling, because I do think that that's a good idea. I'm sure you're going to get a number of requests on that because I do think it's going to be valuable. But I also think that we are in a precarious position. We have a new administration coming in to the state, and so, you know, it's kind of a chicken and egg thing. But we also doing a significant amount of work here And so I not sure if maybe we need to have the administration come in because I think it not going to be helpful when we doing this work and we coming up with solutions to try to keep Medicaid in this state afloat And then we get a budget that counteracts all of the work that this commission is doing. And so, Summer, I don't know if that's for you. I don't know if that's for you, Gretchen, but I mean, I don't think that that will be a very productive way of doing things. Granted, the legislature controls the budget, but to get a budget put forward from the administration that counteracts everything we're doing, I think it's not going to be helpful when time is of the essence on this issue. So one of the key assets that we have is OSPB Director Ferrandino. He is, at his heart, a health policy nerd. And so I think that we could very easily engage with him and see how he might be able to come to the commission. Okay, so I'll just add to that on this modeling thing. do you need a specific request from who to do this modeling?

Yes. I think a little bit like what we, and I hope we made some progress today in giving you information in a way that was easier for you to absorb and understand. And then I think as the process is supposed to work, you said, wow, it's great to see the whole picture, but the whole picture isn't what we can make decisions around. We need places of anomaly, places where policy changes, et cetera. So I think I would be wary of committing department resources to model things and concepts and ideas that don't meet your needs or interests, right? I think, as Summer has said, it takes quite a bit of time across multiple areas of the department to prepare these materials. We are 100% committed to doing that. And so I think some direction on modeling changes of financing, changes of benefit, changes of whatever you all would need as you get further into a deep understanding of how the programs are currently operating would be helpful to us so that we don't spend a lot of time doing the wrong thing. Can I jump in real quickly? Because I just want to share, add to that. I think one of the next exercises that we're going to do, which is around trade-offs, is going to start us getting to think about what are those types of things that we want to know or ask or model in order to be able to make some of those decisions. So, I think we're trying to make some steps to get there because I want to be really thoughtful about making sure that we are asking the department and asking them to work on things that are going to help us make decisions around the tough things that we do need to decide on. So, that's really like I think that's the question I would encourage everyone to keep coming back to as we're making requests is, is this going to help us make decisions in a few months around how to make this a sustainable program? Okay. Can I add one thing really quick? One of the things that is on a future agenda, I forget what date is to talk about the changes to provider fees and the reduction and the amount of ceiling there. And so we will come back at least to start with some high-level information and it will be enough to generate some questions to talk about probably a few different what-if scenarios. And I think that is already planned, but I do not quite remember the date off the top of my head. Okay. I just don't want us to get so far down the road before we've actually made that request that you can't get it done before the budget. So I don know where that is on the agenda either but let make sure that we don leave that go for too long And the other thing the first half a percent is in 2027 Is that correct The first reduction Yes. Like that, absolutely. I heard some hedging about whether that would be in the budget, but it has to be, doesn't it? So, yeah, it has to be.

So Rep Gilchrist is signing off.

Tell us a little bit about your conversation.

So we had a good conversation. Obviously, we identified some of the sort of factual information that we do have, like the total funds, the general fund, et cetera, that you had provided for us. I think when you ask us about what sort of the evidence says, of course we don't have that evidence, but we would be very much interested in understanding how private duty nursing avoids unnecessary hospitalizations, how the cost of private duty nursing compares to facility-related care, whether this is available in rural communities, whether care would be provided in other ways if the state did not provide this, and the money that is directed to the actual care for the patient versus overhead or sort of take administration that maybe some sort of middle entity were taking. What would a change actually save? And we would posit that we don't really know unless we have clear information of some of those different tradeoffs that we just discussed. And then, you know, what would this program look like if maybe some of the admin costs were able to be taken out and more of that attributed to actual patient care and the payment of nurses? And then I think, you know, ultimately what would have to be true is we would want to make sure that we're spending money in ways that promotes better health outcomes at lower costs. So that's where we sort of ended up. So I don't think we have enough information to make those decisions today, but those were the questions that we raised.

what um if you had found out that uh sorry if you could um if you had found out that um you know what it just didn't make financial sense um to continue to offer private duty nursing and instead had to go to say like you know what we can support home health aids what does that what does that mean for the you and the conversation that you had. I think we'd have to know what the health outcomes, what the impact on health outcomes would be. What's the cost savings? What's the impact on health outcomes? Are there other ways to make up for any reduction in health outcomes with lower cost care? This is, I I mean, this is the painful part of talking about Medicaid, which is that any reduction, it is unlikely that any reduction results in higher quality care. I mean, certainly there are ways that we can drive efficiencies, but any time you have a benefit that is being provided, to reduce that benefit probably means some folks are going to receive lower quality care That probably means there are impacts on health And that is just the horrifying reality of the necessity that we face in this state because in large part of decisions at the federal level, to make cuts to Medicaid. And so I think we'd have to know, to go back to your specific question, what are the impacts on health outcomes and how can we mitigate any negative impacts? Thank you.

So for the adult dental program, I'm sorry, what questions do you want me to answer?

You can just give us a summary of your conversation. So I think that we didn't have a lot of information because one of the things that we talked about was changing some of the caps. And the program was already capped, which we don't think is actually reflected here. But keeping in mind that there are long-term health effects for poor dental care could result in cost of additional emergency care. the other question that we came up with, it was like, where do people actually go with dental emergencies if they can't go to a dentist? And we phoned a friend over here, Senator Mullica, and he assured us that that's not actually something that they... Okay. So anyway, he reflected that this is really not something is that dental emergencies are not really treated in emergency rooms, which we didn't really know, but now we know. So not really understanding who actually qualifies for these adult dental benefits. We're not sure if we could look at modeling, capping usage based on age, or what would happen actually. What would be the real changes to what currently costs the state about $75 million a year? what does change if the cap is moved down further. We're trying to figure out what it is now. We think it was changed to about $1,800 to $3,000. Okay. But anyway, so what happened? So there were a lot of uncertainties. We also looked at changing who qualifies for the benefit and maybe narrowing that a little bit. So we ended up with more questions than answers, I'm afraid.

We thought you were going to be on break, so I took over. We have a slacker over here.

All right.

YES. THANK YOU. AND THANK YOU SENATOR KIRKMAYER FOR REPRESENTATION. I HAVE A CONCERN HERE.

I think that's helpful to know because I think we can help to provide some of that additional context as we're, again, getting into some of this decision-making. I would just say I would invite the other members of the Medicaid Commission to join us at the Joint Budget Committee when we're discussing healthcare policy and finance. Yeah, you should come. You're welcome. You're welcome to come and have a good time. Do you all have any reactions after hearing kind of what your colleague shared I mean I just say we experienced this last year It is really hard We don't feel like we have the information that we need to make these decisions. And that's what we're doing here in this Medicaid commission is getting more information and also figuring out how we're going to work better with the department to get a more fulsome view into what all of these things are. and so it's a great exercise because this is actually what we have to do on the JBC and what the General Assembly has to vote on and if our colleagues don't want to make any cuts then that makes this work really hard to do so not only do we need to understand it but we also need to figure out a way to communicate that with the rest of the General Assembly Okay, thank you for that. Oh, yes.

Last exercise for today before we kind of get into next steps. One, thinking about what are we optimizing for, right? So if you're thinking about our Medicaid program in Colorado for three years from now, what do you want it to be known for? And so we've got a list here for you to look at, consider. I'm going to hand out a worksheet that is basically just this screen here and ask you all to choose your top three. But I want to also ask if a couple of you will share your top three so that we can hear from each other around where you land. So give it a minute while I'm passing this out. and then would love to hear someone's top three. And what do you want the Medicaid program in Colorado to be judged on, known for in three years?

Any healthy debate? Senator Bridges?

I'm with Senator Bridges on this this is what we're doing here we have to be able to pick and choose what is the most necessary things programs to offer

I mean, I'll just – I'm going to add to that that I think healthcare costs in America today are unsustainable. This is not unique to Medicaid. Healthcare costs in America are going up way faster than I think our economy can keep track, And it seems like in 20 years, the entire population of America will either – it will be finance bros and nurses. And, like, that will be the economy. And I don't think that's the direction we're headed, and we have to figure something out. I would just add to the conversation as well. It seems to me that there are kind of three, to me, a couple of general topics that kind of oversee all of this. I mean, we are going to have to slow down the general fund cost growth. We don't have the funding for it. And that's why I was talking about the level, the federal poverty level and the expansion populations and where we're at kind of thing. But we're going to have to slow that down. But part of that is truly looking at, and it kind of goes back to what Rep. Brown was saying, that all of these things are important. But slowing down the general fund cost growth means we need to look at program integrity. And there needs to be legislative visibility and accountability. And we should be drawing down every available federal fund we can because that's how we're going to slow down the general fund cost growth. We can't have programs any longer where we had on the NEMT where we were telling some, you know, the metro area $668 reimbursement that they got for, what was it, extra large transport kind of things versus what was going on in the rural communities, which was only $65. But it ended up costing us millions of dollars, not pulling down federal fund matches. We lost out on a lot of federal dollars because with regard to the hospital provider fee and the chase fee, that we didn't increase it up to 99% and that we didn't go after some other dollars. And then it became too late. I mean, like a lot of money. So all of that adds into slowing down our general fund cost growth. If we're making sure we're pulling down every match we can, we also are going to have to look at the waivers. because some of the waivers are waiving people's requirements to be eligible for Medicaid so that they can get Medicaid, and we can't afford it. I mean, we just can't keep affording it. But I think, honestly, for all of us, I would say probably everybody could agree to this, we always want to approve health outcomes and value for the citizens of Colorado. But we do that by making sure that there is administrative efficiency that we are drawing down those federal funds that we are preserving the access to care I mean having 25 counties with maternal health care deserts is not good for anyone in this state And, you know, as I explain to people, that's not just people on Medicaid who are not getting access to maternal health care. That is every woman in that county does not have access to maternal health care. It impacts every single one of us in this state when we lose access to care in any portion of our state. So I think ultimately the goal is that we improve health outcomes, but we have to do that within our budget. And so all of these other things to me fit underneath slowing down the general fund costs. They're all subcomponents to me of the general fund costs because it is going to happen. We are going to have to cut. but they can't be across the board cuts. That just doesn't make sense. And we can't find, I mean, from the department we don't get, and maybe it isn't even possible to get what the cost avoidance is or what we're going to save. Because every time we, I mean, there's a lot of times we'll hear we're going to save money and, you know, three years later it's like, well, how much did we save? We didn't save anything and it grew. The cost grew. So would it have grown by, you know, $60 million instead of only $40 million? I mean, we don't know, but nobody can tell us that kind of information, and I don't know if it's possible to do or not. So, but those are my comments. Thank you.

I'll just jump in. I agree with everything that's been said. We do have to figure out how to slow the general fund cost growth. I think we have a lot of different levers. We have to make sure we're protecting the most vulnerable. And I think something that's outside of the scope of this commission, but not outside of the scope of the General Assembly, is that we have to figure out a way to have more people who are not living in poverty, who don't need Medicaid, who can get insurance on our health exchange or through an employer or in other ways. And if we're not looking at that, then in addition to looking at this, then it's going to be a lot harder for us to solve this. And I know the number of people who are eligible for Medicaid hasn't grown, but it also hasn't diminished. And we actually should be trying to shrink people who need Medicaid. And it was meant to be for the most medically fragile, the people who can't work. And I'm all in on the expansion population. I have several relatives who are on that and who need it. But we ought to be able to figure out some ways where they don't, where they're all working, where they can earn more money, where people can afford other things like housing and whatnot. And so not to, you know, blow it up to some ridiculous level, but this is Medicaid exists in a much bigger economic problem that we should also look at.

Thank you, Summer.

And I appreciate that. And part of this conversation is helping me understand when we get to that decision-making place, how do we frame it and think about it? And how are you all thinking about it so that we can have productive conversation then as opposed to having this conversation three months from now? So I definitely appreciate that. Rick Brown.

Completely fair. Thank you. Any other comments? Okay. Thank you all for indulging in that exercise. Like I said, it is helpful to understand your perspective now as opposed to trying to figure it out two or three months from now. Okay. A couple of just logistical things. Remaining schedule. So before anyone online or in the room gets too excited, we're going to have to change likely the long-term services and supports to early September. So just keep that in mind. We'll try to put out this final schedule by the end of this week. we've got all these different topics especially the next four the delivery payment and operations the financing the long term services and supports meeting nine is going to be what are the things that we have not figured out yet or talked about yet that we need to take into consideration before we start talking about options and recommendations so that's why I said in the beginning the next couple of sessions are probably going to be long late sessions so that, again, you have the data that you need to feel comfortable going into those options and recommendations conversations. My ask from all of you is because you all do have a lot of requests. If you're making a request for a big topic, is there something that we can take off the list, which I know I'm asking you something that's nearly impossible, but trying to be thoughtful around kind of again what is it that you need to feel comfortable making these decisions and recommendations in the fall So that is kind of the framework Every time there a request that comes in I might ask you that to just make sure that we're staying on track. I do have a question around our next meeting. So I sent out the doodle poll. We didn't hear back from everybody, but it looked like the 20th or the 27th. More likely, the 27th was going to be a better date. So I just want to check in and see if that will work for the majority.

I'm sorry, I'll rip around.

Then 27th will be our next meeting. So it will not be the 18th. We'll move the calendar invitation from August 18th to August 27th. We will meet again the following week just as a heads up on September 2nd. So we're going to have two pretty close back to back meetings. We are, HICPF and I are already working hard to make sure we get you those materials well in advance so that you have them and that you're not spending the weekend trying to read a whole new set of materials. Taggart, did you have a question?

I think my understanding of it, thank you for that. I think my understanding is that hopefully we could try to see if there might be some alignment. But judging from all the comments, I think we know the reality of that. I think we should proceed as we want to and need to, especially knowing there's going to be a new administration that's coming in. That would be my recommendation. We can still keep the other factors in mind. Okay, so our next meeting will be the 27th. That meeting will probably be delivery, payment and operations and then we'll move long-term services and supports to the September 2nd meeting. So just as an FYI we finalize the schedule and get that out by the end of this week Rip Brown did you have a question or comment Okay

Okay, let us see. I'm just going to ask you, is there anything that you would take off the table?

I thought that might be the answer, but I was going to ask anyways.

I think there's some people around the table who's going to get really excited about that conversation. Okay. Before we go into public comment, let me check in and see how did today work for all of you? what would you want to change going forward?

But this building is better.

Okay, we can, yes. Anything around how the meetings manage

We just want to focus on the super trivial stuff, okay? I appreciate everyone's humor so late in the day. Okay, I think with that, we can move into public comment. Okay. Thank you. Thank you, everybody. Okay, so I have a list of people, about half of whom are here in person and half remotely, so I'm going to call up all the in person. Camille Harding, and just come on up and sit down at the table, and we might have to pull up another chair. We'll just see who's still left. Maureen Welch, Casey Barrett, Daniel Darting, and Betty Lehman. We've got a chair coming for you. Okay. Okay. Well, we'll start here, and then we'll go down the line, and maybe when we get to the last person, we can shift down a little bit. Okay, go ahead. Tell us your name and who you're with. You've been here. You know the drill. I'm Betty Lehman.

We're going to get them. Okay.

And I think maybe you guys could take that offline. Would that be okay?

Unless he wanted to ask me a question. Well, we're going to get to questions after everybody has their say. Okay. Very good. Okay. Next. Just tell us your name and who you're with, and you have two minutes. And let me just say, I understand this two minutes thing isn't great, but I want to try to enforce it because it makes it fair for everyone, and, you know, some people have really invested a lot to be here today, and I want to make sure that everybody gets a chance to talk. Go ahead. Thank you, Madam Chair and members of the committee.

Okay, thank you. Thanks, Camille. I believe the committee was provided with a press release that goes into a little bit more detail. So just want to kind of get a little bit to the substance. Thank you, members of the commission for being here for giving of your time and your mind and your commitment to this incredibly important effort that we are engaged in in our state. Thank you for the time to present to you today. I'm here representing the People First Behavioral Health Alliance, as Camille mentioned as well.

Okay. Thank you. You're up.

Okay. Thank you. And then if you guys could just scoot down that way, and then if you want to bring your chair around. You're up, Mr. Barrett. Welcome back.

The Office of Administrative Courts has already begun telling families that they are backed up in six weeks. Meanwhile, medically fragile children and adults are left waiting for decisions that directly affect their care. Those of us who have spent years jumping through hoops to comply with the system are now asked to jump through more hoops with less support. I don't think we really need to go into what happened with HIGPUF leadership. I think we all are very aware of everything that went on there. But as a family member living with the consequences of those decisions, what has been difficult to understand is why there doesn't appear to have a corresponding view of the policies and implementation plans developed under that leadership. If the confidence in the department's leadership had eroded to that degree, I believe it's reasonable to ask the commission whether these policies and implementation received the level of independent scrutiny that they deserved. These programs were created for families as a major part of the solution. We provide consistent, high-quality care. I respectfully ask the commission to investigate the concerns raised by families months ago why guidance is inconsistent across agencies who's making medical necessity determinations and please don't let families become your last source of information because quite honestly we should have been your first

the question and Betty I hate to call you by your first name but that's how I I know you. If you would, I think you've heard my question a couple of times that the demographics versus the growth in the CES program in particular don't align at all, and I'm always left a little mystified as to what's going on here. Well, thank you for your question and your interest in the CES waiver. So CES waiver was a statute I spearheaded when my son was four and he was the first child on the waiver when he was five and there were 18 children. The number of children on there right now is .003 or .03% of the 1.2 million. So it is very rare. They're rare children. They're so seriously disabled. And so but just to keep in mind that even though there this growth when my son was diagnosed with autism and he has 36 conditions but autism he was 1 in 10 And today it's 1 in 31. And so these are the children's extensive support. And these are children who are so dysregulated and so dangerous to themselves and others that they require 24-7 line-of-sight care. So the reason that it's grown is that the population of autism, I mean, from 1 in 10,000 when this waiver was passed to 1 in 31 children, it's just an explosion. Which is why I also wanted to say we shouldn't be handing out Applied Behavioral Analysis, ABA, without having any kind of an evaluation component to see if it's working or not. because if it's not working after a year or two, you know, because that's another place where this explosion of children with autism is affecting our state's resources because that has gone crazy too. So I really wanted to just give you guys that information that we do have a population problem, you know, autism population problems all over the world. It's growing at the same rate. But I think that now that's where we're seeing this is some of these children don't just have autism. They are profoundly disabled and dangerous, and those are the kids in that program. Thank you.

Sure. Sir, could you tell us about the exception process? And, you know, because last January so we were told that there was an exception and there really wasn't because they had to get the rules in place. Rules weren't in place until June, July, June. And so, and here it is now August. I'm just curious if you could give us an update or any of you could give us an update from your perspective of how that process is working. And then also are you working with a case management agency for long-term services?

Mr. Barrett, thanks. Yeah, thanks for your question. Yes, I am working with a case management agency. I can tell you that I've been with them for, I think, three years now, and I have had three different case managers just in a turnover. I personally have not had to do an exception yet. I do have a couple very close friends that have. The one had put in, for one, in their case management agency, was very confused about that and told them that they had to apply for all four at once, which is untrue. They're the ones that had to put their case management back in their place and tell them that, no, I can file for one, and that's fine. So that was kind of a case of where there's confusion, where we didn't understand how that happened. And I do know of one other one directly that filed for an exception. Case management agency fumbled some things, and then when they finally got it filed, the response they got back was a request of information that was completely unrelated to their exception. So they had to now provide, had to ask for an extension of their appeals, and then to provide information regarding the original exception and then the new request of information. So as far as that goes, I've heard a lot of both ways. I've heard directly from agencies where some people have not gotten approvals. Some people have had an easy time, I guess. There were one specific case that I know of, a quadriplegic, who was filing for an exception, and when they got a return was told that they were going to reduce some of their hours and removed their caregivers or the clients time allotted for dressing because apparently they didn't need help getting dressed as a quadriplegic. So there were a lot of things that are coming back that don't make sense from a medical standpoint. I can see from maybe just looking at a piece of paper, it might make more sense, but that's kind of where I was talking about having some medical accountability on some of that stuff because there are needs that are being judged without a qualified medical background to understand what some of those things actually mean.

Yes, thank you. And that was a great summary from the medical perspective. I deal with hundreds of families, and what I've experienced is that it feels a bit retaliatory. Exactly what Mr. Barrett said, is that if you ask for one thing, they may look at another, and that creates fear in the community and then the community doesn't ask for the exception. What I've seen is there's a lot of discrimination, in my opinion, in the rule for children under six because they say that it's a normal parental responsibility to have protective oversight. Well, when you have a child who bites, kicks, kicks walls and escapes the home in the middle of the night and the parents have to rotate being next to that child 24 hours a day during sleep and they only allow for five hours a day of protective oversight, And that child also doesn't attend school because they cannot function in school, so they are homeschooled and they have people that come in and give behavioral services in the home. So, yeah, I'm very concerned about the exceptions process. In my opinion, it's completely dysfunctional, the way that they've set up the rules and regs. And I attend every MSB board meeting and give my opinion, too, when they create these rules, so they hear a lot from me. But I do think it needs to be reexamined. And I know that we're not here to nitpick on everything, But I think that that also gives you an example of why parents may not feel comfortable filling out a survey or coming here and speaking at the microphone because it is a very retaliatory culture right now.

Yeah. You know, right now, just to get on a waiver, you know, you have to go through a process through both a state and an agency. If you go that route, I know some people that do CDOS do it a little differently. But so my agency has a nurse that comes to my house, verifies everything. I meet with the agency, verifies everything. We hear from the agency or the case management every quarter. I mean, I get a monthly email from them, but we physically check in every quarter. We do a six-month review. And then there's the big, huge annual one. And those are kind of like the basic things but like the minimum to maintain and stay on the waiver with the new things that are going on in my case because my daughter is such high needs a lot of what I seeing is similar to what I always been doing, but now it's being applied to every level of disability, and the level of documentation that is now being asked for is, it's not something I'm unwilling to do, but when they want access to my daughter's medical record, which I am okay with. We're talking about thousands and thousands of pages of documentation. And I don't trust that they're going to have somebody that's going to understand it, to be honest with you. The medical records, the home exercise plans, any kind of therapy plans that I have on that stuff, it's all now excess documentation that I never was asked to provide, which again, I'm okay with that. Part of me was kind of wondering like why wasn't it asked for before. But at this point, it has become more, like I said, additional hoops that weren't asked for before, and now it's also being applied to essentially less support.

Thank you. Mr. Barrett, I really appreciate you being here. It's always good to see you and Olivia. Did you say that you were, I'm just trying to understand, did you say that these are your experiences or that you're carrying experiences of other parents? Just help me understand sort of your testimony today.

No, no, that's helpful. I just wanted to understand. I don't doubt what you're saying at all. It does make me very concerned that you are concerned that there would be people reviewing your cases that don't have the appropriate training or medical training that is necessary to the extent to which that we can follow up with the department after this and make sure that they are not having people like me reviewing your cases, right, that would be helpful. And I just always appreciate you bringing your perspective here, and, yeah, thanks for being here.

Any other questions? I'll just add on a different topic. I'm reading the People First press release. And I will just say that I think this is a direction that we need to go in, that my experience and so many others is a lot of finger pointing between different providers, different levels, different agencies. It's HICPF's fault. It's the RAIS fault. It's the provider's fault. and if we could try to focus on getting to good outcomes instead of who did what to whom And I think that applies in all arenas And so very much appreciate this organization that you're trying to pull together. And then we'll also just add, you know, we, this committee has gotten started in a big hurry. We have done things very fast. We're trying to be very nimble. And if it isn't everything you dreamed about in terms of the way we're operating, we are sorry. But we are doing the best we can. And we are open to feedback and open to making changes. And I think I've heard that from everyone who's involved with this process over and over again. So we'd like to make sure that we're addressing your feedback, but also would ask for some grace in that we are building the plane as we're flying it. So I appreciate you all being here. We have the people who are waiting online to testify, so I'm going to call them up. Mr. Broyles, Ms. Mool, I might have said that wrong, Ms. Brom. And then I have Miss Brahms and Jessica Cooley and Allie Hayes. I see Tamika Brom. If you want to unmute yourself, and you can start your testimony. Tell us who you're with, and you have two minutes.

Thank you, Casey.

Okay. Thank you so much for being here. I'm sorry that happened. Next we're going to move to Mr. Ronnie Broyles. Is he there? No Ronnie Broyles. Ms. Victoria Mool, and I apologize if I pronounced that wrong.

if you want to turn your camera on you can and you have two minutes

is next for those that we love the most. Thank you. Thank you so much for being here. It's heartbreaking to hear your story. Next, we're going to go to Leah Brahms.

Thank you so much for being here. Next up, we're going to hear from Jessica Cooley.

we saw go through things like that. Okay. Thank you so much for being here and for your testimony. Then we have Allie Hayes.

I'm going to need you to wrap up.

So thank you for your time. Okay. Thank you so much. And we have a question from Senator Mullica.

And I hope that that line of communication is open to these folks who are going through the process to make sure that that is clear that there is no retaliation, nor will there ever be any retaliation for appealing any decisions by this department.