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House | May 28, 2013 | Committee Room | Health Part 2

Full MP3 Audio File

We call this meeting to order. The ?? serving the committee this morning are, Cindy Beaver, Emma Hashtrim and Madison Hendrick. Thank you for your service this morning. Sergeant Arms, serving the committee this morning are Fred Heinz, Reggie Sills, John Brandon, Mike Clampitt, thank you gentleman. We have one bill before the committee this morning, Senate Bill 208 Effective Operation 1915 BC Waiver. There is a PCS before the committee without objection. Representative Dollar present the bill. [Speaker Changes] Thank you Mr. Chairman and members of the committee. What we have here Senator Tucker sent over to us in Senate Bill 205 frame work which what we have done through a number of venerations and I want to thank the staff, Jan Paul, Walker Regan, Dr. Porter, Sarah Riser and I think some others that have worked on this, is to refine the bill that Senator Tucker sent to us. I think it was termed at one point in time The Red Flag Bill, and those that are familiar with that will certainly know that we’ve kept to that spirit and refined it further. Let me just try to explain and ill try to keep it relatively brief and obviously we’ll be available to answer whatever question you might have. This is actually the third, or at least in my view, the third in a series of bills. General Assembly made a decision in 2011 to expand what’s called the 1915-B and 1915-C Waiver state wide. Those waivers, under those waivers we operate in Medicaid our Mental Health Services, our Intellectually and Developmentally Disabled Services, as well as Substance Abuse Services. The state had established a pilot some seven or eight years ago with Piedmont Behavioral Health, that pilot demonstrated both tremendous strengths in terms of the provision of quality services and as well as considerable savings with regard to state funds, it was actually a nationally recognized model. So, the decision of the General Assembly in 2011 was to expand that state wide. Now, since that time, since the passage of House Bill 916 the house also passed last year House Bill 191, if I remember correctly, it was a bill that with some further refining, addressing some managerial issues, governance issues, there was a committee put together of stakeholders, that bill was crafted, it was passed in furtherance of making the transition from the local management entities into the pubic mange-care organizations. The target date was set and will be met, and is being met July 1 of this year for the entire state to be operating under 1915-B and 1915-C Waivers. We knew it would not be an easy transition and its has had its challenges, but the key, I think in Mental Health is for us to have a plan and stick to it. I think that has been the thing that has troubled the state over the year, we don’t always stick to a plan that we make. This time we are trying to stick to it and we’re also trying to make adjustments as we need to make those along the way. Senate Bill 208 in my view is sort of the third bill in this series, some of the issues that have come up, there were questions with regard to the Secretary’s authority to transition to a smaller number of LMNCO’s. As many of you know there were forty some groups that were years ago

The etch which Mandela to 23 from NE OM from anything, should limit to 1915 DNC waivers we transition again down to allow them, we're actually in the process of leaving 210-LS a western, just becoming part of foam smoky from connect them in which the mayor and what was sale closes that need to be very good newbie clarification from foreign secretary, is at issue should have to come up to come to the 4:00 PM EDT clarity in terms of what the 62 use specific authorities or hallows operate in one of those parameters and that is what you see in five U.S. senate bill two L.a. seven from section nine used as an additional five clarifying power of section two, (SPEAKER CHANGES) and that the title says that the actions by the 622 ensure affected management of mental Health Services are under the waiver from today's offense to the web that if you turn over the page two of the bank of page two anonymous 12 for a form of bush's that they left the system not been matched me and the secretary is directed two KR action two um stock and MM film this century failing until a million lives felony and two analysts from this button LME and CNN that is some that is operational ms a compassionate 9-9, and there on page two east bay screen calls financial solvency are a number two is the payment of claims MRI number three is super clear from documentation that two things you have to have an order to be a parade from seven and their specifics in here with regard to timetables and the helm in mime compliant millennium CEOs from four underneath the lookup a story that an alarm for two underwriting DC as seven separate sections 10 MB certain areas said if the LME MCI was found in fish and there were more the serious home there has to be a clear plan of correction put into place home , where we'd have to answer certain women from work to get these items in these areas corrected from moving and M9 that that began at the bottom of page story and the number two on page four we have the provisions are in this bill that from a lay-up Hal the transition 5 to 4 this channel is some banks assume but no other L.a. area men in Chino is to be Sassoon chum of how we can ensure successful transition from two larger group and five issues like for example, ensuring that providers are going to be paying four home and at ninth and if larger areas, the representative of the area that's been taken over from (SPEAKER CHANGES) WesCo served as a lot of technicalities and from 29 was tremendous amount of money and 2:00 AM looking through the study issues to make sure that we have a process that will that will operate efficiently and effectively handle both of service they protection four, clients for individuals receiving services, as well as from projections four from providers and in the process to ensure that during a transition they will be played and that will have a smooth the transition, so you are now there's a transition going home from them with some attention to 9:00 PM nine western Highlands and from what I understand that they're working on from their transition would be able to fit with and now we're looking at the hearing this and this legislation from there are better armed five section if those sections six some page five MM and forward from the mission clarifying that technical language, there is so under Alaska and showed value will say that some are under nine-member H5 minutes that which mechanic commissioner of the ??.....

Advisory board. As these LME MCOs get larger our counties have expressed an interest to continue to be engaged. They're engaged anyway because they're appointing the members of the LME MCO Governor's Board, but we've also provided for an opportunity to have an additional advisory board of county commissioners. It can be established to, sort of, relieve the concern about continuing to have input from the, from the counties. We are also in this process eliminating under section 9 the ability to have a single county LME MCO. Everybody is gonna have to operate in the state under the same set of rules and regulations. So we're taking care of an issue that was there. Mr. Chairman, I covered a lot of ground. We certainly will attempt to answer any questions or probably will call on staff if folks have questions that they want to ask. I would just simply sum up to say that what we are committed to, and what I hope this committee will endorse, and this general assembly will endorse, is a continued commitment to have an effective waiver program statewide in the area of mental health. Mental health is a difficult area in need of reform. I believe that we are, have established a structure to have one of the best mental health systems in the country. But we have to continue to work at it to make sure that it's operational, and to make sure that, that our goal of having statewide effective operation of the 1915 BNC waivers is the reality moving forward. Mr. Chairman I'd be pleased to answer any questions. [SPEAKER CHANGES] Representative Blackwell. [SPEAKER CHANGES] Thank you, Mr. Chairman. A couple of concerns, if I may. Legislature in 2001, as I recall, did mental health reform. And then about 2007 it seemed like everybody was surprised and concluded, well my goodness, it's not working. And it was almost as though we spent six or seven years walking away from a reform that had been put in place, that was supposed to ensure patient care in communities outside of the traditional psychiatric hospitals. And it wasn't happening. My question is, as we move to these new LME MCOs, is there something in this bill, or in the plan for the operation, that is going to provide that continuing monitoring process of patient care and to guard against complaints that I hear often at home of concerns that MCOs and LME are gonna satisfy the state financially by keeping down costs by denying needed services. So, what's the plan for monitoring how well this is working so we don't get surprised down the road that it isn't. And how are we going to be sure that the care is happening rather than just the financial management? [SPEAKER CHANGES] Well it, I would answer that in a couple of ways. One of the things that we did last year in House Bill 191 was to change the government's model. That will not be fully in effect until October 1 of this year. So, and in that governance, what we did was, we ensured that on the LME MCO board, that we would have additional financial and legal expertise so that folks could successfully operate what is essentially a small insurance, well not a small but an insurance company, a significant insurance company. In addition to that, we balanced that by bringing back what had been lost over the years, and that was representation on those boards of consumers and of the CFAC??, the advocacy folks in the various areas. So, folks from substance abuse, mental illness, and IDD would all have representation, voting representation, on the actual LME MCO boards. And the reason why the element was brought back was to ensure that the...

Boards would be able to, would be responsive, and the voices that you’re talking about would be heard, right there as those boards are making those decisions. And we’re in the process of transitioning to that. And that will not really be fully complete until October 1 of this year. [SPEAKER CHANGES] Follow up. [SPEAKER CHANGES] Follow up. [SPEAKER CHANGES] Does the department have any role in monitoring these local LMEs as it relates to whether services are being provided, quality of services. For example, something as simple, maybe it’s not simple except to state it, as whether or not a person who’s got a mental illness is taking a medication that if they take it, they tend to be able to function and stay out of emergency rooms and stay out of problems with the law. Is that kind of data monitored by somebody other than the LME MCO or to determine that the LMEs MCO is not itself overlooking its own shortcomings, notwithstanding the ability of some of the board members to question it. [SPEAKER CHANGES] Yeah. Yes. Yes. [SPEAKER CHANGES] The short answer is yes, but for probably a little more detailed answer, if the Chairman wishes to recognized Kelly Crosby from the Department of Health and Human Services, to talk about how they monitor the LME MCOs, and the other thing that I would mention too is obviously individuals if they feel they’re not receiving appropriate services, they have an, there is an administrative appeal process internally and then ultimately with OAH. [SPEAKER CHANGES] Miss Crosby? [SPEAKER CHANGES] Kelly Crosby, Division of Medical Assistance. To start back to your earlier question about monitoring utilization. We don’t just monitor solvency, because I hear your concern that the MCOs will be staying within their budgets but cutting services. We do monitor appeals and grievances on a monthly basis, and authorizations and denials, so we actually know how many services are denied on a monthly basis at the MCO level. We also monitor the number of appeals and the number of appeals that are overturned at OAH. We also monitor annual access. We require all the MCOs actually CMS requires all the MCOs to do a gap analysis annually of all the services to ensure that there are adequate services provided to their attachment area. When NCTracks comes live beginning in October, we will start collecting shadow claims. So a copy of every claim that an MCO pays to a provider, so we can monitor utilization just like with did with our old system. We can actually know how many people are served by service, how many units they’re getting, how much those services are costing the MCOs, so we can actually track per service. You know, this month there were a thousand individuals, next month there’s only 850, what happened to those 150 individuals? We also have annual reviews and part of our annual reviews when we go on-site, we do look at the administrative operations but we actually do chart reviews. So we look at services that were authorized and denied. We do a sampling of those to be sure that the correct clinical decisions are being made by the clinical folks at the MCOs. The MCOs also use something called Gold Star Monitoring. It’s something that’s in process but that’s the piece I think that you’re getting at to really at the provider level, are the providers doing the right thing for their clients? Are they making sure people are taking their medication or actively engaged in treatment? That’s really hard to do on the individual level but the MCOs really do monitor their provider network to make sure that they’re providing the best quality of services. And finally, we do have consumer satisfaction surveys that we do do annually, so we see how consumers like or don’t like the services they’re receiving or not receiving. And we also collect annual measures of utilization from the MCOs so things like ED utilization and hospital readmissions, we do look at on an annual basis just to ensure that folks aren’t missing low levels of care and ending up in the ED or the hospital so there are a lot of different ways we monitor patterns of service and patterns of care, to look at some of those bigger questions. [SPEAKER CHANGES] Just one quick comment and then I’ll be quiet and let somebody else have a chance.

It seems to me that as we, I understand, are moving towards more electronic medical records and the filling of prescriptions that especially with people that we have a concern whether they're being compliant in taking their medications as they should, that if somebody is electronically filing for reimbursement for a medication, and if we've got a medical record for someone who's on Medicaid saying they're supposed to get it every thirty days, it ought to be sort of a technological assignment that doesn't sound to me like it ought to be tough to say is Joe Blow being compliant in taking his medicine, and if he isn't is somebody following up with him? [SPEAKER CHANGES] Ms. Crosby. [SPEAKER CHANGES] Kelly Crosby, Division of Medical Assistants. I agree with you, and I would say that, through CCNC who is our medical home for most of the individuals with serious mental illness who are on these types of medications, one of the things that CCNC does do for Medicaid recipients is look at their medications, try to justify the medications against each other, look at who's refilling these prescriptions. CCNC is doing a lot of this in partnership with the LME MCOs, they do have to have access to all those medications through their database so they're able to see some of our higher end individuals who have mental illness to make sure that they're refilling their prescriptions, that different prescriptions aren't counteracting each other, and I know that at least one, maybe even more of our of our MCOs have actually hired specialty pharmacists to actually look at this. So we do use our pharmacy data to make these type of decisions. It's really more at the - people can fill their prescriptions, and you can monitor that, but really it is the individual provider that has a relationship with the person, that knows that they're actually taking those medications or not, so that's what I was referring to before about the MCOs having to monitor their provider network to ensure that that, those clinical interventions are happening. [SPEAKER CHANGES] Representative Fulghum. [SPEAKER CHANGES] Thank you Mr. Chairman. Is the question for the sponsor in regards to the contemplated further MCO development for the rest of the Medicaid delivery, are they going to overlap these MCOs as we see them now for behavioral healthcare, to cut out confusion or perhaps add to the confusion, is there going to be an Eastern, Central, and Western MCO, contemplated at least in the HHS proposals that we've heard floated around that will actually be proposed for these same regions? [SPEAKER CHANGES] I think ultimately, well, The General Assembly will make the decision on what kind of Medicaid system that we have in the state. What we launched into here in 2011 was again an expansion of an incredibly successful pilot that started out in five counties, it's expanded now. PBH has become a cardinal innovations - none of these things are easy, and what we're doing in this senate bill is a further refinement of that process so, I think the general assembly is, in my impression, is very committed to having a successfully operating statewide 1915BNC waivers for our mental health substance abuse and intellectually and developmentally disabled services, and I would expect that we would want to continue to keep that strong and moving forward, down the road, that's certainly the intent of this legislation in which we're further clarifying, we're ensuring that these LME MCOs are going to be strong, if they have to merge, how they merge, how they operate, what the standards are, and obviously ensuring that our partner, our very critical provider partners all across the state will be paid, particularly if they're transitioning to fewer LME MCOs. [SPEAKER CHANGES] Representative Farmer-Butterfield. [SPEAKER CHANGES] Thank you Mr. Chair. I had a couple of questions. The first one was in reference to the fund balances in section 5B on page 5, and my question basically is, I think that change, if I'm correct is due to...

him me off with the CMC vision emerging commenced here. how has that worked the existing situation through the prorating funding from the transfers as a portfolio with the NCOs emerged as well that will work and in the staff maybe better to answer the question, but what we thought we have had, prior to has-been enemies transitioning into MCI's full which we had procedures and then contracts and like to do that with this is doing more with the merging of an element of an existing Army NCO when one another. LME MCM and trying to be clear about how that of process works and management to ensure that providers are going to pay that people are going to be served that the areas that are being subsumed under a large area and have representation on the board. make sure that you click at risk reserve is used to be able to be maintained in the process and adolescence: Warner, further staff firmly tells [SPEAKER CHANGES] Mister chair about our letter felt with regard to specifically how that has worked in the past research staff would need to defer either to our financial staff of the department or fiscal research staff, not who is who was present out with Bogart how that had actually come a practical standpoint, operated on the ground in the past. I don't know Ms. Bush is president for fiscal research has anything to add. we know we haven't had is we are just now having our first in CO merging with another MC, which is see of the merger as process with the Western Highlands and smoking them. and it's my understanding there there close to a contract agreement for Hal that is merging together and it I've been in certain respects, it's going to be the HSK seven speak for how how to make that the functionally happen in an appropriate way in. they seem to be moving forward well considering the circumstances and discussed with on specifics in terms of us worked with governments that have merged other question in a heated follow-up. yes, follow family on who provides consultation and assistance to the NCOs name originally go with the waiver. those of you who helps them move forward into the system to make it work. I know we get what pH which is what continent of a gloomy conversation assesses the other way to offer vacation and well I have lived. they've done a tremendous amount of West couple of years and trying to ride assistance and help, and the like, but honestly that that the department is the one who is taken that the lead in and providing their consultation and oversight and assistance reason I asked because a person comments about the need for neck to be grown-up version of Avila. [SPEAKER CHANGES] thank you Mister Russert have a couple questions on one of the things and presentations, as well as in private conversations with managed-care companies him a Taliban advantage of something that they are not able to do is provide services that are necessarily paid for by Medicaid. in other words, what was a perfect example, we heard repeated several times by our director of Medicaid was the issue of the lady repeatedly going to the emergency room because she didn't have air conditioning to the McKinsey has with their budgets. the debate under there, so they free of that same type of the restrictions and they can have a flexibility to really do they see a need that is an claim on the list that they can take care of it where they do manage to the Iranians. he has also managed eight dollars, as well as federal Medicaid dollars and in terms of working to assist someone with a women need it might be outside of the of them on the medical needed. it's my understanding that

work and do that sort of thing in these communities. People know where resources are that are outside the realm, and obviously they work as they can to help people identify additional resources, whether it’s an air-conditioning program or fuel program that’s run through some other part of state government, making sure people get hooked up to those resources. [SPEAKER CHANGES] Follow-up? [SPEAKER CHANGES] Follow-up. [SPEAKER CHANGES] There’s language in here about an LME-MCO disengaging. What is the process for one of the clients or service people who are receiving services disengaging, and I mean by that moving… if they move in the state from one MCO to another? What is the process? Because we recently heard some issues and I actually had run a bill on the county of origin that was kind of a stumbling block. What has been put in place to make the movement of our citizens from one area of the state with this new setup more convenient and no lapse in services and things of that nature? [SPEAKER CHANGES] Well I think we’re hopeful your bill’s going to pass the General Assembly because I think it takes care of that. I don’t… That’s not really part and parcel of this legislation. Ms. Crosby… Well at the direction of the Chair… [SPEAKER CHANGES] Ms. Crosby. [SPEAKER CHANGES] I don’t know if Ms. Crosby has comments she wants to make about those individuals. [SPEAKER CHANGES] I’m Kelly Crosby, Division of Medical Assistance. Right now, at least on the Medicaid side, and the state funds follow, there’s a contract for a particular catchment area. That’s how they set the capitation, that’s how they enroll providers, that’s how Medicaid eligibles get services; they know their catchment area. That’s the LME that’s on your Medicaid card, so to actually have one county go to another LME-MCO, it’s a big deal, so a lot of things need to get changed at the system level in terms of resetting the capitation, making sure providers all move to the other MCO, consumers all are able to maintain their services, so getting the waiver approved by CMS to move one county to another LME, so were that ever to happen, and I think Smoky Mountain and Western highlands merging together is a good example of that, what they have done is put together a project plan for us, and it’s something that we monitor with them on a weekly basis because on a state level we’ve got to do all those things in terms of tell CMS we need to change the waiver application, that these new counties now belong to this MCO. We have to change to capitation rate entirely and get it actuarially certified by CMS. We have to have a transition plan that says if you are a provider formally enrolled with Western Highlands, Smoky will be able to just accept you into their provider network. If you are a recipient, how are we going to do outreach and education to all the recipients to know that they can maintain their services, hopefully with the very same provider who’s now just a Smoky Mountain center provider. So it really is… there’s administrative things we have to do, but there really is an on the ground level project plan that has to happen in terms of educating providers and consumers and making sure that to the consumer at a provider agency, people are transitioned into services, and that’s something that we’ve required all along throughout this transition, that MCOs touch every provider and all recipients to ensure that folks are able to transition from one provider to another or one MCO to another, but it’s a lot of work and it’s quite complicated. [SPEAKER CHANGES] Mr. Chair, a clarification please. I was asking actually the consumers changing. So if you lived in Buncombe and you move to Raleigh to Alliance, what process do they go through when the provider that they’ve been using in Buncombe and they’ll need somebody new, what’s the step-by-step process you use for that person to reestablish services and get payments and things of that taken care of. [SPEAKER CHANGES] Kelly Crosby, Division of Medical Assistance. I’m sorry I answered the wrong question. That’s not as… That’s a bit of a messier answer, to be perfectly honest with you, and I think that is why you’ve introduced your bill. Individuals are tied by their county to particular LME. Their county in our Medicaid eligibility system determines which LME they’re assigned to, and we know that that is challenging for children and adults who have a county of eligibility in one LME but may have a residency or a treatment facility several counties away or many counties away, so what actually

...happens is two things. Sometimes people just move and they have to go to the new county DSS and register their new address and get a new county of eligibility. Therefore they get a new LME on their Medicaid card and they’ve got to engage with services there. At that point, when they go through that process and they get a new LME, the LME is notified. They know every month new eligibles are. They have to provide outreach and information about their provider network and their services to engage in a new county. That is if they have moved. Probably the worst part about that process really is is that sometimes the county of eligibility can change can take 30 to 60 days and that is something that we’ve got a group trying to figure out how to streamline that for individuals who literally just move across the state and have to get re-established in a new county. Probably the more challenging, and again we do have a work group looking at this too, are those individuals who may have a county residence in one area and they’re just being placed as a treatment provider somewhere else. So we have providers across the state all over the place who have to enroll with different LMEs. Some of them only have to enroll with an LME for one individual that they’re serving and it’s pretty complicated. I do believe we have a very dedicated group looking at both law around eligibility to see if there’s anything we can do to switch county of eligibility a lot easier and quicker, but also besides that, while that gets done, what can we do for providers who are providing services for single people across multi-county lines. To do a very quick standardized, uniform contract so the individual can maintain their same provider, the provider can get paid in a timely fashion and not have to wait to go through a lengthy enrollment or credentially process with another LME. I think, ideally, we just really want to have a statewide uniform credentialing for any provider. Yes, an LME can choose which providers they want to be in their network, sure, but all providers are credentialed and enrolled in Medicaid, if you will. The LME can choose which providers they want to deal with. So providers it doesn’t have to be difficult no matter where an individual lives they can go, they can maintain their same providers and providers can get paid. It is not a neat process right now. Not at all. [SPEAKER CHANGES] Representative Insko. [SPEAKER CHANGES] Thank you, Mr. Chairman. I have just a couple of questions. One has to do...I think, Representative Dollar, you mentioned that all LMEs...the phrase I use is the back room functions that there’s something in this bill that would authorize this secretary to standardize the back room functions or did I miss that? I think that’s been one of the big problems with the mergers is that a lot of LMEs have their own financial system or their billing system and they haven’t been able to….it’s caused billing problems. [SPEAKER CHANGES] Obviously that’s being worked on. Let me refer that to Ms. Paul. Or Mr. Chairman, if you could recognize Dr. Porter, I think she can respond to this question. [SPEAKER CHANGES] Dr. Porter. [SPEAKER CHANGES] Pat Porter, consultant to the General Assembly. Could you ask the question one more time again? [SPEAKER CHANGES] It has to do with….let me put it this way: I believe that House Bill 916 authorized the department to ensure that the LMEs that were coming on board with NCOs would adopt the backroom functions that were held by PBH. That didn’t happen. That’s created some problems and so I understand that there’s a process going on. I’m fine of PBH needs to change. Some of this needs to be negotiated, but how is that going of getting the backroom functions the same. Especially if an NCO fails and has to merge, if their backroom functions are different that’s going to make their merger more difficult. [SPEAKER CHANGES] There are actually three things going on in relation to that. The first one is internal. The council community programs has been working with each of the 11 LME/MCOs to begin to standardize their backroom processes, information technology, claims, billing, contracts, so that’s going on within that group so that they can transmit information one to the other and to that...

I will insist on that. the second thing that's going on is that the department is working okay to make each of them more compliant with the standards that they have said the third is within this bill. this calls for standardized contract that hasn't been in place online that aluminium CIOs. some of them have a contract. this not entirely, but significantly different from the other only NCOs, and this requires a standardized contract and that will help considerably follow-up, Change speaker: follow-up, I think my mother and my expectation actually is partly a concern and that is that it that is no, I didn't seem to be any of them small that it is indeed minimal number of realities that we've established that we would therefore have to do against the nine are we one had fewer than six or whatever and I'm concerned that that that that are in Seo 's will actually get it to be so I and the example I be using is that is a lot less expensive for the high school of five thousand students interested you save a lot of money. administratively, but you lose so much in the charts to become anonymous on loose quality and I can happily in CO2. there was a reason why the NCOs. originally I think we had it in the original bill in two thousand one by driving the NCS was small enough that they would actually know their providers and very well personally and also know you have contact with a lot of the consumer so that they could sure what he was really, I didn't find Hollywood is being delivered and we wanted, so I had. I have a concern that there's no show floor that if the infidelities and CIOs are feeling that they won't get the kind of support they need to succeed at the representative farmer Butter field asked of an attitude that and that we could get our realities are in Seo is actually pick it to be negatively wanted to give you the established a kind of minimal member that you're working toward or Change speaker: I don't have a minimum number. I think that because we start our web and Morgan have can I think the liquids. the key for us is they have to be fully functioning, they have to be able to to clearly perform the functions in one, two and three that are set out alcohol on page. do you have to be able to address those items that we have listed under item day and obviously you have for your contracts and other obligations, and there could be some additional consolidation, but in a based only the ability. ability to perform but I don't do. we don't have a set number for that if we can have nine or ten that are on that they can perform as they should perform, then I'd then I think that would be. I think that would be certainly find a think about it once to see strong Alan EMC is, but we also have to have process in place to ensure that and to make sure that if that is not the case that we have a orderly transition of the use of the as I can hear you for the sake of love. obviously, the number of patients as well as some others receiving services, is it as well as some of our provider networks and in the light home that none of them in the standardization page four, section three deals with the standard contract and questionnaire that I might, at Change speaker:one of the things that were representative and Scarlett asking about was the reference to health, nine, sixteen, was that it required fidelity to the PBHmodel and this particular bill, hopefully in some of the provisions, particularly the standard contract, and all the provisions in section two of the bill are to help specify what exactly that means they were running short on time, I would just like to say I really do appreciate that you were

Tough this novel and to make it work better appreciate 25 percent black hole for up to become a question, quick question, first half of following the promenade concern that Russian defense goes discussing about how strong we might get the best approach and that an SMS budget that allows for merger does it lead that two separate but over time a reduction in the number the army's elegance and that's why this would also allow that pain and all (SPEAKER CHANGES) I can to take a break when a good bet, where the defending system and can be divided now wishes it were no special edition of the work to get smaller profit centers potion would be a bit and that the data that means you should I Post a 12 or 13 billion shares that batch mode not be the direction become good smaller but it would not give me my bill archer and an unassuming and coach looking 22259 in terms of where they or through December by Jewish charities from ocean park ridge afterward, I think this chair a move that we give the proposed House Committee cents to two to senate bill 208 a favorable report unfair Melissa the ratio for the motion of those in favor say I,(SPEAKER CHANGES) as opposed to guess that motion passes the bill will be required to the four NFS chairman of the Panama Canal in the 757 seconds ms bank and from traveler from this legislation takes aim at this meeting is adjourned ??...........