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House | May 3, 2016 | Committee Room | Health and Human Services

Full MP3 Audio File

Lower ones in the congregation a chance to get here. I know the weather might be a little iffy this morning, so [BLANK_AUDIO] Good morning every one Everyone. You're so nice and quiet. I love that. Welcome, this bright sun shinny day. At least it will be in here. Before we get started, I'd like to do our usual house keeping, and thank the people who help us keep straight and in line, and that will start out, welcoming out pages for this week Glad to have you with us. Caroline Harris if you'd please stand. Thank you. She's from Pitt county and she's sponsored by representative, Jean Farmer-Butterfield. Emily Wilder? >> Good morning. >>She is from Wake county and she is sponsored by representative Nelson Dollar. Our sergeant in arms This morning will be Young Mbay, Jim Moran, Russell Salisbury, and Martha Garrison. Thank you all so much for being with us. We'll start this morning with a brief introduction from [INAUDIBLE] Richard, with a vision of medical assistance. >> Thank you Thank you madam chairman, and members of the committee. I'll be very brief and then we'll turn it over to Tray to head in depth on the re base. Put up here is the executive summary, we wanted to use today, is obviously to give you the recommended adjustments, and talk briefly about those. But deep dive into the other re base. Talk about the drivers for the The budget reduction the drivers for growth over the current year and a little bit of historical context as we go through the budget process for you to see that and obviously hear our conclusions as we go through this. Here are some of the key points is that these recommended adjustments to include expansion of critical services Services in issues around funding for administration. The re-base request is pretty significant. Reduction in re-base from last year, the 318 million lets you know that 60% of the reduction is due to lower than anticipated enrollment and favorable federal match for North Carolina. Drugs Pending, drug rebates and other changes account for the balance of the reduction and the most important thing is that we believe that the proposed budget that we've sent for will adequately fund the medicated program for 2017. And again briefly wanted to mention the items that you'll see in the expansion part of this One is that, I think you've seen the governor's announcement around the need to increase cap DA slots for those with Alzheimer's and other who are older. It's keeping in with the governor's commitment toward supporting people with the most significant needs those of vulnerable citizens in North Carolina. In addition to that, to bring up additional 250 Slots in the innovations waver which I think you all know is the waver for those individuals with developmental disabilities and that again is to reduce the waiting list and support those citizens who have the most need in North Carolina. We do have a couple of administrative items inside the expansion request. One is that for Or DMA itself is we're making this transition to division of health benefits and changing the way we run the medicate program to support training in ways in which we can keep key staff inside of the division of medical assistance. We believe that we have a talented group and you see he improvements we've made but we need to make sure that Sure that we're training folks to be a part of this new environment that we're heading to. We also have a request for critical personnel inside of the budget and I think you've seen some of the results when we have the right people you'll hear from tray and depth about the budget items but there are additional folks that we need to continue to operate the high level The level in the current program, but we wanna assure you is that if we're doing that work, those positions will all transition into the new division of health benefits. We're not gonna hire people that will not be a part of that new world. And then obviously the continued investment in medicare reform for the division of health benefits that'll see that you have more opportunity to talk about Talk about throughout this session. Then finally this is just a sheet that talks about those adjustments I've just mentioned and you'll see through all of them the big numbers is a medicaid rebate which is the reduction. So, I'll turn it over to Trey Sutton to discuss the details of that and we're of course we're ready for any questions once we are finished. [BLANK_AUDIO} Good morning. My name is Trey Sutton, and I welcome the opportunity to talk a little bit about what our rebates represents. As Dave mentioned, the total reductions equals about 308 million dollars includes changes in our rebates related to enrollment services and to some other things as well Well as the expansion on themselves that they've touched on. The waterfall chart in front of you,

this is high level summary of what the drivers for change are. And I just wanna take one minute and say that the model used for LSPM's presentation as well as the numbers that your currently seeing here today. They are same Same model, same output etc. It's just a slightly different view and what I am trying to do, through this presentation is talk a little bit about what's causing the numbers to look different in our 17 and so how much has enrollment contributed to that change. How much was our Federal match contributed to that change. And so that's really what you're gonna see Needed and I'll talk about each one of this components in a little bit more detail. So the first one I wanna talk about is enrollment, here what you'll see is that a little over $170 million of the reduction to the 17 ASP/g is related to enrollment. Later on in the presentation I'll get into a little bit about what year over year represents But again I wanna make sure everybody is clear that I'm articulating this well. That we are talking about budget the budget, and so two years ago we developed a 17 budget and today we are looking at what the reductions will be against that budget. As we get into year over year growth you'll see how much more enrollments actually contributed in over this current year. About 172 reduction related to enrollment. Here you can see more specifically the change in our enrollment trends. That doted blue line the upper line there, that was our original projection on our enrollment growth. And what we actually experienced is that green solid line. So what you can see there is that for a while it trended lower than our expected budget growth. But it's since picked back up and what we really feel like is gonna happen, is it's not a change necessary in the trend, but actually a shifting our of the trend. Particularly given the last two quarters and the growth that we've seen there we do feel strong that we are counting or or the enrollment reference that we will experience in 17. The next item is, for 17 we are gonna enjoy a full one percentage point higher in a federal match. That really will contribute a little over $87 million to reduce our need for state appropriations. Those two factors alone contribute to over 60% of the $318 million reduction. The next item is related to drug expenditures, and these two factors combined are in our favor of about $118 million and what's happening here is our drug expenditures are the number of scripts that our providers are writing us down, but are percentage of rebates on those drugs have gone up and so we've got these two things working in conjunction and it's resulted in a very favorable change to our budget. Again total of $118 million for those two factors. Factors. We're basically going from a rebate percentage of 50% up to a rebate percentage of 58. While at the same time our total expenditures are going down so very good story, very fortunate story there. Well you can see on this next page is the trends that our expenditures is really we're based on as we entered SFY 2015, we saw very aggressive growth trends as we developed our model we accounted for that and wanted to make sure that we would have enough money, but right at the end of that year we saw it begin to tapper off and actually decline a bit and so that's really contributed to that lower than experienced drug expenditure that I talked about which is, if I go back one page, that's really the first piece there, the $62.1 million. At the same time our rebates have gone up significantly, I mentioned growing from 50 to 58%. What you're gonna see there is for a while it was very flat and we've really enjoyed Enjoyed an increase in rebates more recently and so those two factors working in conjunction again contribute about $118 million to the change. We go on to supplemental payments and recoveries, really what this is hospital supplemental payments as well as our third party liability recoveries as well as our program integrity recoveries, and so what I mean by those last two is third party liability when there's another payer on a particular claim this represents our activity going and working with that third party payer in collecting those revenues. Alternatively the PI recoveries, this is related to fraud and other activities and so supplemental payments and recoveries in those two flavors are working in our favor and will contribute about $48.5 million. Something working against us in the 17 budget is the Medicare premium We have an obligation for certain individuals to pay the Medicare premiums for these individuals.

They're dually eligible both for medicaid and Medicare. The federal government increased these rates and so our expenditures related to these folks is going up by about $48 million. And that's something that every state is experiencing. Now I'm gonna switch and talk a little bit about how 17 budget looks relative to our current year spending. What you can see is that in total, the increase is our current year represents about a 5% increase in state appropriations. And again I'm gonna I'll work through these pretty quickly, but I wanted to share with folks before we are looking budget to budget, now we're saying how much did we spend this fiscal year and how much we're gonna spend next state fiscal year. Well you can immediately see enrollment is playing a very significant factor. In fact over our current year projections it's gonna cost us about $104 million related to new New folks on the Medicaid program. We've got a rapidly growing group called family planner and family planning waiver. They are far less expensive, and so that's the reason we provided both numbers there. The 3.3 year over year growth for everybody else and then approximately 5% for folks including the family planning waiver. About $64 million of year over year growth is related to cost and utilization trends. What that means is we're expecting more folks to go to the ER for example, and when they visit the ER we're expecting the average cost of that visit to go up slightly but across all of our service category we're really talking about $64 million in growth so not that significant. Again here we've got these premiums I mentioned before. This is just a year over year change in our medicare obligations. Do we get into the price changes from the federal government. The next one is program participants. There are certain programs Medicare premiums being one example of that or innovations, waver being one example of that. So the $19.4 million just represents additional participation in some certain programs that will derive about $19.4 million. This is a very fortunate story in total for drug expenditures and that of rebates. What we're really talking about is about a $4 million increase in pharmacy spend being a very positive story there. One that I think a lot of states would really like to enjoy. Then now that it's a little bit counter intuitive so I wanna make sure I just spend one second explaining this. So the $49 million here represents an increase of federal match which is lower in our obligation if you will. So This well it's presented in red, it's a reduction in our obligation because the feds are picking a larger portion of the term. That's gonna contribute about $49 million in our favor. So that's really the two years what we went from budget to budget in 17 and then how we look 16 growing to 17. Now let's just switch and talk a little bit about some historical context where you can see there is if you move down to the bottom line, our actual per member per month calculation which is largely been driven by things like supplemental payments, hospital assessments, changes in policy e.t.c. It's really represented about 17% decline since fiscal year 13. There a number of other factors going on here but what I really wanted to do is just share some historical context so that as you consider these state fiscal year 17 budget, you have some of that broader prospective. What we're really asking for in 17 is about A 5% increase over state fiscal year 16 or what we believe our current year and results will be. The 17 budget is about a 5% ask but we have been trending very favorably on a per member per month basis. So with that I'll just wrap up. As they've mentioned, there's a few things that we're asking for and that we think are important to fund critical services, for folks with Alzheimer's as well as individuals with developmental disabilities. We've also asked for a few items that relate to the operation in the upkeep of the Medicaid program administration as well as transitioning to the division of health benefits. We believe that those investments are very important, and we'd hope that you would support us on those. In total, the rebase itself represents about a 318 or 319 million dollar reduction from our buying in budget that was developed back in 15. But it does represent a 5% or increase over our current year projected And lastly, I'll just say, based on everything that we know today, the rebase that we're requesting will cover our full needs for

the program in 17. Thank you. [BLANK_AUDIO] >> I guess I'd ask before to the question from the committee, if any of the other members form DMA, would like to add anything or bring anything to our attention, before we go into Q&A. If not, representative Pendleton. >> Thank you madam chairman. On page four, it [INAUDIBLE] at 250 slots. I don't know what slots mean. Does that mean additional personnel, or people that you can treat? >> Representative Pendleton, it means they were actually with the DHSS, it means additional people that will serve in the way these waiver programs work, actually general assembly approves the number of slots Slots that we have for those programs. >> Okay, follow up. [BLANK_AUDIO] On page 14, it talks about recoveries. And you said last couple of weeks ago, that the reason you didn't pursue a lot of these recovery cases is it costs about $500 to spend, to collect the dollars. I don't understand, and a number of us have talked about that. We don't understand why you don't just withhold payment from medical providers and hospitals. Just all settled against the next invoice. >> So then it depends on the specifics of the case and I'll be sure to get you some more information. But in some cases if they can appeal it and we're not able to withhold those funds legally until that appeal plays out. Where there's a final judgement, we're absolutely able to do that. And that's how we recover a lot of our funds. In cases where there's a rate adjustment for example, very clear cut, we'll absolutely withhold funding. Hardship advances, that's another one where we know that they owe us money. We have a legal stand and we will withhold that money. >> Follow up Follow up. [BLANK_AUDIO] Representative Murphy. >> Thank you Madam Chairman. Trey/g can you answer me, flesh out something for me? We have to pay secondary policy premiums for any Medicaid patients? >> For Medicare patients. Certain Medicare patients, the Part B, Part D Premiums we have to pay those. >> Okay. That's news to me. I was not aware about that. I mean I've once in a while seen a patient who has both Medicaid and then Blue Cross Blue Shield as a secondary. Are we obligated to pay that Blue Cross Blue Shield policy? >> No. In that case what we actually do is we're the payer of last resort. And what we'll do is we'll That's where the third party liabilities comes in. We'll actually go collect money from Blue Cross. If on the claim we discover that we were the first payer, then we'll go and collect our money from Blue Cross Blue Shield. We work with an outside company that's very good at that. And so. >> Follow up. >> Follow up. >> Also just We're approaching a cataclysmic problem with Alzheimer's. People don't really I think realize this. In probably 2025 we're gonna have 40 million Americans with Alzheimer's. And that's an exceedingly expensive, exceedingly provider and family Dependent disease. Where is our largest segment of enrollment growth that you're seeing now? It had been down, but what is the largest segment that you're seeing now? >> It's different by percentage and total numbers. I mean family planning is our fastest growing component. But we have another very inexpensive As a percentage, we are seeing a very large increase in our aged, blind and disabled folks and that's our most costly category so that's the one that we're watching closely and ties back to your question. I'd be happy to get you charts on those two categories if that would be helpful. >> I just want to follow up. >> Follow up. >> I'm not telling you any thing you don't know Obviously it's much less expensive to keep these people in their homes not institutionalized having family members care for them. It's an exceedingly difficult task. I don't know if anybody's ever had [UNKNOWN] Alzheimer's. It is a 24/7 job but it's keeping folks at home And that's really obviously where our focus needs to be. >> If you don't mind, Representative [UNKNOWN], just to thank you for that point because that's the reason why we wanted to increase the cap DA slots. And the Governor and the Secretary's commitment towards that is that our values is the same is that we believe that as long as we can help people stay in home support people both Aging, people with disabilities at home it's the best answer for the families. We do have more institutional type settings that we fund and we obviously need to keep those available for people but the longer

we can help people stay at home, it's better for the individual and certainly is less expensive for the state. >> Representative Dobson/g >> Thank you, Madam Chair. I have three quick questions, if I may, two for Mr. Sutton and one for Mr. Roberts. I'll start with Mr. Sutton. On the projections on page nine, a new enrollment expectations, can you talk a little bit about The reasons for, or an explanation for that temporary reduction in overall growth against a reduction as opposed to a growth and the explanation for that and also the reason that the trend is continued to do you need to go up after that. >> I'm not going to be able to answer that question as probably to your satisfaction my understanding working with our enrollment team, is that there was a number of things that were delayed that in the impact of those has caused that to remain flat or actually decline for a period of time. I am gonna have to to follow up with more information though , so I can get you the details that you need. >> Thank you. One question if I can for Mr. Seton. After you factor in the re-base, it looks like a 5% increase in spending for HHS as your proposal. For division medical systems for DMA. >> Yes sir okay Does the expansion of Alzheimer's, they reduce the backlog and expand Medicaid services, retrain and train Medicaid work force, the critical personnel, invest in Medicaid reform. Is there anything else that accounts for that 5% or is that it? No that's it. >> Well so let me see, say that a little bit more clearly. The attribution tables that we went through if I could get the clicker for just one second here. So the specific expansion request contribute for about $10.7 million. This chart right here really says about everything else that's happening the program for that, that leads to that five percent growth. So we've got enrollment, we've got some additional premiums that we've got to pay. So this is in total the attribution of growth year after year. But reflected in there if you look at the very last item in that in the waterfall chart the 10.7. That represents the expansion items specifically. >> Okay. >> Okay. Well, thank you. Madam chair one more problem to Mr. Roberts if I can. Can you talk a little bit about the expand. I certainly support if we can find the funds for it, but expand support for Alzheimers patients and their families through community alternative programs Just expand a little bit on what all that entails so we know what that three million is going to. >> So, on community alternative programs. They are one of the waivers. That's one of the three four waivers we have in North Carolina and the waivers essentially allow us to wave institutional rules, to to provide services inside in the communities. So CMS requires when you do this waivers that they are cost neutral so that you are not paying more money than you wouldn't aggregate than you would in an institutional setting and it disallows people who live in homes. So there'll be things like in home care givers that come inside the home if people need additional care management they'll do that work inside the CAP/DA program but essentially if you think about, older individual somebody with Alzheimer's or other disability would need to be supported in a family home rather than to go say into a nursing home, it's really what the program does and allows for us to wave those institutional rules to allow people to stay at home. One last follow up. So, is it to expand it to more Alzheimer's patients or to enhance the services of those that are already there or receiving in the home or- >> It's expand to more individuals, so it's a little over 320 individuals individuals additional slots, which would mean additional individuals that would be served. Now, not all of them would have Alzheimer's, because what you have to do is meet the criteria to be inside the CAP/DA program, which most people with Alzheimer's do, but we have a waiting list for this program. So you'll have people that are based upon me will get in to the program so you might have might have some with Alzheimer's, some who are just older and haven't exhibited those characteristics yet. But it's expansion of individuals. >> Thank you madam chair. >> Representative [UNKNOWN] >> Thank you Madam Chairman. I'll continue with some more questions on that same issue. I am So the program adjustments that we are making this year are just for the medicate population, when you talk about increase in Alzheimer's is going to be across the whole population probably.

Does any one know whether there is a correlation between income and incidence of Alzheimer's. Is it related to education? No body really knows I guess. So [BLANK_AUDIO] To do this, you were reviewing the Camp Waiver, the Camp Waiver, in order to increase the slots. No ma'am. Actually the CAP/DA review that's going on, the CAP/C and CAP/DA that many of you have heard about, has nothing to do with this. >> This didn't trigger that? >> This didn't trigger that at all. >> Okay. >> Yeah. >> Follow up? >> Yeah, follow up. Thank you madam Sharon. I'm curious also about the projection, the under enrollment. So, we have an increase in our federal match, which means out per capita income is going down. It went down 1% I think, somewhere it said. So that increases are Are federal match. So when the per capita income goes down, you expect a big increase, well not maybe big, but you expect and increase in enrollment. So when I look at the new enrollment expectations, I'm sorry I can't read the page numbers, but there's flat area in there where instead of going up, it actually decreased Declined some. And I guess I'm curious about whether or not that that is the real decline, or whether it was due to the NC FAST and a backlog, of enrollment, reviews. Did that affect this at all? [INAUDIBLE] I think what I'd say if Also echo with tracers we have a lot of trust I can get to you information on this but it was related to multi factors, some of them were related to system issues as people were going through the auto extension when that changed some are more related frankly to how they the ACA push came down from the feds to us and the time in our nodes and so you An increase and then a drop off in [INAUDIBLE]. In others honestly as we were doing the evaluation we haven't been able to determine what happen with those specifically, so we continue to do that work to their part. But we have a lot of information we can share with the committee and am assuming representative of [INAUDIBLE] would be best to get it to you guys to share with the rest of the committee Committee, so I'll make sure we do that. >> Well, follow up. So on the very last page talks about historical context and if you look at the appropriations for average enrollee in 2013 it was just like Um I guess that's $2,221,000 per person, wait wait help me with the numbers, anyway it goes from 2,221 what is this then? >> That's in dollars per month. >> Oh this is per month okay 2,221. >> The $2,000 that's actually That's actually for the full year, if you look at the numbers below bolded that's your per member per month cost and that's just appropriations divided by total membership. >> Okay, so regardless of what every line we shook we saw a decline in 2013, 2014 and 2015 then 2016 that seems to be levelled off. Is that due to efficiencies that have been put in place over the last 4 or 5 years? >> Well, I think there's a lot of factors that go in to that I mean there's been assessments levied on the hospitals, there's been better drug rebates collections, you've also got Changes in freezes/g and rates etc, so there's a lot of factors that have contributed to the decline and the flattening of that per member, per month, so we'd like to believe it's our fault but [LAUGH] >> Thank you. An additional follow ups? Representative Pendleton. >> Thank you chairman. I got a question and then a request. The question is if you start out as a dependent child, say you're 15, what age do you come off Medicaid? [BLANK_AUDIO] Representative Pendleton you've just stumped us not because we don't know but we don't have the right [UNKNOWN] but I believe it's 21 but we'll get you the detail on that if it's okay. >> Follow up? >> Follow up. >> I'd like to request this and twice in the last meetings I've requested ya'll to bring us back a report and I never got them so please bring it back to this meeting, don't Email, bring it to us? I'd like to know this, I don't know if it's true or not. There's about a half a million people that some folks say we need to put on Medicaid, these new enrollees. I don't know what that approximate figure is but I'd like a report

out of that number, whatever it is. It doesn't have to be exactly correct But I'd like to know everybody underage. How many of those bodies, covered lives, are under age 21, and then from 21 to 29, and then every ten years. >> Just to make sure I'm [INAUDIBLE] of the current program you wanna know That or are you talking about the potential new people that would be- >> Potential. Yeah. And when would you bring that report? I'm gonna pin you down. >> Representative Powell if you would, first of all let me apologize that we haven't got you what you've asked for. And the second is that we need to make sure that we have that information. So if you So if you would give us a couple of days to make sure that we can get that for you. >> Oh okay. >> And then report back to you. >> I mean I want you to- >> Follow up. >> Bring it to the meeting. To one of these meetings. >> Yes sir. >> How about a week? I'm giving you more time than you want. >> [LAUGH] Representative [UNKNOWN] In the belief that if I commit to you in a week and I can't get it to you I'm gonna look really bad. So if you wouldn't mind [LAUGH] if you give me just a day to figure out. Cuz what I wanna make sure is that we actually have access to that information. >> Remember I don't have- >> Follow up. >> Alzheimer's yet. >> [LAUGH] >> Well as Chairman I'll enter the conversation again. I have a couple of questions if there are no other Questions from committee members? >> I have a couple [CROSSTALK] >> [INAUDIBLE] >> Thank you. On the drug growth slow dramatically in fiscal year 16. There was this huge fast increase. So do you have any idea of what caused that. Was that just leveled off again now but there was a rapid increase. [BLANK_AUDIO] >> Just to make sure you're talking about this graph in particular okay so. >> Identify yourself please. >> Sorry Trey/g Sutton/g with division Medical assistance. So, I want you to follow up with some information on what precipitate that grow through. >> In that one follow up and this is back to the Alzheimer's question. So, the Alzheimer's patients fall into that age blind and disabled category. So, i'll put as their income Income level for that age, for the eligibility for the program. >> In the CAP/DA program, it allows us to go up to 150% of property and i'll get you the JAG number of 150% of property. >> So, what is the Income eligibility for people who are not in the camp program, just their age of blind and disabled, that category. Is it always a 150 for everybody? >> No, it's not for everybody. It's just a few on that program. For them it's a 100%. Let me make sure. I'll get that. >> For the other age blind, disabled. Okay and then i'll just follow up. >> I can look up at 150. I had one question. It had to do with the drug trend. I'm curious in terms of some of the medications that are in the pipeline and beginning to make their appearance. If they're gonna be accepted in the Medicaid formulary or do we know any forward look. Or is drugs coming down the pike. I don't know who would have any answer to that. I'm thinking particularly in terms of the Hep. C medication. >> We don't have our pharmaceutic director here with us today but what I can tell you is that All of his work around would drugs go into formularity, how do we manage that and how do we manage that process, or really an intricate effort around drug repay issues, the first thing, what's best for patients to go forward and then how we manage the ling term cause for the program. What I think would be very helpful Helpful is to make sure that we get something to you from John/g that goes through the detail about how that process works so every man we can have that. And if you wanna follow up in future maybe we can have them here for that. >> I'd appreciate that. Thank you. Here is the question. I haven't heard anything recently on our upfront attack on fraud, detection Is anyone here that can kind of bring us up to speed on where we're doing that before instead of the pay and chase method that's been prevalent in the past. >> Yes mam, we are basically there's our prepayment reviews that we wind up doing with the providers and I'll tell you we're very successful on that effort as that we have a significant Significant return on investment as we do that and we're expanding that to go to further providers as we go forward. Now, there's a point where you have this great on investment that you wanna continue to do that work. We're trying to do it in a very systematic method so that what we

don't do is want them going overboard on that side of it but But the, so if you begin to think about how we're looking at all over our analyst that we have and one of them is gonna be ad expansion request is that we need to look at our claims as they come in and our claims analysis as we view that so trying to add into how to look at our prepayment reviews Is another piece of where we think we can do a much better job as we're going forward so it really is a link between just good old detective work by staff and our contractors and then once we're prepayment review one of the things that we find is not only do we see an opportunity to gain by seeing claims that shouldn't go through, we also tend to Tend to see a dampening in the number of claims that come through from those providers cuz we don't put people on prepayment that we don't believe really are doing things that shouldn't be done. >> Thank you. Do we have any questions further from the committee? Okay. >> Thank you madam chairman just one more question. So this This is also in the Alzheimer's question, we do have other supports for Alzheimer's for people who are not eligible for medicate program and pace is one. Do you know if maybe we could get a summary of any expenditures the state has for Alzheimer's patients? >> Yes mam, we can do that - >> Identify yourself. >> I'm sorry, Dave Redshire/g with Division Medical Assistance. One of the things that I should have emphasized greater in the front end of this presentation is that medicate is a payer of obviously a lot of services for the state but we have throughout the department A great deal of programs that supplement or frankly are to lead in many of those issues faces a great example, it's a medicate program that is also medicare program. So we have a three way contract on that for those individuals we have the cap DA program and medicate we have PCS inside of medicate which also supports people with significant disabilities at home. but we also have a programs from divisions of aging adult services from our social service agencies we have in our you'll see in our budget request additional million dollars for care gives us support. Which is a key component of how we do this for what we think we have crafted is a budget that is interlinked on all of this things is not something I just realize upon medicate But also ties in to the other state programs that we provide. So we'll make sure we've got all information for you. >> follow up so could you indicate if this is not too much difficulty finding it whether those are all based on some eligibility or whether we have some programs that where there is no eligibility? Especially the pace program I don't know whether it's a care giver relief I think that do the Alzheimer's patients have to be eligible for medicate in order for that to go to the general public. And I'm just like that kind of information for the other programs that you are coming through. >> Yes ma'am >> Representative Pedleton. >> Thank you madam chair one thing I'd like to know who sets the formula is it the fEDS or the states? [BLANK_AUDIO] >> For our drugs inside our drug formula. >> Drugs So it will be there are obviously other things that are driven by the FEDs but the state sets its formulas how the drugs are going to be in the formula. >> Again any further questions from the committee? Any closing remarks from the department? Well that was efficiently done, if there is no further business to be brought before the committee we stand adjourned. [BLANK_AUDIO]