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From YouTube: 3/12/2021 - Senate Committee on Commerce and Labor
Description
For agenda and additional meeting information: https://www.leg.state.nv.us/App/Calendar/A/
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A
C
A
Here,
thank
you.
It's
it's!
That's
a
good
move
center
harney.
I
heard
that
jimmy
kimmel
was
looking
for
a
sidekick,
so
good
move,
okay.
So,
madam
secretary,
I
believe
everyone
is
here
so
one
welcome
audience,
who's
joining
us
remotely
and
anyone
listening
over
the
internet.
A
However,
there
are
various
ways
members
of
the
public
can
engage
with
us
and
participate
throughout
the
process.
These
include
registering
to
participate
through
nellis
when
you
have
the
opportunity
to
testify
on
a
bill
or
provide
public
comment.
During
the
meeting
you
may
submit
written
comment
to
the
committee,
email
address
or
fax
number
listed
on
the
agenda.
A
I
will
announce
the
time
frame.
That's
how
many
minutes
we
have
for
each
segment
or
against
and
neutral.
It
will
be
helpful
if
more
than
one
person
in
an
organization
wishes
to
comment
to
remember.
Ditto
is
a
good
response.
When
someone
has
already
covered
your
points,
this
will
allow
more
people
to
comment
during
that
time
frame
when
you're
on
the
phone
line.
Please
pay
attention
to
which
bill
is
being
considered
and
follow.
The
verbal
prompts
provided
by
bps
staff
so
that
you
know
which
keys
to
press
to
raise
your
hand
or
unmute
yourself.
A
A
I
will
not
entertain
any
amendments
if
the
bill
sponsor
is
not
aware
of
the
amendment.
The
proposed
amendment
must
be
submitted
in
writing.
24
hours
prior
to
the
meeting,
please
include
the
bill
number
statement
of
intent
and
your
contact
information
when
testifying.
Please
remember
to
unmute
your
microphone
and
clearly
state
your
name
and
the
entity
you
represent
at
the
beginning
of
your
testimony,
speak
please
speak
clearly
and
project
your
voice
to
ensure
those
watching
remotely
can
hear
your
testimony.
A
Please
remember
to
turn
the
microphone
off
when
you
finish
speaking
and
as
a
reminder,
it
also
testify,
pursuant
to
nevada,
revised
statutes,
218
e
085.
It
is
unlawful
for
a
person
to
knowingly
misrepresent
facts
when
testifying
before
legislative
committee.
A
person
who,
knowing
knowingly
does
so
is
guilty
of
a
misdemeanor.
A
The
chair
and
any
member
may
request
a
testifier
to
submit
documentation
supporting
their
testimony.
The
committee
members,
during
these
virtual
meetings,
when
an
agenda
item,
calls
for
a
vote.
Our
committee
will
be
using
roll
call
to
do
so
when
the
committee
secretary
calls
your
name,
please
answer
with
a
yes
or
no,
so
that
there
is
no
confusion.
A
H
Thank
you,
madam
chair,
for
the
record
cesar
mel
grejo
community
policy.
Analyst
senate
bill
90
is
sponsored
by
senator
hardy
and
it
was
heard
on
march,
8th
of
2021
and
senate
bill.
90
requires
a
health
care,
licensing
authority
and
health
authority
that
determines
as
a
result
of
an
investigation
that
there
are
no
reasonable
grounds
to
believe
that
the
provider
of
health
care
has
committed
a
violation
to
refer
to
the
investigation
as
a
review
and
evaluation
in
all
records
maintained
by
the
authority.
G
Thank
you,
madam
chair.
I
needed
to
clarify
that
the
national
practitioners
data
bank
only
gets
the
complaints
after
the
board
has
had
a
decision
that
documents
an
adverse
decision.
However,
as
we
talked
in
the
hearing,
any
form
or
application
that
asks,
if
you
are
quote
under
investigation
unquote
still
is
the
applicable
challenge
that
we
have
currently,
and
this
bill
will
correct
that,
and
I
appreciate
your
indulgence.
Thank
you,
madam
chair.
G
A
I
have
a
first
by
senator
senator
settlemyre.
Do
I
have
a
second
second
second,
by
is
that
senator
scheibel?
Yes,
it
is
okay,
first
motion
made
by
senator
sotomayor
and
second
by
senator
scheibel.
Is
there
any
discussion
in
the
discussion
on
the
motion.
G
I
A
Yes
and
let
the
record
show
that
the
motion
passed
unanimous
senator
hardy,
would
you
agree
to
take
the
for
statement
for
this.
A
A
A
You,
I
guess
the
one
area
over
from
all
of
this
is
when
we're
talking
in
person
we're
gonna
have
to
ask
everybody
to
unmute
if
we
don't
want
to
hear
them.
So
thank
you
senator
hardy.
So
let's
begin
work
session
on
senate
bill,
one
hundred
mr
mcgregor
and
committee
terry,
do
you
all
have
the
amendment
that
was
proposed.
H
I'm
madam
chair,
cesar
mcgregor,
for
the
record.
We
don't
have
the
amendment
that
was
mentioned
earlier,
and
this
would
be
an
amendment
in
addition
to
what's
provided
in
the
work
session
document.
A
Okay,
so
what
we'll
do
is
we'll
go
through
the
hearings
this
morning
and
I'll
come
back
after
the
hearing
to
see
if
you
all
have
had
a
chance
to
have
the
amendment.
Excuse
me
and
the
amendment
provided
to
the
committee
members
so
that
they
can
address
any
questions
that
they
may
have.
Okay,
senator
receivers
answered,
we
will
move
forward
after
we
get
the
amendment.
Okay,.
A
Okay,
so
let's
begin
now
with
a
hearing
on
senate
bill
139,
that's
senator
scheible
and
brooke
mayloff
with
transgender
allies
group
along
with
elliot
butler,
so
senator
scheible.
Please
begin
when
you're
ready.
J
Thank
you
so
much
chair,
spearman
and
members
of
the
senate,
commerce
and
labor
committee.
For
the
record,
my
name
is
melanie
scheibel.
I
am
the
state
senator
from
district
9
representing
the
southwest
part
of
las
vegas,
and
it
is
my
honor
to
be
here
today
with
brooke
malaf,
eric
matson
and
elliot
butler,
to
present
sb
139
to
you.
J
Should
there
be
one
to
answer
the
question
on
everybody's
mind?
Yes,
we
have
discussed
some
possible
amendments,
but
no,
we
have
not
yet
reached
an
agreement
with
that.
I
will
turn
first
to
ms
malath
will
walk
us
through
the
bill.
She'll
provide
us
with
some
background
on
the
bill,
explain
the
purpose
and
the
policy
proposal.
J
Then
I
will
turn
it
over
to
mr
butler,
who
will
help
us
understand
the
challenges
of
confronting
gender
dysphoria
with
inadequate
health
coverage,
and
then
we
will
get
to
hear
from
mr
matson
who
will
help
us
see
how
important
and
life-affirming
adequate
coverage
can
be
for
someone
facing
gender
dysphoria
after
these
presentations.
We
will
all
be
available
for
questions
and
right
at
the
outset.
J
I
just
want
to
express
my
very
deep
and
sincere
gratitude
to
all
three
of
these
individuals
who
have
not
only
taken
the
time
out
of
their
day
to
be
here
but
who
have
volunteered
to
share
with
us
their
incredibly
personal
stories,
and
I
know
that
you
will
all
be
respectful
and
thoughtful
with
your
questions,
and
I
hope
that
you
will
direct
most
of
those
questions
and
all
of
the
policy
questions
at
ms
malath
and
to
me
and
with
that,
it
is
my
pleasure
to
introduce
brooke
maylath
to
introduce
all
of
you
to
sb139.
K
Good
morning
and
thank
you
for
being
able
to
be
here
this
morning
and
to
and
to
listen
to
what
we
have
to
say,
I
thank
you
for
this
opportunity
to
present
the
need
for
you
to
be
able
to
pass
sb
139.
My
name
is
brooke
malaf.
I
am
presenting
this
bill
as
a
citizen
of
nevada
and
not
representing
any
organization
entity
or
agency
for
full
disclosure.
K
While
I
am
employed
by
the
division
of
public
and
behavioral
health,
my
presence
here
in
my
testimony
does
not
reflect
in
any
way
the
views
of
the
division
or
the
department
of
health
and
human
services.
I
am
experienced
in
transgender
issues
and
health
care
policy
on
state
and
federal
levels.
I
also
have
a
deep
experience
in
the
byzantine
interplay
of
health
insurance
and
healthcare
delivery
and
how
that
interplay
often
leaves
patients
outside
of
the
conversations
that
leaves
them
vulnerable
and
left
in
harmful
situations.
K
First,
a
quick
background
on
the
history
of
gender,
affirming
health
care
coverage,
beginning
in
the
1980s.
It
was
common
for
health
insurance
plans
to
have
specific
exclusions
for
any
coverage
of
medical
treatment
to
change
or
alter
sex
of
a
person.
This
type
of
exclusion
was
banned
under
section
1557
of
the
affordable
care
act.
That
document
has
been
provided
to
the
committee
in
nevada,
the
insurance
commissioner
issued
a
bulletin.
K
It
was
both
in
15.002
in
june
of
2015
that
interprets
section
1557
to
mean
that
any
procedure
covered
by
an
insurance
plan
cannot
be
denied
to
another
person
cannot
be
denied
to
another
person
just
because
of
their
transgender
status.
For
those
plans
that
are
self-funded
and
are
governed
under
erisa,
they
are
still
subject
to
follow
the
employment
non-discrimination
law
under
nrs
651.070,
as
detailed
in
the
nevada
legislative
legislative
council
bureau's
opinion
of
september
3
2015
provided
to
this
committee
as
an
exhibit
and
provide
coverage
for
gender
reforming
procedures
to
their
transgender
employees.
K
In
other
words,
if
a
cisgender
woman
has
her
hormone
replacement
therapy
covered
by
an
insurance
plan,
a
transgender
woman
must
also
have
her
hrt
covered
a
plan
that
covers
a
medically
necessity
necessary
mastectomy
for
a
cisgender
woman
must
also
cover
a
medically
necessary
mastectomy
for
a
transgender
man.
Despite
these
laws
and
policies,
transgender
persons
still
experience.
Denials
of
coverage
bias
still
exists
within
claims
departments
and
is
still
present
throughout
the
bureaucracy
during
2020,
I
personally
counseled
an
individual
through
multiple
pre-authorization
denials
from
the
third
party
administrator
contracted
with
their
employer's
self-funded
plan.
K
K
Finally,
after
eight
months
of
work
by
the
employee
and
their
hr,
representative
reimbursement
was
finally
accomplished.
This
scenario
featured
a
well-compensated
professional
that
had
scrimped
and
saved
to
have
the
means
to
pay
for
medically
necessary
surgery
out
of
pocket
for
a
procedure
that
was
specifically
supposed
to
be
covered.
K
Similar
stories
occur
daily
in
nevada,
with
persons
seeking
medically
necessary
treatment,
but
are
denied
by
a
faceless,
biased
and
historically
discriminatory
industry.
Those
denials
are
most
heavily
felt
amongst
our
black
and
brown
sisters
and
brothers,
whose
intersectional
marginalizations
cause
multiple
barriers
to
health
and
opportunity.
K
Insurers
have
a
history
of
supplanting
their
judgment,
applying
their
biases
in
place
of
physicians,
judgment,
best
practices
and
accepted
standards
of
care
which
constitute
a
discriminatory
act
when
injuries
fail
to
cover
medically
necessary
care.
People
suffer
anxiety,
depression,
social
ostracism
and
a
higher
risk
of
suicide.
Sb
130
did
sb.
139
is
designed
to
send
a
clear
message
to
the
greater
health
care
community
discrimination
is
not
acceptable
in
nevada.
K
Let's
also
address
the
practicalities
of
what
this
bill.
Does
it
eliminates
thinly
veiled,
biased,
discriminatory
exclusions
of
treatments
for
gender
dysphoria
for
such
things
as
voice
therapy
and
facial
feminization
surgery,
denials
for
such
treatments
have
been
ruled
discriminatory
when
denied
by
state
employee
health
care
coverage
in
florida
in
oregon
and
in
wisconsin,
as
well
as
in
other
jurisdictions,
ruling
against
insurance
carriers
and
employer-based
health
plans.
K
Attempts
to
use
bias
denials
it
have
cost
far
more
than
the
coverage
for
medically
necessary
procedures
would
have
been
every
health
care
plan
in
nevada
that
excludes
these
procedures
is
risking
paying
far
more
in
penalties,
if
litigated
than
they
would
by
providing
coverage.
K
K
K
In
one
analysis,
I
reviewed
a
few
years
ago,
the
actuaries
assumed
that
every
covered
transgender
person
would
have
gender
reforming
surgery
every
year.
For
the
rest
of
their
lives,
keep
in
mind,
these
are
once-in-a-lifetime
events
and
not
every
person
who
identifies
desires
or
is
medically
eligible
for
these
procedures.
K
K
Additionally,
it
needs
to
be
pointed
out
that
this
bill
is
not
asking
for
free
health
care,
transgender
people
and
their
families
pay
into
health
care
plans
through
insurance
premiums
and
through
employee
compensation
packages.
We
pay
for
coverage
of
of
medically
necessary
treatments.
Having
those
unique
treatments
denied
due
to
administrative
bias
is
discriminatory.
K
Now
is
the
time
to
recognize
the
needs
of
the
transgender
and
marginalized
community
and
welcome
them
into
the
circle
of
humanity
by
providing
the
necessary
coverage
to
ease
the
suffering
caused
by
gender
dysphoria.
I
urge
you
to
pass
sb
139,
and
I
am
grateful
for
the
time
to
be
able
to
present
this
bill.
L
Good
morning,
everyone
can
you
all
hear
me
well
perfect,
all
right.
So
thank
you,
senator
scheibel,
for
inviting
me
to
speak
in
support
of
sv139.
L
L
L
L
L
Luckily,
my
first
therapy
appointment
and
the
10
that
followed
were
covered
by
my
employer
provided
medical
insurance
with
a
small
out-of-pocket
expense
to
myself.
Without
that
coverage
I
would
not
have
been
able
to
afford
11
sessions
at
150.
Each
one
session
alone
was
the
equivalent
of
two
and
a
half
weeks
of
groceries
from
my
wife,
and
I.
L
L
L
J
M
Hello,
I'm
elliot
butler.
I
have
been
on
testosterone
for
one
year
and
right
now,
I'm
in
the
process
of
trying
to
get
top
surgery
right
now.
My
insurance
has
denied
my
first
letter
from
my
referral
from
my
doctor,
and
I
have
to
raise
ten
thousand
dollars
almost
to
get
top
surgery,
which
is
a
struggle
lately
because
work.
I
have
to
work
for
jobs
and
also
pay
other
bills.
M
So
with
my
insurance
denying
the
letter
at
first
was
kind
of
heartbreaking,
I
had
to
figure
out
ways
to
find
fundraisers
to
get
raise
the
money
for
my
top
surgery.
At
this
moment
in
time
I
did
get
my
referral
letter
from
my
therapist
to
review
with
my
insurance
to
cover
the
top
surgery,
I'm
in
the
process
of
getting
my
consultation
on
march
26th,
so
I'm
hoping
that
the
insurance
company
does
approve,
but
right
now
it
is
looking
very
slim
that
I
won't
be
able
to
afford
top
surgery
and
it's
getting
really
difficult.
M
But
with
my
my
personal
timeline
with
being
on
testosterone,
I
was
able
to
afford
the
ejections
and
stuff
swimming
with
through
the
clinic,
which
is
a
reasonable,
affordable
fee,
and
now
that
I'm
just
waiting
to
hear
if
I
get
approved
or
not,
I
just
hope
that
you
guys
will
proceed
with
passing
this
bill
and
helping
all
the
transgender
people
in
las
vegas.
Thank
you.
J
Thank
you
so
much
and
chair
spearman.
That
does
conclude
our
presentation
of
the
bill.
I
am
happy
to
answer
questions.
I
would
also
like
to
let
everybody
know
that
we
do
have
a
representative
here
from
medicaid,
because
I
anticipate
that
there
will
be
some
questions
about
how
this
will
affect
medicaid
and
mr
young
has
very
generously
offered
to
join
us
to
answer
those
questions
on
that
side
of
the
of
the
policy
questions.
A
Thank
you,
senator.
Are
there
any
members
of
the
committee
who
have
questions
and
I
see
our
reliable
hand
from
senator
picker.
I
I
just
have
a
couple
of
technical
questions
and
and
medicaid
was
going
to
actually
be
the
third,
as
I
review
the
bill,
I
noticed
that
when
we
go
in
and
we
start
looking
at
the
definitions
and
then
we
refer
to
or
we
require
practitioners
to
abide
by
the
definitions
here,
I
I
I
wanted
to
get
a
little
more
information
on
this,
so
I
looked
up
the
dsm,
5
and
realized
that
though
they
are
substantially
similar,
the
definitions
are
different
and
so
haven't
we
created
by
not
following
the
definitions
in
the
dsm-5
verbatim.
J
Okay,
so
a
couple
of
different
things,
the
first
one
is
that
I
think
that
you
know
this
is
language
from
lcb
that
matches
other
language
in
nevada
statutes,
and
I
am
not
sure
that
it
has
to
match
the
dsm-5
exactly
in
order
for
providers
to
be
able
to
utilize
the
dsm-5
and
also
be
compliant
with
our
law.
But
we
looked
more
closely
at
the
wpath
standards
and
the
wpath
standards
match
these.
J
I
think,
if
not
verbatim
then
as
close
as
possible
to
allow
for
consistency
with
nevada
statutes
and
the
purpose
is
to
be
consistent
across
insurance
plans
and
to
be
consistent
across
providers,
and
I
think
I
I
don't
know
what
the
exact
differences
are
with
the
dsm-5.
Perhaps
if
there
were,
if
there's
specific
language
or
something
that's
missing
from
the
dsm-5
that
you
don't
see
in
the
bill,
I
could
speak
to
that.
I
K
K
It
does
not
set
out
a
treatment
plan,
a
treatment
plan
within
the
scope
of
what
is
written
in
the
both
in
these
wpath
standards
of
care,
as
well
as,
within
the
the
context
of
this
bill,
formulate
the
the
boundaries
of
of
what
the
treatment
plan
could
possibly
cover
so
to
be
able
to
apply
a
diagnosis
from
the
diagnostic
manual
does
not
give
enough
detail
on
an
appropriate
treatment
plan
that
really
has
to
be
tailored
for
the
individual.
K
Not
everybody
wants
to
have
gender
affirming
procedures
done.
They
might
be
just
happy
with
you
know:
social
sec,
acceptance
and
affirmation.
Some
people
might
want
to
have
simply
hormone
therapy.
It's
a
very
inexpensive
overall
treatment
to
be
able
to
have
other
people
in
in
certain
situations
may
need
to
treat
their
symptoms,
a
higher
level
of
intervention
and
additional
medical
treatments.
The
same
is
what
you
know
you
might
have
in
dealing
with
high
blood
pressure
heart
disease.
I
Right-
and
I
appreciate
that
and
because
we've
mentioned
wpath,
that's
a
private
organization
and
I
don't
believe
that
nevada
has
adopted
their
criteria
within
our
our
diagnostic
panel.
But
I'm
not
an
expert
in
that.
I
I
I'd
be
interested
to
know
if
this
is
intended
to
adopt
that.
K
K
This
bill
has
the
language
to
be
able
to
put
that
into
a
context
for
an
individual
patient
within
an
appropriate,
experienced
clinical
pathway
of
providers
to
get
to
that
medically
necessary
designation
for
a
particular
treatment.
This
is
not
an
open
door
to
anything
and
everything.
This
is
a.
This
is
a
pathway
to
be
able
to
have
a
desired
result
for
that
particular
patient.
I
Sure,
and-
and
I
appreciate
that
that,
but
does
that
it
sounds
like
you're
saying
then
that
this
does
not
adopt
the
wpath
standards
and
I'm
thinking
you
know
we
adopt
standards
for
two
reasons:
number
one
to
give
guidance.
We
we
start
with
a
diagnosis
which
is
presumably
going
to
be
based
on
the
adopted
dsm-5.
I
Then
they're
going
to
have
to
treat
based
on
another
standard,
but
we're
if
we
don't
adopt
these
standards
and
something
goes
awry.
But
now
we
don't
have
an
adopted
standard
to
look
at
and
it
creates
confusion
when
this
gets
litigated
and
and
so
that's
kind
of
the
genesis
or
the
the.
The
crux
of
of
my
question
or
my
concern
and
and
the
second
question
I
have
with
your
indulgence,
madam
chair.
I
If
I
may
I
I
I
read
over
the
bulletin
1502
and
this
seems
to
fly
in
the
face
of
or
I'm
sorry
the
experience
we
just
heard.
The
denial
seems
to
fly
in
the
face
of
this
department
opinion.
I
I
J
Melanie
scheibel
for
the
record,
and
I
think
that
you
have
kind
of
hit
the
nail
on
the
head-
that
the
what
people
are
experiencing
in
practice
is
inconsistent
with
the
decision
or
the
ruling
by
the
commissioner
or
the
department
of
business
and
industry,
and
so
I
I
think
that
I
am
not
the
first
legislator
to
encounter
this
problem
and
come
up
with
a
legislative
solution
and
that's
what
this
bill
does.
Is
it
puts
into
law?
What
the
the
department
of
insurer
or
division
of
insurance
has
already
said
is
their
interpretation
of
the
law.
I
K
If,
if,
if
I
may
brook
mail
after
the
record,
this
is
a
typical
bureaucratic
puzzle
because
of
how
insurance
works,
that
pre-authorization
can
go
in
and
be
denied
and
because
of
the
the
terms
and
conditions
of
the
insurance
plan
before
a
complaint
can
be
made
to
the
insurance.
K
Commissioner,
often
one
and
I'm
speculating
here,
but
often
what
happens
is
that
the
process
requires
the
individual
to
appeal
the
denial
and
if
the
denial
is
appealed,
then
that
may,
depending
on
what
is
buried
in
the
contract,
be
able
to
appeal
the
denial
to
a
higher
source
such
as
the
insurance
commission.
This.
What
from
what?
Mr
butler
related?
It
has
not
gone
to
that
to
that
point
in
the
process
yet,
but
that
inherently
is
one
of
the
ultimate
issues.
There
may
be
a
policy
that
is
understood
in
the
legal
department
of
the
insurance
company.
K
It
may
be
understood
by
those
that
represent
them
in
this
building,
and
they
say
we
are.
You
know
we
are
meeting
the
obligations
of
the
law,
but
when
the
fact
comes
down
to
that
person
who
didn't
read
the
memo
didn't
read
the
memo
from
six
years
ago,
and
you
still
automatically
denying
those
things
you
know
arbitrarily
or
capriciously.
I
don't
know,
then
we
put
that
patient
into
distress
and
potential
harm,
despite
it
being
illegal.
K
What
we're
trying
to
do
with
this
bill
is
to
create
a
sweeping
mandate
that,
if
you've
got
the
letters
of
recommendation,
if
you
follow
that,
you
know
the
standards
of
care
that
mandate
for
top
surgery,
that
you
have
a
letter
from
a
therapist
that
you
have
persistent
and
in
insistent
symptoms
of
gender
dysphoria
and
the
best
treatment
is
to
be
able
to
have
top
surgery
in
in
this
particular
case.
K
I
All
right-
and
I
appreciate
that-
I
manager
I'll
let
someone
else-
ask
the
question
about
medicaid.
I
would
like
to
know
how
this
impact
impacts
that,
but
I
don't
want
to
monopolize
any
more
of
the
time.
Thank
you
for
your
indulgence.
A
I
A
G
I'm
going
to
ask
a
little
more
basic
thing
when,
when
we
talk
about
medically
necessary,
so
we
don't
do
mastectomies
or
build
up
breasts
for
plastic
surgery
that
aren't
medically
necessary,
and
so
somebody
ends
up
having
to
pay
for
it
out
of
pocket,
and
so
I'm
just
kind
of
trying
to
figure
out
that
the
definition
of
medically
necessary
what
I'm
hearing
is
medically
necessary
is
to
have
the
person
vocally
conform
to
their
feeling
of
gender
affirmation
or
confirmation,
whereas
most
people,
if
they
go,
get
a
breast
implant.
G
For
instance,
that's
that
is
not
covered
by
insurance,
because
it's
not
medically
necessary,
even
if
they're
a
person
that
works
in
the
casinos
with
all
positive
prominence
that
is
attractive.
G
So
that's
one
question
I
have
and
then
I'm
going
to
ask
a
very
basic
question
and
I
don't
understand
I've
struggled
with
the
name
spelling
that
we
have,
but
I'm
seeing
that
on
our
participants,
but
the
surgery
type
that
you're
explaining
is
apparently
an
abbreviation
and
I
would
love
to
have
it
spelled
as
well
as
defined
with
the
words
that
I
mean.
I
don't
know
what
the
name
of
the
surgery
is,
where
you're
using
it,
but
I
don't
know
what
it
is.
K
For
the
record
brooke
malek
senator
hardy,
can
you
point
me
in
a
better
direction
on
which
term,
which
abbreviation
of
the
procedure
that
you're
referring
to?
So
I
can
better
explain.
J
This
is
melanie
scheible
for
the
record,
and
I
think
I
understand
senator
hardy's
question
and
I'll
go
from
the
second
question.
First
then,
back
to
the
first
question
and
say
that
the
point
of
this
bill
is
to
cover
any
number
of
different
procedures
and
science
improves,
medicine
improves
and
we
develop
new
procedures
on
a
regular
basis.
J
One
of
the
procedures
that
we
did
talk
about
during
testimony
was
commonly
referred
to
as
top
surgery,
which
is
a
procedure
for
people
who
are
born
and
assigned
female
at
birth,
so
they
have
breast
tissue
and
they
want
to
have
that
removed
and
they
have
to
have
that
removed
in
order
to
affirm
their
gender,
which
is
actually
male,
and
so
it
is
akin
to
a
mastectomy,
but
it
could
take
different
forms
for
different
people.
Some
transgender
men
might
need
both
breasts
completely
removed.
Some
transgender
men
might
only
need
them
reduced.
J
They
go
through
that
process
that
our
advocates
talked
about
with
a
therapist
with
a
plastic
surgeon
with
an
endocrinologist,
and
they
they
determine
which
procedures
exactly
are
necessary
for
that
person
and
in
what
time,
and
in
what
order,
so
that
the
whole
team
can
come
together
and
say
to
the
insurance
company.
This
is
what
this
person
needs
in
order
to
be
whole
in
order
to
live
in
the
body
that
they
have,
and
so
I
think
that
the
short
answer
to
your
question
is
that
it
could
be
any
different
number
of
procedures.
J
The
longer
answer
to
your
question
is
that
the
one
we
were
talking
about
is
top
surgery,
and
that
would
include
you
know
different
types
of
mastectomies
and
chest
reconstructive
surgeries.
It
could
also
include
breast
implants
for
trans
women.
It
could
also
include
vaginoplasties,
which
is
kind
of
the
creation
of
a
vagina
for
lack
of
a
better
term.
J
It
could
also
include
something
like
what
we
call
a
tracheal
shave
for
for
trans
women,
who
have
a
very
prominent
adam's
apple,
or
I
don't
know
what
the
technical
term
is
for
adam's
apple,
but
the
tracheal
shave
you
know
helps
to
smooth
out
that
line.
We
might
also
talk
in
testimony
about
facial
feminization
surgery,
and
I
would
also
be
happy
to
follow
up
offline
and
talk
about.
J
You
know
some
of
the
various
procedures
that
trans
people
today
are
able
to
access
and
some
of
the
new
procedures
that
are
becoming
accessible,
that
are
being
invented
quite
literally
every
day,
and
I
hope
that
helps
to
answer
your
question.
K
Yes,
yes,
for
the
record,
brook
mail
out
it's
top
surgery,
as
in
above
the
waist
surgical
interventions,
as
opposed
to
bottom
surgery
below
the
waist
types
of
surgery.
It's
just
a
a
common
vernacular
within
the
transgender
community
and
those
that
are
medically
attending
to
them.
K
You
also
had
a
question
about
essentially
breast
augmentation
and
what
is
considered
medically
necessary
and
covered
by
insurance.
Companies
is
breast
augmentation
for
chest
reconstruction
for
a
cisgender
woman
after
a
mastectomy
in
order
to
be
able
to
regain
the
contours,
the
the
the
physical
manifestation
of
how
they
presented
before
they
had
to
have
their
breasts
removed.
K
The
breast
augmentation
for
transgender
women
is
really
only
necessary
if
the
effects
of
of
the
feminizing
secondary
sex
characteristics
induced
by
hormonal
therapy
have
really
not
made
an
effect,
and
that
only
happens
after
the
individual
has
gone
through.
A
male
puberty
for
young
people
that
are
coming
out
that
have
identified
and
have
been
now
started
treatment
for
their
gender
dysphoria
at
an
early
age
and
been
put
on
puberty
blockers,
which
again
are
already
covered
under
the
memo
from
the
insurance
commissioner.
In
2015.
K
So
then
that
a
hormone
replacement
therapy
regimen
can
be
introduced
at
an
appropriate
age.
So
they
only
have
to
go
through
one
puberty
and
I
will
attest
personally
having
gone
through
two
puberties.
One
is
enough
for
anybody,
so
you
know
it's
a.
It
can
benefit
these
the
insurance
community
overall
by
allowing
an
appropriate
pathway
early
on
through
puberty
blockers,
hormonal
therapy
etc,
and
that
can
mitigate
the
need
or
even
the
desire
for
later
surgical
interventions,
which
is
better
outcomes
for
everybody.
G
Well,
I
I
appreciate
I
mean,
as
far
as
I
know,
there
is
not
a
quote
procedure
that
is
medically
turned
up
procedure,
so
I
appreciate
senator
scheible
you
elucidating
and
enumerating
the
surgeries
and
keeping
open
the
door
for
the
new
inventions
and
surgeries,
because
it
helps
me
understand
the
generic
term.
I
guess
you'd
call
it
or
the
vernacular
thought
surgery
that,
because
there
isn't
a
pop
surgery
to
senator
pickard's
point
about
you
know,
where
does
it
fit
into
the
ems
eye
or
the
any
of
the
other
vernacular?
A
Thank
you
write
your
neil.
E
Thank
you,
madam
chair.
I
I
wanted
to
address
my
questions
to
mr
young,
see
it's
still
on.
E
Oh
okay,
great
okay,
mr
young,
so
so
this
bill
really
reminds
me
of
the
sickle
cell
bill.
I
had
last
session
and
my
I
wanted
to
talk
about
this-
the
prescriptions.
What
are
the
like?
The
cost
of
the
prescriptions
that
are
going
to
go
into
this,
because
I
know
in
the
bill
I
had
last
session
I
had
to
specifically
get
into
the
formulary
I
had
to
prescribe
in
statute
what
I
wanted
to
see
in
terms
of
drug
access
through
medicaid,
but
I
I
didn't
see
the
language
in
here
is
that
contemplated.
N
Your
music
wayne,
young
deputy
administrator
for
the
division
of
healthcare
financing
and
policy
senator
spearman
to
you
through
you,
the
chair
to
senator
neal,
mr.
N
Thank
you
for
that
senator
senator
neil
to
answer
your
question.
Medicaid
policy
when
it
is
administered,
covers
both
fee
for
service
and
managed
care.
Now
there
are
differences
and
correct.
The
prior
authorizations
are
the
same
because
the
managed
characterizations
do
present
on
our
drug
utilization
review
board,
but
there
are
differences
in
what
is
preferred
and
non-preferred,
because
each
pharmacy
and
therapeutics
committee
is
run
by
it
separately
by
its
own
nco
and
by
the
state
through
its
silver
script.
N
States
board
in
this
particular
bill
medications
are
not
called
out
and
we
worked
with
the
senator
because
those
medications
are
already
covered
and
there
is
there
while
there
may
be
some
nuances
and
criteria
about
what
is
preferred.
There
is
an
acceptable
alternative
in
each
category
and
of
pharmaceuticals
that
are
covered
for
these
drugs.
N
What
the
state's
fiscal
note
refers
to
is
there
are
additional
services
and,
as
you
all
are
aware,
this
fine
body
passed
the
governor's
executive
budget
in
2017,
which
added
these
services
to
the
medicaid
chapter
600
on
physician
services.
N
There
are
some
services
that
are
not
currently
covered
by
medicaid
and
because
there
is
a
nuance
as
dr
hardy
so
alluded
to,
of
what
is
considered
medically
necessary
by
both
our
fiscal
agent
and
by
the
managed
care
plans
that
relate
to
some
of
the
more
cosmetic
procedures,
voice,
therapy
and
hair
transplantation,
and
so
that
those
services
are
represented.
In
our
fiscal
note.
N
I
will
note,
though,
that
we
have
spoken
with
the
sponsor
and
to
work
through
some
of
those
issues
so
that
to
align
it
more
closely
to
our
current
policy.
E
Thank
you
for
that,
mr
young
and
then
my
second
question
to
you
is
the
fmap,
so
you
had
that
in
your
fiscal
note.
So
is
there
what's
the
so
typically
there's
like
a
contribution
rate,
so
what
what's
going
to
happen
with
the
federal
contribution
rate
in
this
scenario.
N
Again,
dwayne
young
for
the
record,
senator
neil.
Thank
you
for
the
question.
The
f
map
is
applied
based
on
a
person's
eligibility
and
aid
category,
so,
for
instance,
if
they
are
the
traditional
mabbit
population
or
medically
disabled
or
blind
population,
they'll
have
around
what
is
a
66
f
map.
If
they
are
newly
eligible,
it
will
be
90
and
so
happy
to
I.
N
We
have
not
had
a
great
number
of
these
cases,
and
so
I
do
believe
that
they
fall
across
all
f
maps
but
happy
to
follow
up
to
see
a
specific
trends
regarding
fmap
for
the
cases
of
gender
reassignment.
We
have
already
had.
E
Thank
you
for
that
third
question
for
plastic
surgery:
what
is
the
provider
rate
for
plastic
surgery
in
in
these
cases?.
N
Again,
deputy
administrator
dwayne
young
for
the
record
again.
Thank
you
for
the
question.
I
do
not
know
our
physician
rates
off
hand,
but
I
will
tell
you
that
plastic
surgeons
are
enrolled
as
a
part
of
what
we
call
provider
type
20,
our
physicians
group,
and
so
they
are
paid
no
differently
than
any
other
physician
that
would
be
performing
surgery,
services
and
also
just
to
clarify.
N
Medicaid
does
not
allow
federal
reimbursement,
bars
certain
plastic
surgery
in
certain
instances
and
what
have
been
referred
to
here
as
the
top
surgery.
We
do
pay
for
plastic
surgeries
in
the
cases
that
ms
nylab
have
pointed
out
as
why
there
is
a
medical
need
for
those
services,
and
so
that
is
covered
as
part
of
what's
considered.
The
top
server.
E
And
so
you're
not
off
the
hook.
Yet.
Madam
chair
one
more
one
more
question,
I
I
just
because,
because
this
bill
really
made
me
think,
do
we
cover
plastic
surgery
for
cancer
patients
who
need
who
have
had
a
double
mastectomy.
N
Deputy
administrator
dwayne
young,
I
can
look
at
bring
back
the
specific
instances
in
which
that
would
occur
if
there
is
a
medical
necessity
need
for
those
services,
and
the
physician
has
gone
on
record
as
to
it
being
medically
necessary,
then
those
services
would
be
applied.
N
I
think
that
there
and
one
of
the
interesting
things
I
think
we've
argued
in
the
history
of
medicaid,
is
the
definition
of
medical
necessity
and
how
that
applies,
and
dr
hardy
could
speak
to
this
so
much
more
better
than
I
could,
but
as
a
physician,
he
knows
that
the
physicians
have
to
attest
what
the
absolute
medical
need
is
for
surgery
as
part
of
the
prior
authorization
process,
and
then
that
surgery
is
approved.
N
Based
on
that
definition,
and
I
think
that,
of
course,
some
cases
there
will
be
denials
because
it
did
not
meet
the
threshold
of
medical
need
and
in
other
cases
there
will
be
approval
because
it
did
meet
that
threshold
of
medical
need.
J
This
is
senator
scheibel,
I'm
I
was
going
to
cut
in
for
a
second.
I
don't
want
to
speak
for
anybody
else,
but
something
that
might
be
some
good
food
for.
A
thought
in
my
research
on
this
subject
was
that
we
found
that
there
were
some
times
when
people
did
when
plastic
surgery
was
covered
for
things
like
accidents.
If
somebody,
you
know,
broke
a
limb
or
had
some
kind
of
you
know
a
traumatic
injury
to
some
part
of
their
body
that
required
both
internal
and
external
repairs.
E
Thank
you
for
that,
because,
honestly,
you
know
when
I
saw
medically
necessary,
I
had
a
bill
dealing
with
a
population
that
was
roughly
about,
I
think
2
000
people
in
the
state
and
the
private
organizations
that
were
drawn
into
the
bill
by
some
of
the
chapters
really
tried
to
get
me
to
move
away,
because
I
had
comprehensive
care
right,
which
has
a
total
different
medical
meaning
to
seek
comprehensive
care,
and
they
literally
spent
a
couple
of
months
in
the
session
to
get
me
to
change
it
to
medically
necessary
and
my
understanding
them
getting
me
to
try
to
change
it
to
medically
necessary
was
so
that
they
could
reduce
what
they
covered
and
give
them
some
wiggle
room
on
what
they
weren't
going
to
cover.
E
And
so,
when
I
read
this
language,
you
know
it
looks
good
sounds
good,
but
you
may
find
that
the
application
of
those
two
words
gets
you
into
a
medical
fight
of
what
you
say
is
needed
in
your
interpretation
and
then
what
a
doctor
then
says
they're
going
to
do,
and
so
I
I
just
I'm
just
I'm
saying
this
because
I
traveled
this
road
and
you
may
I'm
just
I'm
just
putting
out
some
caution
there
that
if
there's
already
bias
these
two
words
are
going
to
make.
You
have
to
fight
just
putting
that
out.
There.
A
A
O
O
It
sounds
like
this
is
already
required
by
law,
but
yet
some
of
the
counties
like
clark
county,
saying
it's
a
1.5
million
fiscal
hit
potentially
and
I'm
just
curious-
are
we
the
first
state
to
bring
forth
said
language
in
that
respect
in
other
states
that
have
had
this
language
if
they
are
any
states
that
have
had
this
language?
How
much
has
it
raised
insurance
premiums?
Overall,
you
know
you
always
I
remember
when
we
did
the
autism
one.
O
You
know
they
all
swore
that
if
we
did
the
autism
bill,
the
sky
would
fall
and
everybody's
rates
had
double
and
it
actually
only
ended
up
being
a
dollar
or
two
in
as
far
as
the
increase
that
was
really
necessary
to
handle
that,
and
it
was
obviously
more
than
worth
doing
to
help
people
out.
So
I'm
just
curious
whether
states
have
had
similar
language.
K
If
I
may,
I
can
address
that
this
is
brook
mala
after
the
record.
We
would
be
the
first
state
to
be
able
to
have
something
that
is
this
broadly
mandated.
There
are
many
states
that
are
still
refusing
to
follow
the
the
guidance
of
the
affordable
care
act,
although
the
federal
law
does
still
apply.
K
It
just
makes
the
process
for
an
individual
patient
to
go
through
a
complaint
and
an
appeals
process,
much
more
difficult
regarding
the
overall
impact,
when
the
the
memo
came
out
in
2015
and
mandated
the
expansion
of
procedures
that
were
already
being
covered
by
insurance
plans
for
cisgender
people
and
now
it
because
of
the
affordable
care
act
and
our
memo
it
mandates
that
you've
got
to
do
those
for
transgender
people
as
well.
K
You
know
it's.
The
the
increase
was
measured
in
pennies.
The
increased
cost
was
really
pennies.
A
study
out
of
san
francisco
when
they
expanded
on
it,
ended
up
that
it
cost
the
individual
member
an
additional
three
cents
per
member
increase.
K
When
we
looked
at
other
plans
here
in
nevada,
it
comes
out
to
a
rounding
error.
You
know
it's
a
when
we're
looking
at
a
20
million
dollar
payout
from
an
employer.
You
know
for
their
overall
employee
packages
and
serving
their
transgender
employees
and
their
employees,
families
the
expense
is
under
fifty
thousand
dollars.
K
You
know
it's
a
it's
a
it's
a
decimal
point
of
of
a
percentage
rate,
it's
pennies
for
this
life-affirming,
very
beneficial
type
of
treatment.
What
this
bill
does
is.
It
expands
very,
very
slightly
a
few
other
types
of
procedures
that
are
met
that
are
considered
medically
necessary
by
wpath
in
their
standards
of
care
and
have
been
and
whose
exclusions
have
been
challenged
in
the
courts
throughout
the
country
and
the
plaintiffs
have
won
costing
the
insurance
plans,
hundreds
of
thousands
of
dollars
in
penalties
above
and
beyond
the
cost
of.
K
Actually,
you
know
paying
for
the
procedure,
so
in
one
sense,
this
bill
is
to
insurance
companies
best
interest
to
be
able
to
remove
that
potential
litigation
where
they're
going
to
lose
and
have
to
pay
hundreds
of
thousands
of
dollars
of
penalties.
K
That's
what
we're
doing
all
we're
saying
here.
The
the
bill
is
designed
to
be
equitable
to
all
of
the
stakeholders,
to
the
health
plans
and
to
the
patients
and
to
medicare
and
and
the
citizens
of
nevada.
K
O
A
O
Squid,
thank
you
chair
in
that
respect.
What
are
we
going
to
do
about?
Unfortunately,
the
definition
of
medically
necessary?
Is
there
any
provisions
in
law,
because,
unfortunately,
I
know
none?
Unfortunately,
I've
known
individuals
who
have
sadly
found
bad
doctors
that
were
willing
to
allow
them
to
do
things
that
weren't
medically
necessary.
O
So
in
other
words,
I
I
can
find
a
a
safety
and
comfort
in
what
you're
discussing,
but
sadly,
we
already
have
situations
where
people
go
find
doctors
to
allow
them
to
have
surgeries
that
are
merely
you
know,
non-medically
necessary
and
purely
aesthetic,
and
therefore
they
find
a
doctor
willing
to
give
them
that
excuse
and
what
what
type
of
penalties
in
law
exist
will
those
some
penalties
cross
over
in
this
realm,
so
that,
if
we
find
out,
people
are,
unfortunately
gaming,
the
system
per
se?
How
do
we
deal
with
that.
J
This
is
melanie
scheible
for
the
record,
and
I
think
there
are
a
couple
of
different
ways
to
deal
with
that.
One
of
them
would
be
through.
You
know,
medical
malpractice
statutes,
another
one
would
be
through
fraud
statutes,
because
a
doctor
who
is
fraudulently
approving
procedures
writing
prescriptions
fraudulently,
representing
to
an
insurance
company
that
something
is
medically
necessary.
That's
not
would
be
liable
for
that
fraud,
and
I
also
want
to
point
to
what
I
think
is
a
really
important
part
of
the
definition
of
medically
necessary
as
it's
written
in
the
bill.
J
It
starts
on
page
three,
it's
part
of
section
one,
but
if
you
look
at
page
three
line,
twenty
line,
19
a
part
of
medically
necessary
includes
being
not
primarily
provided
for
the
convenience
of
the
patient
or
provider
of
health
care,
and
I
think
that
that
is
a
a
bar
to
overcome
for
anybody
to
prove
that
what
they
are
doing
is
not
for
their
convenience
or
for
their
providers.
J
Convenience-
and
I
think
that
that
kind
of
strikes
at
the
heart
of
the
issue
that
you're
asking
about
and
that
a
couple
of
other
members
of
the
committee
have
asked
about,
which
is
how
do
we
separate
people
who
just
want
this
procedure
because
they
want
it
versus
people
who
need
this
procedure
because
they
actually
experience
gender
dysphoria
and
having
a
procedure
or
going
through
a
surgery
will
alleviate
that
dysphoria,
and
I
think
that
you
know
I'm
open
to
amendments
I'm
open
to
working
on
this
definition.
J
But
I
think
that
the
difference
between
need
and
convenience
is
a
good
barometer,
and
that
is
one
of
the
safeguards
that's
already
written
into
the
bill
to
ensure
that
providers
have
some
guidelines
to
what
is
medically
necessary.
They
can't
just
say
I'm
a
doctor,
and
I
say
it's
necessary.
It's
I'm
a
doctor.
I've
evaluated
points
one
through
five
and
this
is
medically
necessary.
O
This
is
the
senator
settlement
again.
I
appreciate
that
answer.
Senator
and
again,
I
just
worry
not
about
the
true
cases
we're
discussing,
but
about,
unfortunately,
bad
doctors
and
bad
actors
out
there
I
mean,
could
they
you
know?
Potentially
they
could
use
this
and
say:
hey,
I'm
I'm
getting
older
as
a
guy
and
I'm
tired
of
losing
my
hair.
O
So
I
just
claim
this
somehow
and
then
automatically
get
to
get
some
rogaine
or
something
paid
for
as
part
of
the
insurance
or
something
of
that
nature,
and
I'm
just
worried
about
those
type
of
potential
loopholes
that
sadly
bad
people
can
do,
not
individuals
that
we're
discussing
that
need
some
assistance.
So
thank
you
for
that.
O
O
A
Are
there
any
other
questions
from
the
committee?
I
don't
see
any
other
hands,
so
this
is
probably
going
to
be
a
comment
and
a
question
rolled
into
one.
A
And
it's
difficult
because
you're
dealing
with
a
science
that
is
relatively
new
and
whenever
things
are
new,
sometimes
they're,
scary,
and
I
will,
I
think-
that's
that's.
That's
that's
a
historic
fact
there
once
was
a
time
when,
in
the
early
1900s,
when
there
was
a
supposition
that
black
people
were
genetically
inferior
to
those
of
european
descent
and
they
proved
it
in
various
and
sundry
ways
to
which
we
found
out
later
that
that
that
wasn't
true.
A
So
as
science
advanced,
we
we've
been
able
to
kick
that
to
the
curve.
The
only
thing
we
haven't
been
able
to
deal
with
now
is
the
residue
of
racism
that
we
incurred.
Because
of
that
I'm
thinking
back
on
the
first
bill
I
had
when
I
came
to
the
senate.
That
was
one
that
included.
A
That
would
include
transgender
persons
into
the
hate
crime
statute,
and
I
remember
some
of
the
questions
that
I
got
well.
You
know
how
do
you
know
that
they're
really
transgender?
Maybe
they
just
stand
up
at
a
concert
and
say
I'm
transgender,
and
then
they
start
a
riot
and
I'm
like
no
because
most
when
once
they
once
they
make
the
transition.
A
That's
where
they
are.
The
other
thing
that
I
I
guess
I
want
to
say
is,
as
we
try
to
wrap
our
heads
around
this
from
my
seminary
years.
I
remember
that
there
once
was
a
time
when
people
who
had
some
type
of
physical
disability
were
not
allowed
to
take
communion
because
it
was,
it
was
postulated
that
they
had
that,
because
they
there
was
something
that
god
had
against
him,
and
I
mentioned
that
because
I'm
sure
that
that
the
quote
religious
aspects
of
this
will
probably
come
into
play.
A
Those
are
things
that
we
probably
can't
do
anything
about,
because
what
people
think
they
think.
Yesterday
we
heard
a
bill.
Senator
orrinshaw
bought
a
bill
about
children
who
were
in
facilities.
A
So
here's
the
question
in
this
field,
and
I'm
sorry,
maybe
maybe
it's
there
and
I
didn't
see
it
is
in
this
field.
Is
there
anything
that
would
that
would
say
that
one
of
the
one
of
the
things
that
you
have
to
overcome
is
the
doctor
a
doctor
and
a
psychiatrist,
a
psychologist.
Somebody
would
have
to
work
together
in
determining
quote
what
would
be
medically
necessary
before
you
answer
that.
Let
me
say
say
this,
because
we
we
know.
A
Unfortunately,
we
have
never
never
dealt
with
the
number
of
trans
women
who
are
killed
and
they
are
killed
because,
because
of
who
they
are,
which
is
one
of
the
reasons
why
we
have
the
you
know
the
hate
crimes
piece.
A
So
so,
if
a
psychiatrist
and
a
medical
doctor
are
talking
about
this
at
the
same
time-
and
I
have
a
friend
who
who's
a
plastic
surgeon
and
one
of
the
things
that
they
do
when
you
talk
to
talk
about
cancer
patients
is
it's
it's
the
way
the
woman
sees
herself
and
is
that
going
to
be?
A
A
J
Thank
you
for
your
comments
and
your
question,
and
I
I
really
appreciate
your
insight
into
this
and
I
I
agree
with
you
and
I
the
short
answers.
I
think
that
there
is
because,
in
my
in
working
on
this
bill
and
talking
to
people
who
have
been
affected
and
talking
to
the
healthcare
plans,
I
don't
think
that
there
exists
a
provider
network
that
would
approve
these
procedures
or
these
treatments
without
the
sign-off,
from
both
a
mental
health,
professional
and
a
physical
health
professional.
J
I
just
that
is
something
that
can
be
written
into
the
plan
that
I
think
would
be
written
into
the
plan.
I
think
you
also
touch
on
an
important
issue
that
we
face
of
a
provider
shortage,
and
I
can't
solve
that
problem
with
this
bill.
I
can't
ensure
that
we
are
going
to
have
enough
providers
here
in
the
state
of
nevada
to
treat
all
of
the
people,
especially
members
of
other
marginalized
groups
and
people
of
color
who
experience
gender
dysphoria,
and
I
and
I
wish
that
we
could
do
that
with
this
bill.
J
But
I
do
think
that
this
provides
a
groundwork
for
everybody
to
have
their
insurance
cover.
These
procedures
so
that
we
can
attract
more
providers
to
nevada,
and
I
the
bill
is
not
designed
to
tell
insurance
companies
how
to
evaluate
what
is
medically
necessary
other
than
the
the
five
the
the
five
factors
to
consider,
and
I
I
was
certain
I
guess
what
I'm
saying
is.
J
I
would
certainly
hope
that
everybody
who
is
utilizing
this
bill
or
who
is
benefiting
from
this
bill,
has
a
team
of
experts
by
their
side,
who
is
helping
them
through
this
to
get
the
best
care
possible.
J
But
I
also
don't
think
that
we
should
be
setting
up
a
system
that
that
further
prevents
them
from
getting
adequate
care
if
they
can't
find
all
the
providers
that
they
need
and
all
the
providers
that
they
deserve.
And
so
it
provides
some
flexibility
for
nevadans
to
work
with
the
doctors
that
they
have
and
work
with
the
doctors
who
they
can
find
and
get
their
insurance
companies
to
help
cover
the
cost
of
these
procedures
and
and
treatments.
A
Thank
you,
and
just
something
to
maybe
think
about
not
to
add
another
barrier,
but
maybe
there
is
some
type
of
a
compromise
that
would
set
a
standard
for
medical
medically
necessary
that
includes
mental
health
and
physical
health.
So
that
could
just
be
something
to
consider
and
the
last
thing.
Well,
I
I
think
senator
sutherland
brought
up
a
good
point.
You
know
what
what
about
people
who
are
going
to
gain
the
system
who
would
gain
the
system
is
mr
young
still
on?
A
I
think
so,
mr
young,
let
me
let
me
ask
you
this
question
where's
this
bill
to
pass.
A
Would
this
be
the
first
time
that
someone
would
try
to
gain
medicaid,
or
would
this
be
the
first
time
that
there
would
be
medicaid
fraud?
Just
a
question.
N
Senator
spearman
dwayne
young
for
the
record.
No,
it
would
not
be
the
first
time
that
mary
kate
has
experienced
fraud,
waste
abuse
and
we
do
have
a
whole
unit
that
is
dedicated
to
rooting
out
fraud,
waste
and
abuse
within
medicaid.
A
Is
that
what
does
that
amount?
To
I
mean?
Is
that
like
a
thousand
dollars
or
oh,
two
thousand
dollars?
What?
What
does
that
look
like,
because
I'm
trying
to
establish,
if
there's
going
to
be
a
precedent
that
we've
never
dealt
with
before
or
if
this
is
something
that
the
system
expects
based
upon
some
type
of
an
algorithm,
or
something
like
that?
So
so
talk
to
me
about
that.
N
Senator
if
I
may
address
your
question
in
two
parts,
the
first
part
and
again
dwayne
young
for
the
record,
the
first
part
being
that
yes,
medicaid
experiences
million
dollars
of
fraud,
but
it's
spread
across
multiple
provider
types
in
multiple
disciplines
and
happy
to
provide
that
data.
In
that
report,
I
will
speak
to
this
particular
set
of
services
within
medicaid
chapter
600,
section
7.
On
page
three,
we
do
have
guidelines
that
spoke
to
the
switch.
N
Some
of
the
other
earlier
fears
that
they
do
have
those
seeking
gender
reassignment
surgery
do
have
to
have
a
letter.
That's
separate
opinions
from
a
psychiatrist
or
psychologist
as
well
as
a
medical
doctor.
N
Those
two
letters
have
to
also
state
and
attest
that
they
have
performed
certain
levels
of
therapy
and
so
as
well
as
medical
interventions
before
qualifying
for
the
surgery.
So
the
policy
as
it
exists
now,
is
fairly
rigorous
to
ensure
that
an
individual
has
been
diagnosed
with
gender
dysphoria
disorder
and
has
sought
several
levels
of
treatment
prior
to
having
this
surgery
paid
for
and
authorized
by
medicaid.
So
there
are
safeguards
within
the
policy.
N
I
will
not
stand
here
before
you
and
say
that
our
policy
is
perfect
by
any
means,
but
medicaid
staff
have
done
their
due
diligence
in
meeting
those
who
pass
standards
that
were
mentioned
earlier
to
assure
that
those
receiving
the
surgery
have
followed
the
appropriate
steps
and
have
aligned
with
other
policies
and
procedures
within
the
medicaid
chapter.
A
Okay,
thank
you,
sir.
This
is
my
last
comment
and
then
broadcast.
Let's
prepare
to
move
towards
public
testimony
and
the
first
one
we'll
go
to
would
be
four,
but
here's
my
last
comment-
and
this
comes
as
no
surprise,
I'm
sure
to
miss
maylock
and
anyone
else
who
works
with
the
with
dhhs
in
the
lgbtq
space.
A
I
continue
to
be
appointed
because
of
the
lack
of
diversity,
not
just
in
testifiers,
but
diversity,
geographic
diversity,
someone
from
the
south
and
someone
from
the
north
diversity
based
upon
ethnicity,
because
the
one
thing
that
another
thing
that
people
in
the
lgbtq
community
really
don't
like
to
admit.
But
racism
exists
there
as
well
and
it
exists.
A
If
you
are
a
white
gay
man,
you
can
still
have
the
same
privileges
of
any
cisgender
white
man,
because
nobody
will
know
who
you
are
unless
you
tell
them
or
unless
you
act
like
that,
but
for
people
of
color,
then
there's
that
intersection
of
gender
identity
and
race
that
comes
about
and
there's
no
way
to
compensate
for
policy
to
compensate
for
that.
Unless
you
have
those
eyes,
those
those
those
lived
experiences
at
the
table
and
so
right
now,
in
my
opinion,
it's
lopsided
because
we
don't
have
diverse,
lived
experiences
at
the
table.
A
That's
that's
my
that's
my
own
beef,
but
I've
said
it
before
and
I
will
be
glad
when
we
come
to
the
table
and
we
can
say
that
there
is
diversity
in
this
part
of
what
dhhs
deals
with
lived,
experiences
and
representation
matter.
A
That's
my
comment:
it's
not
against
you!
It's
just
the
way
the
system
is,
and
I
think
that
the
system
needs
to
change.
Somebody
needs
to
change
the
system
and
recognize
that
there
are
diverse
opinions
and
you
can
only
get
that
from
people
who
are
diverse,
or
at
least
people
who
have
worked
with
diverse
communities,
and
there
has
some
credibility
because
the
thing
one
of
the
reasons
I
say
that
is
because
if
this
does
pass,
you
will
need
people
in
the
community
who
have
credibility
to
talk
about
what
this
looks
like
to
explain.
A
A
It's
going
to
be
very
difficult
to
get
it
later
and
I
see
see
senator
hardy's
hand
up
yes,
sir.
G
Thank
you,
madam
chair.
So
if,
if
I'm
understanding
this
correctly,
this
doesn't
just
affect
medicaid,
but
I
I
think
it
also
involves
insurances
and
I'm
not
sure
how
it
affects
the
erisa
plans.
But
I
think
it's
it's
bigger
than
medicaid,
and
I
I
just
want
to
make
sure
that
I'm
understanding
that
right.
J
Yes,
this
is
senator
scheible
and
you
are
correct.
This
would
not
just
affect
medicaid.
This
would
affect
all
insurance
plans
and
in
fact
I
think
we
will
have
a
couple
of
providers
on
the
line
who
are
testifying
today,
and
in
fact
I
did
want
to
let
you
know
that
the
nevada
association
of
health
plans
is
in
support
of
the
bill.
A
Okay,
so
broadcast:
let's
go
now
to
the
telephone
lines,
those
and
support,
and
we
will
have
30
minutes
for
those
in
support
three
minutes
per
person,
and
if
someone
has
already
covered
what
you
want
to
say
after
you
say
and
spell
your
name
feel
free
to
say,
ditto
that
way
we
get
more
people
who
are
able
to
come
in
and
for
those
who
think
this
is
only
something
that
happens
because
we
are
working
remotely.
A
I
would
encourage
you
to
go
back
and
look
at
any
of
the
committees
from
last
sessions
last
session,
especially
the
ones
that
I
cheered.
We
do
the
same
thing
because
we're
always
under
some
type
of
time
constraint.
So
this
is
nothing
new
for
the
remoteness
of
our
operations,
so
broadcast
30
minutes
three
minutes
per.
Thank
you.
B
B
B
C
C
C
Normalized
the
american
academy
of
pediatrics
supports
early
gender,
affirming
care,
including
social
affirmation,
access
to
mental
health
treatment,
legal
affirmation
and
when
age
deems
appropriate
medical
and
surgical
treatment,
it
is
important
to
note
that
most
treatments
recommended
for
young
people
are
completely
reversible
and
pretty
much
all
treatments
under
the
age
of
16,
and
I
state
this
in
anticipation
of
arguments
against
these
treatments
for
youth.
This
treatment
is
not
accessible
for
most
people
if
it
is
not
covered
by
health
insurance.
C
B
P
P
P
B
C
I
mentioned
this
because
it's
real
and
it's
happening
to
loved
ones,
loved
ones,
meaning
they
have
another
worry
about
finance
housing
and
healthcare.
Brexit
needs
vulnerable
groups,
require
healthcare
based
on
medical
necessity
and
must
not
be
denied
coverage
based
on
external
biases
and
discrimination.
C
Medical
providers
must
have
the
discretion
to
treat
vulnerable
patients
without
the
interference
and
bias
from
insurance
providers.
Public
and
private
insurers
currently
have
have
to
consider
I'm
sorry.
Public
and
private
insurers
currently
have
conservable
discretion
and
routinely
ignore
or
bypass
medical
expertise
and
rendering
coverage
decisions
without
adequatable
justification.
B
Q
Q
All
of
the
expenses
for
the
transition,
the
hormone
therapy
endocrinologist
visits
and
the
top
surgery
that
is
scheduled
have
been
denied
by
our
insurance.
So
we
are
in
the
lucky
position
of
being
able
to
afford
this.
Q
I
mean
we
will
go
into
some
debt
to
pay
for
it,
but
we
are
going
to
be
able
to
afford
it
and
pay
for
it
so
that
our
our
son
will
be
able
to
exist
as
a
as
a
healthy,
healthy,
individual,
healthy
man,
and
I
just
want
to
reiterate
how
important
it
is
to
get
insurance
companies
to
accept
these
kinds
of
coverages
and
to
reduce
denials,
because,
yes,
we
can
probably
fight
the
denial
we
can
try
to
go
through
legal
means,
but
again
that
throws
more
more
cost
to
us
to
get
this
procedure
covered.
Q
So
again,
please
support
bill
senate
bill
139
and
thank
you
for
your
time.
B
B
R
Good
morning
my
name
is
alby
a
lbi
smedley
s-m-e-d-l-e-y,
I'm
a
proudly
non-binary
transgender
and
asian
american
person
born
in
las
vegas.
I'm
a
ccsd
educator.
I
teach
high
school.
This
is
my
seventh
year
teaching
a
former
small
business
owner,
and
I
run
a
small
grassroots
activism
group
in
vegas
called
trans
vegas,
and
I
urge
everyone
to
support
sb,
139
and
consider
the
human
lives
of
the
bill
effects.
R
Health
care
plans
that
exclude
gender
affirmative
care
are
discriminate
discriminatory
and
dehumanizing
when
something
so
fundamental
and
so
necessary,
as
healthcare
for
basic
needs,
is
not
covered
by
your
trusted
employer.
It's
an
entirely
demoralizing
experience.
R
R
R
So
I
I
can't
stress
again
the
dehumanizing
effect
of
seeking
care
for
fundamental
health
needs
and
being
unsupported
by
your
employer,
your
insurance
or
your
government.
So
please
consider
supporting
sb139
so
that
residents
of
vegas
will
get
the
same
levels
of
care
as
everyone
else.
Since
I
have
a
second
I'd
also
like
to
say
that
well
living
your
life,
authentically
as
a
trans
person,
is
empowering
and
affirming
it.
R
It
comes
with
societal,
stigmas
judgments
and
you
know
some
inner
turmoil
so
to
suggest
that
people
would
be
willingly
going
through
those
processes
to
gain
a
system
or
something
is
it.
It
minimizes
those
experience
greatly
and
I
think
it's
a
dangerous
argument
to
make
in
the
road
to
go
down.
Thank
you
very
much.
B
Q
B
M
Good
morning,
madam
chair
members
of
the
committee,
this
is
holly
welborn,
h,
o
l,
l
y
w
e
l
b
n
policy
director
for
the
eclu
of
nevada,
testifying
and
in
strong
support
of
this
legislation.
Thank
you
to
senator
scheible
for
bringing
this
bill
forward
and
to
their
presenters
and
everyone.
Who's
testified
today
for
their
meaningful,
thoughtful
testimony.
M
The
aclu,
nationally
we've
been
successful
in
courts
across
this
country,
litigating
this
in
a
variety
of
different
states,
but
having
that
extra
protection
in
the
in
state
laws
insulates
us
from
any
future
changes
at
the
supreme
court
level.
Should
that
happen.
I
am
incredibly
grateful
for
this
and
I
also
want
to
take
a
liberty
to
say
that
you
know
my
soon-to-be
brother-in-law
he's
just
finished
transition,
and
this
is
a
process
that
takes
years
it's
grueling.
M
B
B
C
Good
morning,
madam
chair
and
members
of
the
committee
for
the
record,
chelsea
capper
that
c-h-e-l-s-e-a
last
name
c-a-p-u-r-r-o
here
this
morning
on
behalf
of
the
health
services
coalition.
I
think
we
just
first
want
to
start
by
thanking
the
sponsor
and
everyone
working
on
this
bill.
Everyone's
been
great
to
work
with
we're
here
in
support,
but
are
still
working
through
an
amendment
with
the
senator.
C
B
C
Hello,
my
name
is
sai
burnaby
s
y
last
name
b-e-r-n-a-b-e-I.
I
am
a
gender
justice
nevada.
We
are
a
local
advocacy
group
for
trans
non-binary,
gender
non-conforming
people
in
nevada.
I
myself
am
a
trans
and
non-binary
person.
I
personally
paid
out
of
pocket
close
to
nine
thousand
dollars
for
my
recent
top
surgery,
because
I
actually
I
just
didn't-
want
to
go
through
the
mess
of
dealing
with
private
insurance
or
other
pe,
so
I
paid
out
of
pocket.
I
want
folks
to
know
this
is
not
something
that
trans
and
gender
non-conforming
people
do
lightly.
C
It
is
an
act
of
bravery
to
begin
social
and
medically
transitioning.
I
very
much
appreciate
the
the
work
that
senator
scheible
and
that
book
have
done
in
bringing
this
to
your
attention.
Personally,
I've
been
working
over
20
years
in
this
community.
I
have
seen
depression,
self-harm
and
yes,
suicide.
One
gender
from
procedures
and
hormone
therapy
are
not
covered
by
insurance
and
making
health
care
not
as
accessible
increases.
Those
things
living
authentically
is
the
most
important
thing
that
we
can
do.
C
Gender
dysphoria
is
real
and
for
those
who
might
not
understand
the
experience
of
trans
folks
or
what
gender
dysphoria
means,
I
would
invite
you
to
any
of
our
trainings
or
any
other
discussions
that
we
have
talking
about
the
transgender
non-conforming
community.
Again
I
work
with
gender
justice
nevada.
You
can
reach
out
to
us
or
you
can
email
me
or
you
can
call
me
702-324-1271
and
thank
you
very
much.
We
very
much
support
this
bill
and
looking
forward
to
how
much
this
will
help
our
community.
Thank
you.
B
C
Good
morning,
sarah
spearman
and
members
of
the
committee
for
the
record,
this
is
nicole
n-I-c-o-l-e
willis,
w-I-l-l-I-s,
hyphen
grimes
gri
g-r-I-m-e-s,
with
the
for
our
group,
I'm
here
speaking
on
behalf
of
silver
summit
health
plan,
and
we
just
wanted
to
be
on
the
record
in
support
of
sb-139.
Thank.
C
B
B
C
H-O-L-D-R-E-D-G-E,
thank
you,
madam
chair
members
of
the
committee,
I'm
a
cis
woman
of
color
mother
of
two
10-year
resident
of
nevada,
clark,
county
and
a
ccsd
parent
volunteer
and
an
organizer.
C
I
I'm
not
trans
or
gender,
diverse,
gay
or
intersex,
but
I
know
my
life
is
better
because
of
transgender
non-conforming
members
of
or
gender
non-conforming
members
of
my
community.
I
am
a
human
being
just
like
my
trans
brothers
and
sisters.
Trans
folk
are
worthy
human
beings,
just
as
we
all
are.
They
deserve
the
equity.
Many
of
us,
even
a
cis
black
woman,
are
afforded
more
often
than
they
are.
F
C
C
B
F
Thank
you,
so
the
asme
retirees
most
of
whom,
if
not
all,
are
members
of
the
pebb
program
in
one
form
or
another,
either
as
retirees
on
the
medicare
exchange
or
non-medicare
retirees
in
the
regular
peb
program.
We
are
in
support
of
this
bill.
Briefly,
I
would
like
to
note
that
it
was
discussed
yesterday
at
the
pebb
board's
legislative
tracking
board
meeting
that's
a
special
meeting.
They
just
have
during
the
sessions
where
they
go
through
the
bills.
F
They
are
concerned
about
the
only
discussion
around
this
issue
of
of
sb
139
regarded
costs,
and
there
was
certainly
some
robust
concern
debate
about
the
initial
findings
from
the
program.
It
was
a
modest
cost
under
any
circumstances,
but
even
that
may
be
subject
to
some
revision,
as
we
in
the
public.
Employee
coalition
asked
for
further
clarification
on
that
cost,
feeling
that,
along
with
the
subject
matter,
experts
who
testified
yesterday
that
that
cost
was
somewhat
exaggerated
for
the
bill.
F
F
That
would
add
these
additional
costs
so
these
again
globally
our
services
already
covered
and
then
finally,
I'd
like
to
add,
on
a
personal
note
that
just
in
the
last
10
days,
I
myself
got
a
phone
call
from
a
loved
one
whose
family
is
going
through
treatment
for
one
of
their
individuals
for
gender
dysphoria
and
the
reason
they
called
me.
F
A
fifth
older
woman
was
because
I
had
had
a
medically
required
mastectomy
for
cancer
six
years
ago
and
they
wanted
to
talk
to
me
about
the
procedure,
and
I
can't
stress
enough
that
having
a
good
treatment
plan,
whatever
your
life
situation
is,
is
really
really
important
to
somebody's
recovery
and
and
in
this
context,
to
someone's
transition
into
a
happy
and
healthy
and
meaningful
life
in
our
society.
F
So
on
a
personal
note,
not
speaking
for
the
ask
me
retirees,
I
am
very
much
in
support
of
this
bill
and
I
was
very
touched
by
the
phone
call.
I
got
asking
me
important
questions
nerve
damage.
B
B
R
A
Right,
we
will
move
to
those
in
opposition,
same
thing,
30
minutes
three
minutes
per.
B
C
C
Favor,
oh
thank
you,
chair
spearman.
Thank
you
for
this
time.
For
the
record,
my
name
is
jasmine,
margarita
tobin
last
name
kias
and
tom.
Oh
as
an
oscar,
be
as
a
boy,
oh
as
an
offer,
and
as
a
nancy,
I
am
an
organizer
with
planned
parenthood
votes,
nevada,
planned
parenthood
votes,
nevada
is
in
favor
of
sb.
139.
C
Access
to
health
care
is
a
critical
issue.
Many
lgbtq
plus
people,
especially
transgender
two-spirit,
intersex
non-binary
and
gender
non-conforming
individuals,
have
long
been
denied
their
rights
for
medically
necessary
treatment.
Despite
the
aca
mandating
equal
coverage
for
transgender
affirming
procedures,
their
identity
does
not
exempt
them
from
the
necessity
of
health
care.
It
instead
exacerbates
the
barriers
to
receiving
health
care.
Trans
non-binary
and
gender
non-conforming
folks
are
subject
to
greater
hurdles
to
health
care,
including,
and
especially
those
who
are
low-income,
unhoused
living
with
chronic
illness
or
have
pre-existing
conditions.
C
Vulnerable
groups
require
health
care
based
on
medical
necessity
and
must
not
be
denied
based
on
external
biases
and
discrimination.
Sb
139
would
address
and
expand
health
care
access
and
disparity
for
nevadans
and
create
a
more
equitable
health
care
system.
This
bill
would
quite
literally
save
lives.
Thank
you
again
for
your
time.
B
B
B
B
D
This
is
josh
foley,
jlsh
foli,
I'm
the
lion
county
comptroller.
I
apologize.
It
takes
a
while
for
this
to
to
register
that
I'm
unmuted,
but
I
think
I'm
live
now.
I'm
speaking
against
this.
For
a
couple
of
reasons,
number
one,
I
believe
from
a
fiscal
standpoint.
That's
all
I'm
going
to
address
that
this
is
one
of
the
more
expansive
bills
or
laws
that's
proposed
across
the
nation.
D
Just
so
you're
aware
what
that
does
to
insurance
rates-
and
I
know
when
you
take
a
look
at
it
as
a
percentage
of
a
very
large
plan.
It
can
be
a
very
small
percentage,
some
of
the
things
that
we're
talking
about
here,
but
when
you
take
a
very
small
plan
as
an
example
in
lyon
county
when
we
had
a
single
person
go
on
humera,
which
is
a
common
prescription.
That's
out
there.
We
had
a
significant
increase
in
our
insurance
from
year
to
year.
D
D
Our
rates
are
going
up,
another
10
percent
this
year.
That's
what
the
existing
coverage
is.
So
I
know
that
this
is
a
very
challenging
plan
or
bill
to
get
your
arms
around
what's
medically
necessary
and
what
is
not,
and
people
taking
advantage
of,
as
we've
had
testimony
my
only
two
cents
worth
on
this
is
it
has
a
disproportionate
impact
on
smaller
health
insurance
plans
for
smaller
entities
out
there,
and
if
we
can
keep
the
language
to
where
it
is
really
just
to
what
is
medically
necessary
and
not
be
expanding
significantly.
D
B
A
And
so
we
will
open
it
up
to
those
in
neutral
and
just
want
to
clarify.
There
was
a
person
at
the
beginning
who
said
that
they
signed
up
for
in
support
but
weren't
able
to
get
in.
We
still
had
eight
minutes
left
on
that
and
that's
the
only
reason
I
allowed
that
testimony
to
be
heard.
So
we
still
had
eight
minutes
on
that.
So
I
wanted
to
clarify
that.
So,
let's
go
now
to
those
who
are
speaking
in
neutral.
Please.
N
Morning,
sheriff's,
chairman
and
committee
again,
my
name
is
dwayne
young
for
the
record.
I
am
the
deputy
administrator
for
the
division
of
healthcare
financing
policy.
I
won't
be
labored.
The
committee,
as
I
have
provided
some
clarification
earlier,
but
I
do
want
to
just
speak
to
the
most
immediate,
is
that
nevada
medicaid
has
probably
covered
these
services
since
2017.
N
There
is
some
language
in
the
bill
which
there
are
providers
that
we
cover,
but
it
says
without
without
limitation,
and
so
those
providers
perform
other
services
that
are
not
currently
covered
in
our
policy,
as
well
as
some
providers
such
as
voice
therapists
that
are
not
currently
in
our
policy
that
have
been
added
to
the
language
of
this
bill.
We
have
worked
with
senator
scheible
on
some
potential
language
and
we're
also
aware
by
I'm
here
representing
medicaid.
N
We
know
that
other
state
agencies
such
as
pebb,
builds
their
policies
based
off
the
coverage
of
medicaid,
and
so
we
have
been
communicating
with
them
as
well,
and
so
we
recognize
that
this
does
have
a
small
fiscal
note
of
less
than
a
million
dollars,
total
computable
and
exactly
214
000
over
the
biennium
and
state
general
funds.
N
And
so
we
look
forward
to
continue
working
with
the
senator
and
all
those
who
have
spoke
today
and
support
to
get
this
into
a
place
that
aligns
with
policy,
but
also
the
objectives
to
provide
equitable
coverage
for
these
all
populations
across
medicaid.
Thank
you.
B
B
Q
T-O-M-D-L-A-R-K
here,
on
behalf
of
the
nevada
association
of
health
plans,
to
reiterate
the
sponsors
of
their
schedule
at
the
beginning
of
the
hearing,
we
are
continuing
to
work
with
her
on
this
important
legislation.
Q
We
are
in
the
mutual
position
and
hope
that
we
can
work
with
the
senator
and
with
the
other
stakeholders
to
come
up
with
amendments
that
can
make
it
a
piece
of
legislation
we
can
all
support.
Thank
you,
madam
chair.
B
M
C-R-I-S-P-I-N-A
hernandez
h-e-r-n-a-n-d-e-z
and
just
calling
in
for
support
for
the
bill.
A
Thank
you.
Any
of
the
committee
members
have
additional
questions.
A
I
don't
see
any
hands
going
up.
Senator
scheible,
just
a
couple
of
things
that
I
heard
one
of
the
gentleman
who
was
in
opposition
mentioned
increased
insurance
rates,
so,
if
possible-
and
I've
heard
heard
what
mr
young
had
to
say,
but
perhaps
you
all
might
be
able
to
get
some
type
of
actuarial
component
of
this.
That
shows
this
is
what
it
is.
A
This
is
what
it
would
be,
and
if
and
and
and
and
try
to
get
that
to
the
committee
members,
because
I
think
that's
a,
I
think-
that's
a
valid
valid
point.
So
if
you
could
get
some
type
of
actuarial
comparison,
that
would
that
would
be
helpful
want
to
mention.
I
think
it
might
be
the
same
gentleman
that
costly
for
smaller
companies
that
have
insurance
so
may
consider
some
type
of
a
floor.
A
As
part
of
the
part
of
the
negotiations-
and
I
just
want
to
say
that
there
there
may
be
some
who
who
have
listened
to
testifiers
on
this
bill
and
listen
to
the
presentation
of
the
bill.
A
The
psychological
abuse
that
transgender
people
go
through
is
not
real,
so
I'm
just
going
to
share
with
you
something
that
happened
a
couple
years
ago
when
I
was
called
by
an
individual,
a
pastor
who
called
me
because
they
had
one
of
their
parishioners
in
a
rehabilitation
center
and
the
person
was
recovering
from
being
shot.
It
was
hate
crime
and
the
the
place
that
the
person
was.
A
Although
this
person
had
the
new
name
and
the
new
gender
on
all
the
records,
the
place
that
the
person
was
refused
to
do
that,
because
it
was
quote
they
didn't
like
it,
they
didn't
think
that
that
was
correct.
So
they
didn't,
they
didn't
treat
this
person
in
accordance
with
their
identity
with
their
gender
identity.
A
There
were
some
medical
people
who
refused
to
change
the
band-aids
or
the
bandages
on
this
person's
wound
and
the
person's
mother
had
to
fly
in
so
that
they
could
get
the
help
that
they
needed.
They
called
me.
I
immediately
called
mr
whitley
and,
to
his
credit
in
less
than
24
hours,
that
particular
facility,
which
was
receiving
medicaid
funds,
understood
that
what
they
were
doing
was
not
correct,
so
so
the
pain
and
the
trauma
of
being
ridiculed
of
being
ignored
or
whatever
for
for
transgender
people
who
are
seeking
some
type
of
solace.
A
That
is
real.
Having
said
that,
senator
scheibel,
do
you
have
any
closing
remarks?
It
is
now
day
three
of
the
hearing.
J
It
does
feel
like
day
three
of
the
hearing.
I
I
do
want
to
thank
everybody
for
for
their
patience
and
for
hearing
all
this
testimony.
I
have
to
make
one
small
clarification
on
the
record
that
the
nevada
association
of
health
plans
is
in
neutral.
We
are
working
on
getting
them
to
support
and
I'm
very
confident
that
we
will
be
able
to
do
that.
And
finally,
I
just
want
to
say
that
I
think
you
have
heard
some
very
compelling
testimony
today.
J
I'd
like
to
remind
the
committee
that
when
we
don't
treat
gender
dysphoria,
we
end
up
treating
the
symptoms
of
it
and
in
treating
people
for
other
mental
health
crises,
treating
people
for
suicidal
ideations
and
in
the
very
worst
cases
we
end
up
paying
the
completely
incompetable
cost
of
suicide
of
young
people,
adults,
old
people-
anybody
can
really
be-
can
be
affected
by
gender
dysphoria
and
the
effects
of
not
having
it
properly
treated.
A
Thank
you,
senator
and
absent
any
additional
questions
or
comments
from
committee
members.
I
will
now
close
the
hearing
on
senate
bill
139
and
we
will
open
it
up
now
for
public
comment.
Public
comment,
those
who
are
on
the
cell
phone
and
would
like
to
comment
broadcast,
take
a
couple
minutes.
Let
you
get
set
up
and
then
there's.
H
H
A
My
bad,
we
did
well,
it's
been
so
long.
It
had
been
196..
I
am
so
sorry
so
we'll
come
back
to
public
comment
and,
let's
open
it
up
now
for
senate
bill
196
senate
bill
196..
A
Those
who
are
here
to
present
on
that
are
still
here.
You're
invited
to
go
first
and
I'm
sorry,
that's
that's
one
of
our
committee
members
senator
lang.
Please
forgive
me.
Senator
196
prohibits
the
performance
of
pelvic
examination
in
certain
circumstances,
so
senator
lane,
please
begin
with
you.
T
Thank
you,
chair,
spearman,
we're
all
good,
I'm
here
to
present
senate
level
196..
It
prohibits
the
performance
of
a
pelvic
examination
in
certain
circumstances.
T
Good
morning
cheers
spearman
and
the
committee
I'm
roberta
lange
representing
senate
district
7
in
clark
county.
Thank
you
for
the
opportunity
to
present
senate
bill
196
a
bill
that
seeks
to
prohibit
health
care
providers
from
conducting
public
examinations
on
patients
without
their
informed
consent.
T
A
little
bit
of
background
health
care
providers
are
required
to
obtain
informed
consent
from
patients
to
provide
medical
treatment.
However,
currently
state
law
does
not
prohibit
providers
or
medical
students
practicing
under
their
supervision,
from
performing
pelvic
examinations
on
anxiety
and
unconscious
female
patients,
and
while
it
may
be
surprising,
this
appears
to
be
a
common
practice.
T
In
a
new
york
times,
article
published
on
february
17
2020,
a
nurse
in
arizona,
outlines
her
unsettling
experience.
After
being
admitted
for
stomach
surgery.
The
nurse
who
has
a
history
of
sexual
abuse
reported
having
panic
attacks
and
triggering
traumatic
memories
after
she
learned
that
a
resident
conducted
a
public
exam.
T
In
fact,
the
issue
is
so
pervasive
that
women
have
begun
sharing
their
stories
with
the
hashtag
me
to
pelvic,
while
medical
teaching
is
crucial
in
training,
medical
professionals
to
identify
normal
and
abnormal
anatomy
is
necessary.
Some
exams
by
their
very
nature,
are
intimate
and
invasive.
A
study
published
in
the
lancet
found
that
100
of
women
reported.
T
That
quote,
they
would
prefer
to
be
asked
before
their
pelvis
is
used
as
a
teaching
tool
quote
the
pelvic
exam
performed
without
a
woman's
consent
in
any
other
context,
is
considered
sexual
assault
senate
bill
196
does
not
prohibit
performing
public
examinations
when
they
are
necessary,
nor
does
it
prohibit
instruction
of
medical
students
to
perform
this
exam.
Instead,
the
bill
requires
obtaining
the
informed
consent
of
a
patient
section.
One
prohibits
health
care
providers
from
performing
and
supervising
examinations.
They
are
not
appropriately
licensed,
certified
or
registered
to
perform
and
that
are
not
within
their
scope
of
practice.
T
Section
one
also
prohibits
health
care
providers
from
performing
or
supervising
public
examination
unanswered,
an
unconscious
patient
without
first
obtaining
the
patient's
informed
consent
unless
number
one.
The
public
examination
is
within
the
scope
of
a
surgical
procedure
or
diagnostic
examination
to
which
the
patient
has
given
informed
consent.
T
These
unlicensed
individuals
are
also
prohibited
from
supervising
the
performance
of
a
public
examination
if
conducted
by
a
person
outside
the
immediate
president
presence
of
his
or
her
supervising
provider
of
health
care.
Finally,
in
sections
2
through
12,
it
authorizes
the
imposition
of
professional
discipline
or
denial
of
a
license
or
certificate
where
providers
of
health
care
who
perform
or
supervise
a
public
examination
when
prohibited.
T
T
Currently,
15
states
have
banned
unauthorized
public
examinations
and
seven
seven
states
have
introduced
similar
language
in
2021..
On
one
final
note,
I'm
happy
to
have
worked
with
former
senator
ivana
gonzalez
on
this
legislation
and
senator
joe
hardy.
I
hope
you'll
all
agree
with
us
that
codifying
and
statute
the
requirement
to
obtain
a
patient's
informed
consent
is
vitally
important
for
women
in
nevada
and
then
chair
spearman.
I
have
a
letter
from
the
ladies
who
asked
us
to
bring
this
forward.
T
If
I
could
read
that
letter,
it
says
dear
senators,
lange,
hardy
hammond,
schleibel,
demate
harris
or
in
sean
down
cert.
We
are
writing
to
express
our
strong
support
for
senate
bill
196
and
to
thank
the
sponsors
and
co-sponsors
of
the
bill.
We
first
heard
of
the
practice
of
medical
providers
and
medical
students
conducting
pelvic
examinations
on
women
under
anesthesia
without
their
consent
in
2019.
T
It
was
hard
to
believe
that
this
practice
is
legal
in
most
states
we
have
contact,
we
contacted
senator
ivana
kanthal
and
asked
her
to
introduce
the
bill
that
would
prohibit
this
practice
in
nevada
under
anesthesia.
A
patient
no
longer
has
control
over
what
happens
with
their
body.
While
we
understand
that
the
pelvic
examination
is
a
critical
tool
for
diagnosis
of
women's
health
conditions
and
an
important
skill
for
students
to
master
before
coming
physicians,
it
becomes
an
intrusive
exam
when,
if
not
medically
necessary,
performed
on
an
unsized
patient.
T
Without
the
expressed
consent,
patients
should
have
the
freedom
to
decide
from
whom
they
receive
treatment
and
what
aspects
of
their
medical
care
will
be
performed
by
a
student
or
student,
particularly
if
they
were
not
awake
during
the
treatment.
This
legislation
improves
the
process
for
obtaining
documenting
and
ensuring
consent
for
examination
under
anesthesia
and
supports
patients.
Freedom
to
make
informed
decisions
about
their
medical
treatment.
Thank
you
for
supporting
this
informed
legislation,
christine
smith
and
terry
greenman.
T
I
also
received
a
note
from
susan
fisher.
T
A
Thank
you
senator
lang
and
just
for
clarification.
The
letters
that
you
read
were
part
of
your
presentation,
correct.
A
Okay,
all
right
do
you
have
anyone
else
presenting
with
you,
no
ma'am,
okay,
so
I'll
open
it
up
now
to
questions
I
think
I
saw
and
then
senator
pickard.
O
Thank
you,
man,
I'm
sure
I
appreciate
this.
I
think
this
is
a
good
bill
to
try
to
address
the
issues
we.
Unfortunately
in
person,
city
area
back
in
the
late
90s
had
a
doctor.
That
was
a
dentist
who
is
terrible
anyway.
So
in
that
respect,
will
this
cover
all
actions
or
is
it
just
dealing?
Does
it
help
strengthen
or
enhance
the
problems
that
are
occurring
with
in
this
realm?
You
know,
I
don't
know
how
to
say
this.
I
apologize
dealing
with
just
public
exams
or
is
it
other
will
help
curtail
other
bad
actions.
A
I
Thank
you
man,
I'm
sure
I
you
know,
I'm
gonna
ask
the
same
question
I
asked
in
the
last
hearing.
Is
this
not
already
law?
I
know
there's
there
was
the
comment
that
made
that
it's
legal
in
many
states,
but
I
seem
to
remember
many
cases,
even
those
that
reach
the
nevada
supreme
court
that
have
held
that
this
sort
of
thing
was
violative
of
of
the
law.
So
this
is
not
currently
illegal.
T
Thank
you
senator
pickard,
currently
under
in
teaching
hospitals.
This
is
a
practice
that
seems
to
be
done
all
the
time
and
is
legal
under
a
teaching
hospital,
and
so
what
this
bill
is
trying
to
do
is
to
say
in
nevada.
This
is
not
okay
and
that
you
must
have
the
consent
of
the
woman
first
and
that
you,
you
know
you,
and
there
are,
I
listed
the
three
circumstances
of
which
it
would
be
okay,
but
yeah.
So
right
now
it
is
legal
for
people
to
do
it.
T
We
want
our
doctors
and
and
student
doctors,
and
we
want
to
make
this
a
practice
where
you
have
to
get
consent.
It's
just
it's,
not
okay,
just
to
do
it
on
your
own,
you
know.
Do
it
no
matter
what
you
have
to
get
consent.
First,.
I
All
right,
I
appreciate
that
and
and
since
dr
hardy
works
at
a
teaching
at
a
medical
school,
it
would
be
interesting
for
me
to
get
his
take
on
this.
I
know
that
one
time
I
underwent
a
procedure
at
a
teaching
hospital
and
I
had
to
fi
or
I
had
to
sign
an
informed
consent
form
that
allowed
for
students
to
be
present
during
the
procedure
which
I
did.
I
I
didn't
have
a
problem
with
it,
but
I
wonder
if
this
then
needs
to
be
specific
as
to
those
informed
consents
that
they
have
to
specifically
address
the
issue,
as
opposed
to
a
blanket
in
informed
consent
form
similar
to
the
one
I
seem
to
recall
signing
that
might
be
something
to
address,
because
my
fear
is
if
the
goal
of
this
bill
is
to
make
the
exam
specifically
require
the
informed
consent
that
it.
I
A
Thank
you
senator
hardy
and,
I
believe
vice
chair
neil
has
a
couple
questions.
G
Thank
you,
madam
chair.
Obviously
the
focus
is
taking
advantage
of
people
who
are
anesthetized
and
people
who
are
anesthetized
cannot
give
permission,
and
so
it
becomes
somewhat
problematic
getting
permission
from
an
anesthetized
person.
I
would
like
to
clarify
that
medical
residents
are
not
students,
they
are
physicians,
so
they
are
in
a
in
a
different
system,
but
bottom
line
is
dentists,
have
no
business
doing
pelvic
exams,
no
matter
how
many
forms
they
sign?
It's
okay
and
dentists
use
laughing
gas,
and
so
they
they
would
get
into
big
trouble
and
appropriately.
G
So
if
they
so
did,
when
the
physician,
who
is
mentoring,
teaching
precepting
a
medical
student,
even
whether
the
medical
student
is
there
or
not,
the
physician
practice
is
always
has
someone
with
the
physician
whether
they
be
male
or
female,
so
that
the
person
is
not
intimidated
by
one
person.
G
G
You
know
that
you're
going
to
do
a
pelvic
exam
may
be
a
little
redundant
because
in
the
process
of
the
office
visit,
because
these
these
are
in
offices
not
in
surgical
suites,
where
somebody
is
anesthetized
unless
they're
undergoing
surgery
and
you're
looking
for
a
a
mass
after
you've
been
doing
your
laparoscopic
surgery,
and
you
want
to
figure
out,
you
know
how
extensive
that
is,
so
the
things
that
you
sign
for
surgery
allow
some
flexibility.
G
G
You
have
nurses,
you
have
anesthesiologists,
you
have
the
doctors,
so
this
is
trying
to
get
at
a
specific
problem,
and
I
think
this
bill
gets
at
a
specific
problem
and
makes
the
person
who
crosses
this
liable
for
is
her
very
license,
and
I
think
that
there
can
hardly
be
anything
more
motivating
than
you'll,
never
be
a
doctor
again
in
your
whole
life.
G
If
you
do
this,
so
it's
I
think
it's
something
that
is
very
respectful
of
the
woman,
whoever
the
woman
may
be
that
we
make
sure
that
she
not
only
awake,
but
she
knows
what
doctors
are
doing
and
if
it's
in
a
teaching
setting
that
there
will
be
a
medical
student
or
a
resident,
that's
participating
in
this
care.
I
don't
know
if
that's
too
verbose
or
if
it
gets
to
your
question,
but
that's
the
practice
that
happened.
I
Well,
I
appreciate
that
I
I
was
thinking
more
along
the
lines
of
a
you
know.
If
we
had,
you
always
do
the
informed
consent
at
the
beginning,
and
you
know,
while
the
patient
is
awake,
and
my
concern
is
if
we
allow
for
a
blanket
informed
consent
form
without
specifying
that
this
would
require
separate
consent
within
that
form,
it
might
provide
a
loophole
that
we
want
to
avoid.
So
that
was
that
was
it,
but
thank
you.
I
do
appreciate
that
response.
E
Thank
you,
madam
chair,
so
I
had
a
question
on
section
two.
So
it's
section
two
line
37
where
basically
it
it
comes
under,
you
know
grounds
for
disciplinary
action,
and
so
it
said
or
supervising
the
performance.
And
so
that's
that's.
The
part
that
I
want
to
try
to
understand
is:
are
we
allowing
because
I
was
listening
to
senator
hardy,
and
so
this
is
what
I
don't
know
the
answer
to
are
residents?
E
Are
residents
considered
to
be,
do
they
get
registered
or
are
they
licensed
and
is
this
contemplating
that
they
have
a
supervising
doctor
and
then
the
resident?
Is
there
and
then
they're
trying
to
learn
or
understand
like
fibroids,
I'm
because
it
says
or
supervising
so
I
I'm
just
trying
to
get
an
understanding
on
this
bill.
G
Appreciate
it.
Thank
you,
madam
chair.
Thank
you.
Senator
neil,
the
resident
is
somebody
who
has
gone
through
medical
school
in
the
last
two
years
of
medical
school
have
been
what
we
call
clinical
rotations,
one
of
at
least
one
of
which
has
been
in
the
field
of
gynecology
obstetrics,
and
so
you
as
a
medical
school.
G
When
you
come
out,
you
know
how
to
do
a
pelvic
exam
and
as
a
resident
you
are
a
physician,
you
are
an
md
or
a
do
and
you
then
in
residency
are
in
a
position
to
be
supervised,
but
not
necessarily
doing
the
same
pelvic
exam
that
the
attending
what
we
call
the
attending
physician
would
do
so
you
don't
have
to
have
two
people
doing
the
exam
to
ascertain
what
is
happening
now.
It
may
be
that
the
resident
will
say
you
know.
I
noticed
something
that
I'm
not
sure
about,
and
the
attending
physician
will
say.
G
Okay,
show
me,
or
let
me
examine
the
patient
so,
but
the
resident
by
the
time
they
get
into
residency,
has
become
maybe
not
as
good
as
estimating
the
size,
maybe
of
a
six-week
uterus,
but
they
are
able
to
say
this
is
larger
than
I
thought
it
would
be
if
they
weren't
pregnant,
telling
the
difference
between
a
six-week,
uterus
and
an
eight-week
uterus
may
be
a
little
more
refined
than
a
medical
student
coming
out
of
medical
school
who's.
G
Now
a
resident
would
be
able
to
tell,
but
the
the
resident
is
a
physician
and
is
licensed
as
a
resident
position
and
then
at
some
point
in
the
residency
some
states
allow
for
a
resident
to
have
a
unlimited
license,
which
is
what
I
did
after
my
second
year,
residency
that
was
in
arizona.
G
E
A
Thank
you
senator
hardy.
Is
that
your
hand
up
or
again
or
yes,.
G
A
Okay,
so
with
that
we'll
go
into
those
who
are
in
support,
it'll
be
30
minutes
and
three
minutes
per
person
so
broadcast
it's
up
to
you
now.
B
S
S-E-R-E-N-A-E-V-A-N-F
and
I'm
the
policy
specialist
for
the
nevada
coalitions
and
domestic
and
sexual
violence,
we
want
to
applaud
senator
senator
lang
and
all
of
the
co-sponsors
for
sb
196,
and
we
are
here
in
support
of
the
bill.
The
coalition
has
been
working
with
sexual
assault,
advocates
and
programs
throughout
the
state
to
examine
nevada
sexual
assault
and
associated
statutes
and
consent
is
an
important
part
of
that
work,
specifically
in
the
context
of
consent.
S
This
ongoing
work
group
has
had
conversations
around
medical
consent
and
the
unfortunate
victimization
that
occurs
through
uninformed
pelvic
exams,
pelvic
exams,
are
intimate
invasive
and
can
be
very
uncomfortable
and
have
lasting
effects.
Every
individual
should
have
the
right
to
give
informed
consent
to
what
happens
to
their
body
during
any
medical
procedure.
Consent
to
one
medical
procedure
does
not
mean
consent
to
all
medical
procedures,
and
many
individuals
may
not
be
comfortable
being
used
for
learning
purposes.
S
S
It
should
not
be
necessary
to
have
to
enact
protections
to
prevent
patients
from
becoming
victims
of
sexual
impropriety
or
assault,
but
unfortunately
that
is
the
reality
of
the
world.
We
live
in
patients,
athletes
and
others
are
at
risk
not
only
for
medical
proceed
providers,
excuse
me,
but
also
from
physical
therapists,
coach,
coaches
and
others
in
whom
they
place
trust.
Everyone
should
feel
safe
and
empowered
and
seeking
medical
care,
and
we
must
not
allow
providers
to
take
advantage
of
vulnerable
patients.
S
B
C
C
B
B
B
B
C
C
I
just
wanted
to
in
neutral
just
wanted
to
verify
in
conversations,
hopefully
with
senator
lang,
that
this
bill
does
not
impede
the
ability
of
graduate
level
occupational
therapists
to
get
an
additional
certification
in
pelvic
evaluation,
and
this
is
because
the
bill
amends
chapter
640a.
B
B
G
A
So
miss
spells
may
not
be
on
right
now.
She
may
have
hung
up
senator
hardy.
Can
you
follow
up
with
her
offline
and
and
then
bring
the
answer
back
to
us
and
perhaps
misspells?
If
you're
still
listening,
you
can
provide
a
written
response
so
that
other
committee
members
will
know
the
answer
and
we
can
post
it.
As
part
of
part
of
the
discussion
is
bill.
T
Thank
you,
chair
experiment.
I
thank
you
all
for
considering
this,
though
I
think
it's
really
important.
Our
a
woman's
body
is
her
own
and
she
should
have
the
first
right
to
be
able
to
say
I
do
or
don't
want
a
public
exam,
and
so
I
think,
as
was
mentioned
earlier,
this
is
a
great
first
step
in
creating
something
in
nevada
statute
that
deals
with
this
issue,
and
so
I
look
forward
to
working
with
all
of
you
and
getting
this
out
of
committee
and
passing
on
to
the
assembly
thanks.
So
much.
A
Thank
you,
and
with
that
we
will
close
the
hearing
on
senate
bill
196
and
now
we
will
go
to
public.
H
100,
I'm
sure
this
is
my
greyhound
community
policy
analyst.
Yes,
we
have
the
amendment,
it
was
emailed
to
each
of
the
members
and
it
is
now
available
on
nellis.
A
Okay,
so
then,
why
don't
we
go
on
and
work
session
senate
bill
100
before
we
go
to
the
public
comment,
senator
serious
gangster
she's
still
with
us.
H
Okay,
thank
you
ma'am
chair.
I
will,
let's
set
our
services
I'll
run
through
the
workstation
document,
and
then
I
can.
I
include
the
the
additional
amendment
and,
if
there's
any
questions,
we
can
follow
up
from
the
record
says
our
mega
grejo
community
policy,
analyst
senate
bill
100
is
sponsored
by
senator
stevers
ganzar
and
it
was
heard
on
march
5th,
2021
senate
bill
100
enacts
the
physical
therapy,
licensure
compact,
and
there
were
amendments
provided
during
the
the
hearing
of
this
bill
by
nina
laxal
and
they're
attached
to
this.
H
H
The
proponents
of
this
bill
noted
that
physical
therapists
granted
compact
privilege
do
not
receive
a
formal
certificate
or
document,
and
the
last
amendment,
and
this
work
session
document
is
to
amend
subsection
five
of
section
four
to
delete
the
authorization
of
for
the
board
to
charge
a
fee
to
change
it,
a
name
in
the
written
authorization
as
the
board
will
not
be
providing
that
authorization
and
the
amendment
that
was
submitted
today,
that
is
on
dallas.
An
email
to
the
committee.
H
Members
is
an
amendment
to
section
two
of
the
bill,
which
is
the
physical
therapy
compact
article,
seven
section
seven
and
the
amendment
will
include
the
addition
of
language
that
nothing
in
this
chapter
provides
immunity
from
civil
or
criminal
liability
for
any
act
or
omission
resulting
from
the
negligent
conduct
or
intentional
misconduct
by
any
licensee
physical
therapist
or
a
physical
therapist
assistant
and
man.
I'm
sure.
That's
all
the
amendments.
O
Hey
madam
chair,
I
appreciate
it
and
I
just
wanted
to
make
sure
that
the
sponsor
is
okay
with
the
amendment
and
in
that
respect
I
I
have
no
problem
supporting
it.
It
seems
a
reasonable
amendment.
I
am
rather
troubled
by
the
lateness
of
this
amendment.
I
hope
this
has
not
become
a
common
practice
of
individuals
to
give
amendments
at
such
a
late
state
to
the
sponsor.
I
find
it
very
problematic
this
occurred.
I
don't
necessarily
have
a
problem
with
amendment,
but
just
in
the
procedure
that
was
brought
forth.
C
Record
senator
heidi.
C
A
Thank
you,
you
know
and
senator
my
friend,
my
chime
in
they
contacted
me.
I
know
that
they
were
working
on
some
language
and
I
think
senator
stevens
cancer
said
that
answered
one
of
the
questions
when
we
heard
the
bill
about
what
that
would
look
like
in
terms
of
the
qualifications,
so
they
called
me
yesterday
and
said
that
they
had
come
to
a
kumbaya
and
we
just
needed
to
get
so.
I
asked
just
to
get
the
amendment.
So
so
that's
that's
what
happened.
A
She
was
working
with
with
the
stakeholders
to
make
sure
she
answered
that
question
about
the
language.
O
I
appreciate
that
chairman,
if
there,
whenever
there
is
the
appropriate
time,
I
would
recommend,
amend,
amend
your
pass
with
all
the
recorded
amendments.
I
I
do
still
believe,
though,
that
anyone
that
actually
proposes
the
amendment
after
the
committee
starts
should
be
admonished
and
because
this
didn't
necessarily
come
from
the
sponsor
it
came
from
an
outside
source
and
while
the
amendment
is
agreeable
and
is
not
problematic,
it's
just
the
concept
of
the
process
that
bothers
me.
I
Thank
you,
madam
chair.
I
I
agree
wholeheartedly
with
senator
suttlemaire
as
to
process.
I
just
as
as
I
got
this,
I
was
expecting
something
fairly
significant
and
when
we're
talking
about
section
7
we're
talking
about
qualified
immunity
from
activities
it's
within
the
scope
of
the
commission,
employment
duties
or
responsibilities,
I
don't
even
see
how
this
is
necessary
or
frankly,
germaine
to
this
section.
I
So
I'm
not
going
to
ask
senator
sievers
gansard
for
response
as
much
as
if
the
proponent
of
the
amendment
would
please
explain,
you
know,
put
something
in
writing.
We
can
put
it
in
the
record
as
to
why
they
think
this
is
necessary,
particularly
given
the
amount
of
time
this
bill
has
been
in
process
and
and
the
the
custom
that
we
have
of
24-hour
notice.
I
A
Thank
you
so
much
answered
the
organization
that
you
all
worked
with.
Are
they
still
on
the
line
or
are
they
available?
Okay,
let's
do
this
for
those
who
have
some
heartburn
with
this,
with
the
amendment
or
with
the
bill.
A
Whatever
your
vote
is
today,
you
can
always
say
you
reserve
your
right
to
change
it
on
the
floor.
A
I
O
A
And
I
believe
that
the
motion
passes
unanimously,
amend
and
do
pass
senators.
He
was
cancer.
We
take
the
floor
statement,
but
before
we
do
the
floor
statement,
just
make
sure
you
make
the
rounds
with
those
who
had
some
issues
with
either
the
amendment
or
the
timing.
A
B
B
A
Okay,
thank
you.
Any
members,
no
comments
questions.
A
Okay.
Well
with
that,
it
looks
like
we
have
covered
everything
that
we
came
here
to
do,
and
probably
a
little
more
so
I'm
going
to
adjourn
this
meeting
and
we
will
be
right
back
on
monday
monday.
Thank
you
all
have
a
great
weekend.
Okay,
we're.