SmartTranscript of House Healthcare - 2025-01-15 - 1:00 PM

[Chair ]: Four, and this is January fifteenth, HouseHealthcare. First order of business, and I apologize we have not done this previously, but we need to elect a clerk for the committee and for new members. The clerk is essentially the person that calls the role when we take votes and records our committee action and also is incredibly helpful in the process of submitting our bills to the clerk's office, to ensure that they get on the calendar appropriately and get to the floor. So is there any discussion? Is there anybody with a driving passion to be the clerk? One person. One person. [Ashley Berliner ]: I both remark. [Speaker 2 ]: I'll say it right. [Chair ]: It comes with vast experience. And I did learn last night that in the absence of the chair, the vice chair, and the ranking member, the clerk is That's what this is all about. You're going to take those calls out. I would entertain a nomination. Have to do this plan. No. We have to vote on it, don't we? Well, you could you could Oh, I think we voted on it in the past. [Speaker 3 ]: Vote on [Ashley Berliner ]: it. I'd love to nominate Mari. [Chair ]: I'll second that out. And then if [Leslie ]: no more nominations, you can say that you submit one nominations. Seeing none. Yeah. [Chair ]: All those in favor of Mari, representative Mari Fortis being the clerk of health care, say aye. Aye. All those opposed, nay. The ayes appear to have it. The ayes do have it. And representative Cortes, you are the treasurer of our own chair. Thank you. [Speaker 5 ]: Congratulations. [Chair ]: Thank you. And thank you for doing that. [Leslie ]: So you did a superb job last six years. [Ashley Berliner ]: Four years of that experience. No. Two years. [Leslie ]: Four years. Maybe three years. Years. [Chair ]: Frankly, she already has the document, I'm sure, in her computer, which is, you know, the whole thing. [Speaker 6 ]: This has been a session. It's career. [Speaker 3 ]: You know, we'll start. Yes. [Chair ]: I can always resign, though, if I get flustered. I will say she has great flourish when she's calling the role. [Nolan Langwell ]: That's great. [Chair ]: Yeah. Especially once I learn to pronounce your last name, like, or at least fluvial kind of thing. I'll help you out. Alrighty. So moving on, we have with us again Nolan Langwell from JFO, and we're moving from health care one hundred and one to specifically Medicaid one hundred and one and joined by Ashley Baylinner, who is our director of Medicaid policy at AHS. So welcome. And just so you aren't startled, I have an appointment. I only have to leave about one fifteen, but I'll be back. [Nolan Langwell ]: Great. For the record, an old nine eleven fiscal office. And today, we are very lucky and honored to have Ashley Berliner here, and to accompany me or to work together on helping you understand Medicaid. And I'm gonna ask Ashley to quickly introduce yourself and tell people a little bit about specifically what we do. [Ashley Berliner ]: Thanks, Nolan. For the record, Ashley Berliner, director of Medicaid policy, the agency of human services. And I am I have been with Medicaid since the end of twenty twelve. So a lot of lifer right now, came on board when we started transitioning for the Affordable Care Act, and I oversee the Medicaid policy portfolio for the agency, which all of the AHS departments. And I also oversee our eleven fifteen global commitment waiver. [Chair ]: Can I ask just for my own knowledge, because I'm not sure I know this? So you reside within AHS, not specifically with Diva. [Speaker 3 ]: Where do [Speaker 5 ]: you where [Ashley Berliner ]: do you reside? Today, I reside with AHS. Okay. When I started in my same unit, I was at Diva, and then we went to [Chair ]: AHS, and then we went back [Ashley Berliner ]: to Diva, and now we're back at AHS. So your confusion is a lot warranted. [Leslie ]: Okay. [Ashley Berliner ]: Yes. We've been a bit of a ping pong, but I think we're at AHS to stay. [Nolan Langwell ]: Okay. And I'm just gonna say this on the record. Ashley is we're she's a pure asset to Diva and Medicaid. We're lucky to have her, and I go to her all the time for information. I just wanna say I'm a big fan. So I'm a say on the record. [Chair ]: Thanks, man. Embarrassing. [Leslie ]: Fan of Nolan is a fan of us. [Ashley Berliner ]: I'll probably agree. Someone asked Mike about me, though. Yeah. [Speaker 2 ]: I'm [Chair ]: gonna say him partially. No. I've worked with him. [Nolan Langwell ]: So we're gonna tag team this. And when unlike yesterday, when you had specific questions about [Ashley Berliner ]: Let's take the screen off. The privacy screen. The privacy screen. What are [Nolan Langwell ]: you talking about? Oh, that? Oh, you can't see. Oh, no. [Ashley Berliner ]: I took it off. [Nolan Langwell ]: No. It's just stuck on there. [Speaker 2 ]: I got that work. [Nolan Langwell ]: I can see. Yeah. Yeah. Sorry. So if you have specific questions, they are like, well, Wakefield Diva or AHS here now. They are here, and you can ask them. I also had some answer to some of the questions that representative Gina had yesterday, but she's not here. I won't say them until he comes. So the purpose of today, again, we're taking the next step in trying to help you understand the health care landscape, and we're gonna dive into Medicaid. Again, we're gonna take it down a level, but not too too deep. I asked this disclaimer to all actually, this is less relevant here, but I still put in there again, like I said the other day, but it's all my presentations right now because some of the data I use from expenditure analysis or from from my health insurance survey, which does come up with some of these things, is outdated. Our Medicaid data is not outdated. It's pretty up to date. But nonetheless, I have to to make a disclaimer. So we're gonna be covering, I'll start with a high level context of who's covered under what. I'll move into what is Medicaid, then we'll get the Medicaid financing, specifically, much more detail about global commitment. So, again, I showed you a pie chart the other day. This is to give you a sense of the landscape. Bless you. [Speaker 5 ]: Thank you. Yeah. Landscaping. [Nolan Langwell ]: Bless you. Yeah. Oh, god. The landscape that we're living in. Today, we're gonna be talking about the pie chart part of the pie chart that's Medicaid, which is twenty four percent. So twenty four percent per month or so our Medicaid Point four one, we don't know what the number is today, but it's it's safe to say that it's plus or minus three percent. Again, I put this slide in again as I did the other day, but they weren't meant to be back to back. So but this is sort of that show that that's shipped from government coverage to private coverage and or from private coverage to government coverage and I I won't go into detail because I went to see yesterday. So and then you can never have this conversation too much. So I won't get into it again, but remember Medicare and Medicaid are different. And we heard the little pneumatic devices that people like the e in Medicare stands for elderly, you know. Yeah. The second person said it to me today. [Ashley Berliner ]: Oh, wow. I was sitting around. [Nolan Langwell ]: Senator Gulick said the same thing, and [Speaker 5 ]: I was like, alright. Who's that? So [Nolan Langwell ]: So Medicaid, you know go ahead. Do you wanna say it or should I say it? [Chair ]: You should say it. It's your I know. Oh [Nolan Langwell ]: oh, I get it. Everybody together. If you [Speaker 2 ]: If you see one Medicaid [Nolan Langwell ]: program, then you see one Medicaid program. Can I just say it? I think it's the first time I've [Speaker 3 ]: ever had [Nolan Langwell ]: a single line. [Speaker 2 ]: I'll write a I'll write a jingle. [Chair ]: Cheers, Varga. I'm gonna interject. I was at a national council of state governments on Medicaid, and the presenter had on their slides, if you've seen one Medicaid, you've seen one Medicaid. And I thought either they've stolen from Nolan or Nolan's not [Nolan Langwell ]: stolen. What I would say is I didn't make it up. Okay. But it's sort of it's it's sort of in the public domain now. It's like I'm searching. Songs hit a certain point. You can start stealing from them without plagiarism. Like, it's in the public domain. [Chair ]: I still I want you to know I still chuckled and I thought about you. [Nolan Langwell ]: I'm glad you had a laugh. [Speaker 2 ]: Medicaid existed for more than sixty years? [Nolan Langwell ]: Nineteen sixty five. So technically I [Speaker 2 ]: think it probably isn't the public. [Nolan Langwell ]: Well, then but at the time, there was only one Medicaid. [Speaker 5 ]: Yeah. I'm not [Nolan Langwell ]: gonna be there. Yep. Yes, sir. Can you explain to me again the difference between CHIP and Medicaid? Yes. So CHIP stands for the Children's Health Insurance Program. Okay. At the federal level, it's actually not part of Medicaid because we're under different federal statute. But in Vermont, we administer it through our Medicaid program. So it's not part of our global commitment waiver, but we do administer it through our Medicaid. And for all kinds of purposes, those kids are doctor dinosaur. Anything you wanna add? Or [Ashley Berliner ]: No. No. That's right. [Nolan Langwell ]: Again, this is that whole one third versus a quarter on Medicaid versus have a relationship with Medicaid. Alright. Do you want the eligibility and benefits? [Ashley Berliner ]: Sure. So for Medicaid coverage, in order to qualify, you have to be a Vermont resident, and you have to be a US citizen or legally residing citizen. There are a lot of rules around residents and citizenship, but for all intents and purposes, legally residing citizen or resident who's been here for at least five years. Your financial situation is characterized as low income. And previous to the ACA, you had to also be categorically eligible. So you had to have low income and you also had to be pregnant, a parent, blind, disabled, or aged. The Affordable Care Act added a new category called the new adult group, which allows you to be low income without having this other categorical eligibility. So it was a massive expansion of the Medicaid program. And under the Medicaid coverage benefit package, states are required to cover a set of statutorily mandated benefits. And there are also optional benefits that can be added at state's discretion. [Nolan Langwell ]: Bracelets. [Chair ]: May I [Ashley Berliner ]: I have [Chair ]: so many questions still. The new adult population, because we get a very high f map on that. Ninety ten. And ninety ten, and that was created under the ACA. It's my understanding it was to incentivize states to expand Medicaid. Is there plans of that ninety ten going away anytime, or is that permanent? Perpetuity. [Ashley Berliner ]: It's It is, it is in perpetuity as written. It is something that we have heard the Trump administration is very interested in, changing. So it's definitely something worth thinking about, being at risk, but as threatened, it is in perpetuity. Okay. [Nolan Langwell ]: Thank you. There's no sense in that. [Chair ]: There's okay. [Nolan Langwell ]: Thank you. And as I mentioned, it was, you know, when it first happened in in the the some states got a hundred percent for that population. And I think we started at eighty twenty, and they moved everybody to the same place over a period of six or seven So it's actually [Chair ]: Brian, did you have a question? [Speaker 2 ]: We're just at if they don't appropriate money to Medicaid, would like, I I guess here's the question. Like, the policy would be this this policy of coverage and benefits and matching funds and stuff. But if the federal government doesn't fund and, like, appropriate enough money, would there be a point where, like, Medicaid spending would run out? Like, for example, like, halfway through a year, if the federal government didn't appropriate enough money and Medicaid recipients went to their provider and got services, would there be a point where federal money ran out that if the state didn't cover it all, people just there would be no money to [Nolan Langwell ]: pay the providers? You see what I'm getting at? Yeah. I don't know the answer to that other than the fact that, like, it's a Medicaid exists under federal law. If they don't fund it, it doesn't mean that they're off the hook for having to provide funding for it. That said, I don't know if it's ever happened. [Ashley Berliner ]: So Medicaid's an entitlement program, so it's not a block grant the way other federal funds are yet. This is another thing that we're looking at the new administration potentially changing. And so when we talk about these mandatory services and mandatory eligibility groups, they are obligated as under statute to provide federal funding, and we are obligated to provide that state match. When we get into the optional groups, like the new adult group, the incentive right now for states to cover the new adult group is that ninetyten match. And if they bring that back to a normal match rate, that's usually around fifty, fifty five, sixty percent, depending on the state. The idea is that some states may pull back their expansion. [Speaker 2 ]: Thank you. [Nolan Langwell ]: And for us, that's about forty one thousand people. [Chair ]: Mhmm. Thank you. [Nolan Langwell ]: As Ashley mentioned, there's mentor services and optional services. And so this is a list of what those are. Again, mentor would be services that we are required to cover. Optional services are certain that the state has chosen to cover that is allowable. And I think I used this sample the other day, but at the time I've been here, I think chiropractor, for instance, has been added and subtracted at least twice. Then with dental too, like, we offer it, but there's, like, you know, how much mental even is flexibility. Do we offer? Not a little. Do we offer a lot? So, again, this is part of that optional end. If you see one Medicaid program, you see one Medicaid program because every state has different optional services that they choose to offer. But everybody has to offer the mandatory ones. [Ashley Berliner ]: And in Vermont, we offer all of the optional services. And just I always like to note that prescription drugs is listed under optional, which is just quite odd. But a lot of these services listed under optional are covered nationwide. [Nolan Langwell ]: Now we're gonna kinda move into the finance part. Again, this is a slide I had the other day. In twenty twenty, Vermonter spent about six point four billion dollars in health care. Again, I don't have more up to date data, but I would estimate that it's probably closer to eight billion. And that Medicaid accounted for twenty seven percent of Vermonters health spending. Again, I suspect that's in that ballpark, you know, within two percent, give or take. It's probably hasn't changed a whole lot. But Medicaid spending, obviously, is a big piece of the state budget. And as I showed this slide, again, you can never show this stuff too much. But, you know, we had an eight point seven billion dollar budget appropriated in fiscal year twenty four. Two point three billion of that was Medicaid. And, again, these are gross dollars. That's all funds. Just to give you the the the the and when we talk about Medicaid spending, by the way, it's not just it's it's across it's Medicaid spending across all [Speaker 3 ]: of our [Nolan Langwell ]: different programs for which Medicaid dollars go. So it's not just hospital care. It might be mental health. It might be transportation. So it's across and in Vermont, and I have a slide that shows this later on, that kind of trans Medicaid dollar flowed up almost every AHS agency. Almost every. [Chair ]: Of that two point three billion. How much of that is general fund? [Nolan Langwell ]: The answer is about seven hundred thirty million. [Chair ]: Okay. Thank you. [Nolan Langwell ]: I know that because Mike Fisher asked you that about an hour ago. [Ashley Berliner ]: How much? [Nolan Langwell ]: Thanks, Mike. [Chair ]: Thanks. Yes. Go ahead. [Leslie ]: I'm just trying to understand understand your slide. Not this one, but the previous one. Yeah. And maybe I miss misheard. Are you saying the green estate this is all Medicaid. Yeah. [Nolan Langwell ]: So it does. Okay. So this is a slide that I commandeered from the budget presentation. The blue is federal funds. Green are state funds. But I put this in here just as a total because this is a mix of two for a fruity. This doesn't this doesn't match up with the colors. It's really just more I'm gonna show you, like, in the gross, if you took the color away, that's where Medicaid is. [Leslie ]: So that two point three billion you're saying is twenty seven percent of the total Vermont state budget? [Nolan Langwell ]: Two point three divided by eight point seven million. [Leslie ]: Yeah. So that's right. So Medicaid accounts for one quarter of the Vermont state budget. Yeah. Yeah. [Nolan Langwell ]: So oh, here it is. Twenty seven percent. Oh. It ramped me. So yeah. Again, this is just this is just more meant to be a visual of, like, just showing you how much of the state budget is Medicaid spending. Actually, she left it on the slide. The answer is right here. I also like this slide because I had fun trying to split dollar up in the picture. So [Speaker 2 ]: And then we get it sounds like just different levels of match. [Nolan Langwell ]: Oh, I'm gonna get to that. [Speaker 2 ]: Okay. That will be it. Yes. We have a question your slideshow now. Question. [Nolan Langwell ]: And we will get there. It's ahead of time. So the total federal funds for fiscal year twenty four were three point one seven billion dollars. Medicaid accounted for forty percent of our federal dollars appropriate. So so this was really showing that this is all the funds together. This blue box are federal funds, and this right here is the Medicaid portion of the federal fund. Just to give you a sense of how big Medicaid is. So overall, again, Medicaid spending was two point three billion. And it's a match. It's it's it's both combination of state and federal match. We talked about FMAP the other day. So I won't get into too much, detail about it. Or I won't repeat myself. I will move to this slide because this goes to the representative's question. So the majority of our Medicaid's plan is under this fifty eight point one percent Fifty eight point eight one percent. They share forty one point two. Sorry. State share, federal share. But we have these other matches. We have our chip, which is about seventy thirty. We have our childless results that we talked about ninety ten. And then a lot of our admin, I believe, is fifty fifty. [Chair ]: Just a a sort of a follow-up question from something we talked about a little bit this morning. The provider tax. Tax providers comes into the state. We're then able to take that, spend it back in the Medicaid program, receive federal match on it. What are what do I guess? What do we turn that money into that comes in through the provider tax? [Nolan Langwell ]: What is it? Let me take you on a journey. [Chair ]: Okay. Let's go. [Nolan Langwell ]: So let's pretend provider tax is rainwater going into a lake. It's a revenue source. Right? Just like any other general fund revenue source. It goes into the water, and the lake. And then water from that lake is used to hydrate Medicaid. I don't like to make the connection that this dollar goes here. It used to be that way because provider taxes and sick part of cigarette taxes and claims assessment and a few other things, they used to go into this special fund called the state health care and that money was used specifically towards drawing down federal match and Medicaid. It was never completely enough. We had to do general fund in there too. I think it was twenty fifteen in one of the budget adjustment acts where we eliminated a lot of our special funds. And the reason was, at the time, the the crediting agencies were saying to you, you guys do not have a lot of general fund. And it was affecting us too. Like, we have tons of federal state dollars. Like, yeah, but it's in all these special funds. So we put we we pulled a lot of these special funds into the general fund to to for the bond rating agencies, which made sense anyway because the state health care resources fund was just x percent, and we still had time the general fund that was going in. So could I get what was the purpose? Right? If we're if every year we've got more general fund, it might as well all just be general funds. So that was the rational thinking at the time. But when you put it into there, then it becomes rainwater in a lake. So I don't like to say this dollar funds this. It doesn't fund it anymore than that because it goes into the pool. But that was basic rationale when provider taxes were created was to create funding to help pay for Medicaid spending. [Chair ]: So would it be safe to say that the amount of money that is paid in a provider tax goes to the general fund with your chart of how much we spend on Medicaid, general fund and federal funds, would it be safe to say that we probably spend more on Medicaid than what is being paid in a provider tax. Yes. Okay. With us. [Nolan Langwell ]: I just want taxes the question is, are the hospitals getting the hospitals are paying I forget if it's, like, a hundred and fifty or two hundred million. I don't remember the total. It's it's up there. [Speaker 5 ]: Are they [Nolan Langwell ]: hospitals. Yeah. Across the board. I I forget them. I don't have it in front of me. I can easily get it, but it's it's in a it's probably in a two hundred million dollar range. [Leslie ]: That's amazing. [Nolan Langwell ]: The total across all the hospitals, maybe it's a hundred I I no. I shouldn't be back in public. Right? Are they receiving more than two hundred x dollars in Medicaid reimbursement? The answer is they are getting more. So but that's a bigger conversation, and I don't wanna get into politics on it. Yeah. [Ashley Berliner ]: Woody. [Speaker 5 ]: We're talking about the hospital provider tech [Nolan Langwell ]: just now? We were. Okay. Good. Thanks. But we we can have there's a lot of ways of looking at it. And, yeah, it's a rabbit hole. I don't where they wanna go down. I don't want the hospital association to call me up. They're like, you misrepresented it. I I wanna try to present this in a way that is apolitical. [Chair ]: I'm just wondering if we wanna move on. But, Brian, do [Speaker 2 ]: you have a quick quick question? Besides hospitals, who pay pays provider taxes? [Nolan Langwell ]: That's an easy question. So we have our home health does not anymore. They used to. They don't. We have annuals, provider tax. We have hospital, nursing homes. Used to be the intermediate care facility, but we don't have anymore, so they don't pay it. Women in our pharmacy. [Speaker 2 ]: So not primary care offices, not private practices? No. Tricky question. [Nolan Langwell ]: If they're part of a hospital system, they're counseled, [Speaker 2 ]: but not independent ones. Okay. Thank you. That I just just trying to get a sense of who's chipping in for this. You know? Yeah. Okay. [Leslie ]: Honestly, I just wanna let you know that we got into this conversation with Devin this morning. So you're protected. It's because [Speaker 3 ]: Am I [Nolan Langwell ]: getting a text from Devin? [Leslie ]: Yeah. Let's [Ashley Berliner ]: see who Devin is. [Nolan Langwell ]: Watching, I'm sure. [Leslie ]: Because the question is, how do we go in deeper to understand how that money is distributed? I don't know that that's doable hearing about your lake metaphor. Maybe it's not. Well, what is it [Nolan Langwell ]: you want to, what is it you want to understand? [Leslie ]: Well, those of us that sit in these seats have been really tagged by our local hospitals, not how much they hate the provider tax and to try and understand that tax and what opportunities there might be to relieve them. [Nolan Langwell ]: I understand. Okay. So let me point you to the slide behind me. K. If we were to eliminate a hundred million dollars in provider tax, We would have to cut two hundred and forty three million dollars out of the Medicaid budget. [Speaker 3 ]: That's because it's matched. [Leslie ]: Because of the match. [Nolan Langwell ]: We will. We would have a we would have a hundred million dollar shortage in the general fund. Right. Or we'd have to cut two hundred forty three million dollars elsewhere, but we lose two hundred forty three million dollars. We cut a hundred million dollars out of the general fund, and we don't use that have that general fund to use for match. We lose two hundred forty three million dollars. Now if we in the water scenario, if we say, no. No. We're not gonna touch hospitals or Medicaid, then we define a hundred million dollar cuts elsewhere or a hundred million dollars in new revenue elsewhere. That's the whole thing about legislating and prioritizing and funding. Right? It's it's which you know? So that's the way that I look at it. So I wouldn't go and say, okay. If we cut a hundred million dollars, I'm just again, it's more than a hundred million dollars. But we just need an example. If we cut a hundred million dollars that we're gonna turn around and cut two hundred and forty three million out of the hospitals of the Medicaid. I'm not saying that at all. I'm just saying we lose a hundred million dollars in revenue. And if you take it out of Medicaid, it's two hundred fourteen million dollars. If you don't take it out of Medicaid, well, it's a hundred million dollars elsewhere in the budget or you have to raise new taxes. [Leslie ]: Yeah. But if the hospitals are margins are so completely, you know, slim and tight and maybe this is obviously not a conversation for this moment, but that's what I'm hearing from hospitals is, you know, their margins are tiny and we're learning about that all over the place. So where's a opportunity to support them? And they're just thinking this is one. I'm not saying it is, and I get the doubt. I'm just [Nolan Langwell ]: Well, let me also clarify too. That would assume you cut the provider tax completely. So right now, prior or provider taxes are at six percent. So you could lower on the provider tax. So but, you know, but I'm just sorry. I'm not saying Wow. Are you planning [Leslie ]: your own that's a good idea. I get that. [Speaker 3 ]: No. I'm [Nolan Langwell ]: just saying there are there are avenues around provider tax or there's other ways as well. I know hospitals have always hated the provider tax. And I don't wanna say that if you cut provider tax, it's gonna destroy it. I'm not saying that. I'm just saying you cut provider tax, you have less general fund. Whether you cut it by one percent or all six percent, you have a general fund shortfall that you either make up or and through other revenue sources or through revenue reductions or through a program reductions. That's the priority. That's the choice, like, the sliders choose. [Chair ]: K. Thank you. [Nolan Langwell ]: I'm trying to get Oh, I understand. [Speaker 6 ]: So you said it goes in the terminal fund. [Nolan Langwell ]: Correct. Does that money get back appropriated to the health? That's my rain, water, lake. I know. That's what I was thinking. But And it goes into the water and it's it's So it doesn't get get appropriated back into the health care system? It's it some does, probably. It goes to the general fund. Yeah. Then general fund dollars are used to match Medicaid. That's how I'll say it. There's no other way to really say it. There's no way that Okay. Yep. It's it's it's not direct. Clear as water and or clear as mud in Medicaid. [Chair ]: But we know that eighty million dollars comes out of the general fund to fund Medicaid. [Nolan Langwell ]: Eighty million? [Chair ]: Was it eighty? You said seventy eight? It was somewhere around that. Of the two point three, eight hundred. [Nolan Langwell ]: Oh, seven hundred and twenty or thirty four million dollars as general fund. [Speaker 5 ]: Okay. It's a [Nolan Langwell ]: little bit special one in there too, but not the general fund. [Chair ]: We know approximately seven hundred million comes out of the general fund to pay specifically for Medicaid. [Nolan Langwell ]: Yes. Okay. [Chair ]: Thank you. Yeah. This has [Leslie ]: been really helpful. Thank you. [Nolan Langwell ]: And I try to say it in a way that isn't biased in any particular way because I don't have an opinion on this. I just wanna give you the information. Just the facts. But this post conversation get very political very fast. So I was trying to navigate. So back to FMAP. We talked about the COJ. We had the whole gray and white. It goes up and down. But, again, this was just meant to show you the how the FMAP changed over time, how it goes up, it goes down, how we've had relief along the way. But we'll be good this yesterday. Let's get into global equipment because I think you're gonna have a lot of questions. So I'm going to start it off, and then I'm gonna let Ashley fix all my errors Mhmm. And then get into details. But as I sort of touched upon the other day, the federal government we have this thing called wave. Actually, you know what? I was so cute. Where? Yeah. Let's just do it. [Speaker 5 ]: I've done this. Yeah. [Ashley Berliner ]: Alright. So Medicaid is written into the statute, for the Social Security Act, and it says that states have to cover these mandatory populations and these mandatory expenses. An eleven fifteen waiver waives portions of the Social Security Act. And they say that if you have innovations, if you want to do a demonstration around your Medicaid program, we will waive certain provisions of the Social Security Act that states are obliged to follow for their Medicaid program to allow you to do this innovative thing you want to do in your state. The catch is that it must be budget neutral. So there's nothing a state can do in this innovation space that would cost more than what they would have spent without the waiver. So, without a waiver, Medicaid is limited to what's approved by the Centers for Medicare and Medicaid Services in the state plan, which is essentially our contracts between the state and the feds on what Medicaid covers and what we can get federal dollars to pay for. Medicaid without a waiver is strictly administered in compliance with Medicaid regulations, either fee for service or managed care. And in Vermont, we take an enormous advantage of this eleven fifteen demonstration provision. In Vermont, our waiver is called the Global Commitment to Health, and it is currently in effect through December thirty first, twenty twenty seven, but it has been in place since two thousand and five. It's the only eleven fifteen waiver in the country that comprehensively covers our Medicaid program. So most states have eleven fifteen demonstration waivers. However, many states, their waiver is focused on substance use or incarceration or pharmacy or kids. Ours is the only one where it is the entirety of our program. So it's very unique in that respect. Oh, I'm not [Speaker 2 ]: in charge [Ashley Berliner ]: of this. I'm looking at them on my screen. So why do we have a waiver? So in Vermont, our waiver does do things for us. It gives us federal dollars and it gives us flexibility. On the federal dollars front, it allows us to draw down that FMAP from the feds for marketplace subsidies up to three hundred percent of the federal poverty level. It pays for community rehabilitation and treatment, which is a wraparound expansion benefit administered through the Department of Mental Health that provides comprehensive mental health coverage for individuals with severe mental illness or serious emotional disturbance that are above Medicaid incomes. I'll also just boast that Vermont is the only state in the country that has a expansion benefit without an income limit. This is a really big deal. It means that regardless of your income in Vermont, if you have a severe emotional disturbance or severe mental illness, we will cover your mental healthcare. And that is available because of our eleven fifteen waiver. We also have BPharm, which is a wraparound benefit for elderly individuals in pharmacy coverage. It covers above and beyond what is available through Medicare. It allows us to pay for IMDs, which are inpatient facilities focusing on behavioral health, either substance abuse or mental health conditions, that there's a federal prohibition to use Medicaid dollars for those facilities. But we have a waiver, so we're able to pay for some of them. We also can pay for children's palliative care services. We have a whole slide on investments, so we'll get to that, but a category called investments. Substance use disorder expansion benefit. So like the community rehabilitation and treatment that I mentioned above, we're adding also a wraparound benefit for substance use disorder that will go into effect in twenty twenty six. That does have an income ceiling of two twenty five percent of the FPL. And this was something that we talked to CMS about as phase one, we wanna implement this program and then think about whether we can expand that income limit beyond there. And also, did just turn on our permanent supportive housing benefit, effective oneone of this year, that provides, free tenancy and tenancy supports for Medicaid individuals who need help with sustainable housing. And then as of the second of this month, we just got a renewal, or sorry, an amendment to our demonstration that provides the authority, though not the state funding, to be clear. It provides the authority to pay using Medicaid dollars for up to six months of rent and six months of medical respite. [Speaker 2 ]: A million hands go for lunch. I love it. [Chair ]: Daisy, can you talk a [Ashley Berliner ]: little bit to anything that you're exploring as far as coverage for folks who are justice involved or incarcerated? Yes. So we, in twenty twenty four, amended our waiver to allow for reentry services for incarcerated individuals. And what that means is that ninety days pre release, we are allowed for the first time ever to use Medicaid dollars inside the walls of a correctional facility. There has been an inmate exclusion for ever and ever, as long as the Medicaid Act has existed. And this is the first time that CMS has said, and many states have this waiver as of now, but that CMS says, well, we'll actually let you have Medicaid dollars in the facility as they're coming out to help with continuity of care. [Chair ]: What does that go into effect? That was actually my question. [Ashley Berliner ]: So we are turning that on one one of twenty six. We are like deep in the weeds of implementation planning right now. [Chair ]: Okay. And Leslie, did you [Leslie ]: have a question? Yeah. I'm looking at the last bullet. You said it's not currently enacted. And what's the timeframe you think for that? The waiver doesn't allow [Ashley Berliner ]: us to spend any money down until January of twenty twenty six. However, there's also no appropriation available for that. So that'll be a conversation for you guys. [Leslie ]: Oh, good. That that's that was the so I got it says so I figured there's no money. So you're gonna come [Chair ]: back to us with that? [Leslie ]: Maybe. I hope so. I hope so. I think that's the right thing when you think about social determinants of health and what will be saved down, you know, ongoing. I'm sorry. Daisy, did you have a follow-up? [Chair ]: Yeah. Where can we get [Ashley Berliner ]: more information about, back to my first question, where can we get more information about what you're working on with those incarcerated folks? Like what sort of specific services you're looking for? Yeah. So myself or Isaac from DOC can help answer those questions. But I'm the lead on that project from the Medicaid side and then working really closely with DOC. Excellent implementation. Very exciting. I'm really grateful that you're doing that. [Leslie ]: Yeah. [Speaker 2 ]: Okay. Would could you say more about, like, how Medicaid could be used to develop wrap around supportive how supportive housing with wrap around services? Like like, can Medicaid for example, can obviously, like, Medicaid can be used to pay a health care provider. So if there was a clinicians going to home visits, I I would assume that'd be covered because we can do them now in any housing. A clinician, you know, you know, you can do home visits. The code is site code is one, two, twelve. But, I'm just curious, like, how that money could be used potentially to solve the housing prices in a way that also addresses other social determinants of health. Like, is the state looking at working with coalitions of providers to or like the land access and opportunity board or others to actually create housing that's like subsidized by Medicaid? [Ashley Berliner ]: So I know that the state is doing lots around housing, and I can't speak to those efforts specifically on the Medicaid front. What this provides is very specific authority, and it it does not allow for building. So we cannot pay for brick and mortar that is prohibited. So in terms of, like, building new units, Medicaid can't help with that. [Speaker 2 ]: Or rehabbing, you can't? We operate. [Ashley Berliner ]: To some extent, we can with rehabbing. [Speaker 3 ]: You can? [Ashley Berliner ]: Yes. To some extent. But what I also can't do, which is really important to note, is I cannot supplant based funding. So we can't say we're already spending ten million dollars on housing vouchers over here with a general fund, and we're going to match that because that's not allowed. It would only be able to be new, not base funding. So so if [Speaker 2 ]: and then I'll we can talk more later or maybe, like, maybe I could talk with you or whoever outside of the meeting just to, like, explore the idea more. If a government body like the land access and opportunity board had funding to purchase real estate and to invest in the actual infrastructure, could Medicaid be used in partnership with that to then fund, like, resident counselors or peer support specialists or clinicians or even things like, like enhancements to the infrastructure that that are related to health. Like, not the actual building, but things like ramps or railings or payments for I I think you get the gist. [Ashley Berliner ]: Yeah. So theoretically, yes to all of that. But, again, there are a couple of hooks. One is they must be Medicaid eligible, and they have to be specifically eligible for the permanent supportive housing benefit that we've set up. So, homeless, they they're not only Medicaid eligible, but they also are homeless or have a history of homelessness. But yes, under those conditions, in theory, we could use money through Medicaid for that. That's great, actually. [Speaker 2 ]: We'll talk more later. That's really good to know. Thank you. [Chair ]: Oh, I'm sorry. Quick one. [Speaker 3 ]: When you said Medicaid eligible, if somebody is intellectually disabled, then automatically Medicaid eligible, are they not? [Ashley Berliner ]: It depends on whether the Social security administration has determined if I'm disabled or not. I'm not an expert in social security law at all, but I know that there are different categories of disability, some of which can get you into Medicaid and some of which cannot. And the Social Security Administration is the one that oversees that. [Speaker 3 ]: Okay. So [Ashley Berliner ]: But if yeah. I mean, if you have a severe intellectual disability in the form [Speaker 3 ]: of a hindrance as well. [Chair ]: In Vermont. You're off. K. Thanks. Woody? [Speaker 5 ]: If you're a disabled veteran, are you Medicaid eligible? [Ashley Berliner ]: Again, if if your Social Security Administration determines disability, there are certain eligibility requirements that I'm not aware of around Social Security. If you fall under that category, then you would come in through the Medicaid eligibility door if you also have a low income. If you don't meet your income stand the income standards, then your disability wouldn't get you in. You still have to be under a certain income threshold. Okay. Thank you. [Speaker 5 ]: So you could have disability [Nolan Langwell ]: monies coming from the VA or what have you, and that would put you over the Correct. The top. [Chair ]: Moving on? Okay. I I I thought I thought we were moving on. [Speaker 5 ]: No. I I [Speaker 3 ]: need some clarification on that if I could get it. You said if your disability wouldn't, make you eligible for Medicaid, you would have to be economically disadvantaged. Thought it was the other way around. If you're determined as an exempt you you've been found to have autism as an example. You're are you not eligible for Medicaid no matter how much money You [Ashley Berliner ]: still have to meet income criteria. Yes. So like Stephen Hawking, for example, cerebral palsy, that can be a categorical eligibility that could get you into Medicaid if you were under a certain income threshold. But Stephen Hawking has millions of dollars in book deals, and he would not be Medicaid eligible. That's, like, obviously a huge [Nolan Langwell ]: I I don't care. I I don't wanna [Speaker 3 ]: pull along [Nolan Langwell ]: it, but Or [Speaker 2 ]: if someone had a trust fund, they might be eligible. Correct. Unless it was, like, one of those protected trust funds, and then they can't Medicaid can't pull back from it, whatever. [Ashley Berliner ]: That's always kinda the first question with Medicaid is income eligibility, and then there's category on top of that. And not change, but, like, you can have a higher income and be disabled, but if you don't have a disability, you have to have a lower income. But income is still a factor. [Speaker 2 ]: Yeah. Okay. Thank you. [Ashley Berliner ]: This is great. This is great. Rich conversation. So again, a waiver a waiver gets us two things. It gets us federal dollars, which I just walked through, and it gets us flexibility. And the flexibility is the thing that, is kind of my bread and butter. So, it allows us specifically to operate our Medicaid program differently than we would if we were following federal regulations outside of the waiver. That allows us to pay outside of our state plan contract with CMS. It allows us to do really innovative payment approaches, things like participate in all payer model, potentially participate in AHEAD in the future. It allows us to operate things like our designated agencies differently across our state, freedom of choice of providers, and allows us to pay above what Medicare would pay for certain categories of service. [Speaker 3 ]: Slide. [Ashley Berliner ]: So when I talk about this delivery model, I'm really talking about this slide, which is the agency of human services secretary's office. It is the single state Medicaid agency. They are responsible for the Medicaid program. But then we set up a managed care construct with the Department of Vermont Health Access, where DIVA serves as the payer. So in a state like California, they might be contracting with Kaiser Permanente to provide services. And in Vermont, we are contracting with DIVA. So they are a public payer. That public payerness allows us to have a lot of flexibilities, just like Kaiser has a lot of flexibilities in California. We are now afforded a lot of flexibilities in Vermont because we can operate under this managed care construct. And DIVA has agreements with all of the AHS departments. D. O. C. Should be on here now too because of that reentry waiver, to operate our program this way. [Nolan Langwell ]: And again and just to get ahead of myself a little bit, but when you guys get the budget adjustment, Phil, BAA, and you start getting a sheet called the ups and downs, it's gonna show you spending by department or program, and then going across, it's gonna be the funding source. And what happens is it's gonna show some stuff will show state dollars and federal dollars in AHS, and some will slow show global commitment funds. And there's a duplication where it'll show up it it'll show up in it twice. It'll show up in AHS as the state fund and the general fund where it gets matched, but then it'll show up as the global commitment fund in the agencies. So there's it gets confusing. But if you see anything under global commitment fund under h AHS, that's the gross stub dollar, but it's it's matched in state federal on the AHS part of the balance sheet too. So it gets confusing. But, basically, if you think about this chart, all the money goes here. It's matched here, then it goes here. So it's gonna show up twice on the budget because we have to appropriate it to AHS, And then we have to give them the authority to send it to here, then they have the spending authority to do it. So that's why it shows up twice. So just preempting you because I know this question will come up. And I'll say, remember when? [Leslie ]: No. And we're gonna say, [Nolan Langwell ]: And you can. You know, it's I I always start off my presentations by saying, if you don't get Medicaid the first time, it's not you. Okay. If you don't get it the second time, it's still not you. However, if you don't get the third time, it's still not you. This stuff is really, really complicated. Okay? So it's if you ask the same question over and over again, which is why I often show the same slides today as I did yesterday because you can never hear this stuff too much. [Chair ]: Yeah. And can I and I apologize if I missed this? How many other States where we manage how many other States manage their own Medicaid as opposed to contracting it out? [Ashley Berliner ]: So most states have managed care. However, federal law, everything is caveated. Federal law says that certain populations can't ever be subject to managed care. So, again, we're the only state in the country where the whole of our program is under managed care. [Chair ]: The only state. Okay. I guess that's what [Speaker 2 ]: was so [Speaker 5 ]: forty well, forty, however many have expanded Medicaid. Forty seven states forty seven states several years ago had some form of waiver. [Nolan Langwell ]: Yeah. At least one. That's what the number was the other day. Okay. [Ashley Berliner ]: And most of them use managed care. Yes. [Nolan Langwell ]: But they might have managed care and a waiver. Right? But their waiver might be just for a specific population or program. Like like like, Ashley said, we're the only state that does the whole thing as a waiver. [Chair ]: Still using MMIS? Yes. [Ashley Berliner ]: We'll always be using MMIS. Hopefully, someday we'll get a new one. MMIS. It's the Medicaid Management Information System. It's our claims system, so how providers bill and get reimbursed. [Leslie ]: Leslie, could you go back to previous slide for a sec? I'm just wondering where we as a little the legislature have access to any of this. Is it only through the budget? [Nolan Langwell ]: What do you mean? [Leslie ]: Where we write bills? And so I'm just [Speaker 3 ]: thinking about the different pathways that we have. [Leslie ]: So it's that we have. So it's through the budget. It's through writing bills, that kind of thing. So, yeah, like, we put in hearing aids or whatever. Exactly. Okay. Thank you. [Nolan Langwell ]: Or you might pass was Yeah. You passed the legislation, and they figure out. I don't know. [Leslie ]: Yeah. That's their job. We [Nolan Langwell ]: This is back end. This is back end. Right? Mhmm. Front end is a policy. This is the back end. Okay. We're giving you a glimpse of what's in the electronics, so that kind of is how it works. And this is this kinda goes to the back end too. Right? So, like, when you think about when people apply for Medicaid, they just, you know, they get in based on their eligibility status. But when they're in, they just know they're on Medicaid. But in the back end, these are all the different doors and places in which they are [Speaker 5 ]: in from the [Nolan Langwell ]: you know, that they are eligible for. So, like, you're glad you were gonna say something. [Ashley Berliner ]: I was just gonna say, this is a kind of a different look of that first slide I went through on the waiver, which is where does like, what do we use the money for? These are the different populations that we use the money for. This is my favorite slide because it really visualizes what our Medicaid program is or what we can do without a waiver. That top two big categories, and you'll see a thin green line around it. We can do all of that without a waiver. And then in the red box underneath, limited waiver groups and waiver only expenditures, we can only do because of our eleven fifteen waiver. [Chair ]: Can I stop you for just a second? Because think Wendy had a question on the last slide. [Speaker 8 ]: I did. Just from the last slide. I was looking at these contracts at Remgiva. I was curious. This is just for my own. Do they I see that the, premium statement billing is no longer in there. Was that there before? And And that contract expired. Yes. [Nolan Langwell ]: That's okay. [Speaker 8 ]: So Medicaid was being billed through what [Chair ]: was it called? [Speaker 8 ]: Changed its names, like, a hundred times. Wex was the last name. [Ashley Berliner ]: Oh, we have lots of contracts that aren't reflected here. Yeah. This is just these are functions that are shown in contract. We have we have many, many contracts, but these are, like, core functions of the obligation of a Medicaid program. Okay. Which is why they're shown here. Yeah. It's a good question. [Nolan Langwell ]: So to sort of bring home the point that Ashley just made, this bottom piece, if we didn't have our waiver, we would either not have these services or we'd be paying a hundred percent state dollars. [Ashley Berliner ]: So, under our waiver, I think one of the things that legislators are getting most excited about is this concept of investments. And, to think about it in a traditional managed care program, I always like to think about it as profit. So if you are California and you're paying Kaiser, you're paying Kaiser one hundred dollars a month per person, they're only actually spending ninety dollars a month per person. They get ten dollars on profit. They give that profit to the shareholders and everyone's happy. In Vermont, that savings, that profit is reinvested into the Medicaid program. And that's by design and it's required, the RLL team waiver to use those savings to reinvest. And we do that in the term under this category of investments. And those can be spent on programs and initiatives that meet a really broad range of conditions. This is the envy of all Medicaid programs in the country. No one has anything like this. If we were negotiating this today, CMS would laugh at us for asking for this. It is very precious and we're really lucky to have it, but essentially it gives us federal matching dollars to spend on things that Medicaid is prohibited from spending money on, as long as they meet really high level goals, like improve public health or help Medicaid people. It's really, really, really broad. And so we have a list of sixty nine investments that are anything from getting federal match for our public health labs to two-one-one, to hospital diversion programs. Really, there's a huge swath of investments that are all over the place that are are really awesome tool that our waiver provides. [Nolan Langwell ]: We can't just, like, come up with a new program. We're like, oh, that should be an investment. One, we have to get permission from the federal government to to add any investments. And two, we have a cap on how much we can spend each year on investments. [Ashley Berliner ]: Yes. We also have rigorous evaluation criteria that has to go into that. Thank you very much for stating that. [Chair ]: Mhmm. And what is our cap? [Nolan Langwell ]: Oh, I know. I'm sorry. [Ashley Berliner ]: It is about one I think we have about twenty million dollars headroom [Speaker 2 ]: right now. [Ashley Berliner ]: So I think it's about one hundred and forty ish, but give or take a few million. [Nolan Langwell ]: But again, if we wanted to add stuff to it, we'd have to get permission and we'd have to fund the general fund match. [Ashley Berliner ]: Okay. The other thing about this is some of those investments, some of the sixty nine investments are like capped grants where we know that it's gonna cost a million dollars and some of them are caseload pressured. So, DMH in particular has lots of investments that are dependent based on how many people are using crisis that year. And so we don't have a we need room in our investments so that we can accommodate those caseload pressures. And [Nolan Langwell ]: Yeah. We we have often intentionally left that because there's years would've come really close. As you go over that, we are in trouble. So twenty million dollars seems like a lot, but when you're looking at it compared to a hundred and twenty million dollars, there's a certain percentage that you just wanna make sure you have just like you have with your own budget. Because these these pressures come in and easily twenty million dollars with a drop in the bucket in Medicaid. [Chair ]: So we have sixty nine current investments. Right? And I'm assuming a lot of these have been around for a very long time. [Nolan Langwell ]: If you click on the here [Chair ]: I I actually I mean, it's not a hyperlink. [Leslie ]: No. Not a nurse. [Nolan Langwell ]: Okay. [Chair ]: I know I've asked you. I tried this. [Leslie ]: Yeah. We've seen this before. [Speaker 5 ]: Yeah. We've seen this before. Yeah. [Chair ]: So I'm wondering what sort of scrutiny [Speaker 3 ]: review [Chair ]: do we evaluate these investments to see if they continue to be an investment or possibly duplicated duplicative services? [Ashley Berliner ]: I'm so glad you asked. So last year, I'll say you your committee passed a bill to say, evaluate these investments. And we came and said, we just got a contract to evaluate these investments. Help us rewrite your bill a little bit so that it is consistent with our contract. So where we are right now is we are contracting with the University of Chicago and we are going through a subset of investments year by year to go and do a quick analysis of whether we can evaluate that investment. That's the first pass. Is this even a value of the full, evaluating, whatever? And we're hearing no. A lot of these investments, we don't have any way to even determine whether this is effective. You're not collecting the right data. You need to start collecting this data. And so we're in the early stages, we're in year one of this contract of thinking about, okay, well, if we can't evaluate this, is there something else we should be doing with this funding? And I really look forward to when we have the report, which we don't have yet, being able to come here and talk to you about, like, these investments are really working and they'd be really ripe for scalability. And these investments, we don't have anything to show for them. [Chair ]: And we have the ability to keep the money as an investment and move it to so we could take an investment that perhaps we're not getting value from that we've determined, and we could move that money to a program or service that is showing, you know, great return on investment, I guess [Ashley Berliner ]: you would say. Or rates. You have a lot of flexibility on what you can do with that money. If you take it from one investment, you can put it into another investment. You can add it to something new. You can put it into rates. [Leslie ]: So you could put a new one in. [Chair ]: But we'd have to get we'd have to get a new one reviewed. [Nolan Langwell ]: If you want to create a new one, yes. But if you wanted to add money to an existing one Yes. That's You're gonna need permission Okay. As long as you're within the cap. [Leslie ]: Leslie. So what's the time frame of this? Like, when can we expect to hear back from you? [Ashley Berliner ]: It's I wish I had an easy answer to that. So it's a five year contract, and we're looking at a few investments at a time. Our first year, to be honest, didn't turn up much, which was really disheartening because we looked at eight investments and we saw that we really just couldn't say much about them. And so we actually rewrote our contract to help us think about these in a different way and help us look at a lot of them and say, which ones do you think we can evaluate? Let's do a really quick pass on everything right now and see what we can evaluate and then start digging into those. So that's where we are right now is this first pass of everything to just have our evaluators at University of Chicago talk to programs, see what data is available, and then come back to us at, Medicaid leadership and say, listen, this bucket over here, they have to make major changes to what they collect in order for us to tell you anything. And this bucket over here, we're going to start digging into, and we'll get back to you. And we're doing rapid cycle. So I think it's like every four months we're supposed to get a report once we get to that stage. But right now, we're doing this first pass of what's even worth digging into. [Chair ]: Have we done an analysis of what investments are duplicating either other investments or other programs that we have set up throughout different [Ashley Berliner ]: I wouldn't say anything's duplicating. Okay. We've taken a very close look at our investments in that regard. I will say there are a lot of discrete pilots for projects in one area of the states. So there might be something in Memorial and there might be something in Bennington and there might be something in St. Albans and they're not talking to each other and they're collecting different data and everything's just different enough that you can't measure them against themselves. And that's what I think is really right for, let's get a little bit more uniform about this. Let's make sure if we can evaluate it, maybe it's scalable. [Speaker 5 ]: Maybe it shouldn't just be in these three cities. Maybe it should be everywhere. [Ashley Berliner ]: So, we're asking those hard questions. And when we start to have outcomes from this evaluation, we want to be right here to talk to you about it, But we just don't really have much to show right now, unfortunately. [Chair ]: It's the honest truth of it. Okay. Tucker? [Speaker 3 ]: Well, in the past, I think it's five or six years now maybe, I thought we had instituted a program, I mean, a an evaluation program for any new projects or any new programs that were stood up. And I can't remember the name of this thing, but I remember having a little card that that it had different criteria that every new program was supposed to have so you could do just what you are saying. [Ashley Berliner ]: You're talking about the scorecard? Mhmm. Are you talking about the scorecards? Yes. Yeah. So we do have scorecards. And they are some of them are great, and some of them are pretty limited in their usefulness. Yeah. [Speaker 3 ]: Oh, we we're still using that, though. Right? Yeah. [Chair ]: All set, Justin. [Speaker 2 ]: Yeah. Thank you. [Leslie ]: I was like, could we get a list of the investments since [Chair ]: we're at the hyperlink. It's like hyperlink works. Not here. [Speaker 3 ]: I don't know. Shit. [Ashley Berliner ]: I'm looking for mine. [Leslie ]: That's zero for three here. [Nolan Langwell ]: Okay. Yeah. I will send it to Kristen, and she can post it. [Speaker 5 ]: That'd be wonderful. Thank you. Yeah. [Chair ]: Is that the last slide? [Nolan Langwell ]: Yeah. Just the appeal check. I I just added it in there. Two things. One one thing I wanna add real quick while Ashley was talking. I looked up hospital provider tax, how much we raised. So in fiscal year twenty four, it was a hundred and ninety two million dollars. This clear twenty five, we estimate it will be two hundred and nine million. That's what it will be. And then in twenty six, we estimated to be two hundred and twenty nine. Just to give you a sense of the the the size of it. [Chair ]: And if we talk and realizing it's all going into this big reservoir and there's no evaporation or anything because I like my cauldron better. If we use the standard FMAP of fifty, whatever it is right now. And I know you can calculate that in a minute. It's that hundred and ninety you said one hundred and ninety two? If if assuming it all went into the reservoir and a hose removed that exact amount and brought it to my secret room where it gets mixed in the cauldron with federal dollars, how much would total together? [Nolan Langwell ]: Usually, like, four hundred and sixty million dollars. [Chair ]: Four hundred and sixty million dollars. Yeah. K. Two thousand. Okay. [Nolan Langwell ]: That's what that gross is up to. Okay. It was straight up to. [Chair ]: Alright. And it's safe to say that probably hospitals receive more than four hundred and sixty million dollars in Medicaid funds. It's around with two point three billion. And I think they said today that forty eight percent goes to hospitals or forty bypass? [Nolan Langwell ]: So I have the twenty twenty expenditure analysis pulled up. This is old. Just to give you a sense no. This isn't perfect. It's outdated. But according to the expenditure analysis from twenty twenty, remember, this is outdated. Hospitals see, I have this by page. There is a slide in here that talks about types of provider by payer. Here it is. Okay. So this is twenty twenty. And hospitals, according to extension analysis, Medicaid paid hospitals three hundred and forty million dollars. That's five years ago. So it's gonna be a lot more. But I don't know what the number is today off the top of my head. I'm sure if we ask EVA how much you spend on hospitals, they might be able to put something together. But it's, again, not an easy request for them. That's that's this data is five years old. And the provider tax in twenty twenty Oh, we do that. Actually, I have this pulled up here. So the provider tax in twenty twenty look at me doing math. Be public. Nine hundred [Speaker 3 ]: nineteen. It's [Nolan Langwell ]: a hundred and fifty million. So about three hundred and seventy five million. [Speaker 2 ]: So yeah. Then [Nolan Langwell ]: that's straight match, you know, and then it's multiple match rates. So it's it's you can do it as sort of a barometer, but it's not accurate or fair per se. It's both very back in the envelope. So I don't have the answer to that. Sorry. [Speaker 3 ]: So on the back of the envelope, it's three hundred million? [Nolan Langwell ]: So the the two hundred and nine million grossed up to about with a straight match would gross up to four hundred and sixty million one. But that again, that's that's the straight match. There's some ninety ten in there. There's some fifty. It's a mix. [Chair ]: So assuming if you just if you eliminated the provider tax, say, let's just go with hospitals because that's the number we're doing right now and you just eliminated it and you did not cut from any other things that is funded in our state budget. You cut a [Nolan Langwell ]: hundred million or two hundred nine million dollars and said you were gonna not put that towards that general fund towards Medicaid. [Speaker 5 ]: Yes. You'd [Nolan Langwell ]: have to find four hundred and sixty million dollars [Chair ]: Four hundred and sixty million. And if you specifically said what used to go into Medicaid, we're going to cut from Medicaid, you'd be cutting four hundred and sixty million dollars from Medicaid, not the one hundred and [Nolan Langwell ]: Yeah. So that's that's I just I just wanna make the other day. For every one dollar [Speaker 2 ]: Yeah. [Nolan Langwell ]: You know, I mean, we're back up here. [Ashley Berliner ]: Two more. [Nolan Langwell ]: Yeah. Just put the visual up again so you can see it. And I know that representative Black loves this slide. [Chair ]: What was it? The one with the dollars? Yes. That's my favorite slide. [Speaker 2 ]: I know. [Chair ]: I don't know if anyone's ever noticed, but Nolan has literally gone to the trouble to make sure that the quarter is the Vermont quarter. And the pennies, he has heads and tails on the pennies. [Speaker 5 ]: Anyway, so I did [Nolan Langwell ]: thank you for noticing the Vermont quarter. But, yeah, the point is that for every dollar you cut for every dollar we put in, we get two dollars and forty three cents. And every dollar you cut, you cut two hundred two dollars and forty three cents of service if you were to cut to that of Medicaid. Yeah. So the hospitals are paying two hundred nine million, and then the reimbursements are that they're getting in Medicaid are more than that. But, you know, I don't wanna get into that. [Leslie ]: So they still don't pay their bills. I mean [Chair ]: no. I understand. Yes. I wanna [Nolan Langwell ]: There's, you know, there's some history there with when the provider tax was created and Mhmm. And I think that's part of where the hospitals are go to in terms of, like, when they passed the provider tax, they felt there was an understanding and an agreement. And that was a long time ago, and I think they feel the state isn't upholding their end of the agreement from twenty years ago. Oh, that's right. Thirty years ago. Whatever provider tax was passed. But that's I'm not gonna make for their case, but I think that's part of where they're coming from. [Chair ]: Doctor, did you want I I could make [Speaker 3 ]: a statement too. Please. We to the home health agencies, we did away with it. And maybe they feel that should happen to them too. [Nolan Langwell ]: So I did an analysis. I never said it publicly. But I looked at the amount of money that they were putting into provider taxes and the amount of money they're receiving in Medicaid reimbursement, and they were losing one. So we the home health agencies, I'm or recall, were not getting more money back than they were receiving a Medicaid reimbursed. [Speaker 3 ]: Yeah. That's why we hear. [Chair ]: And that's because when we did hear from Jill Olson today that the their Medicaid is their lowest reimbursed. It's not [Leslie ]: and [Chair ]: and they have a very high percentage of Medicaid. [Nolan Langwell ]: And they were home health looked for I have it all up here. Home health, I think, was paying more in, like, the six to eight million dollar range and not in the two hundred million dollar range in terms of how much provider tax they were. Yeah. Four, five. So they were in the six million dollar range when they their last payment. [Speaker 3 ]: That [Chair ]: I'll shut it up. Alright. [Nolan Langwell ]: I got just to quick. How did all these provider taxes originate? They just the ambulance service, you just decided to So I would say that they all originated differently. And I can't speak to the history of the hospital provider tax. But I can speak to the history of the emergency medical services provider tax because I was involved in that. And, essentially, this legislature was trying to find ways to try to get more money to ambulance providers. And we worked with the ambulance provider agencies to come up with the tax. Now what happens is several years ago, there was talk about doing one for dentists. And with the problem we ran into was that so with hospitals, we regulate hospitals, home health, nursing homes. Like, we know who they are. We know how much money they make because we regulate them and they have to provide this stuff to us. When you start getting into, like, the minutiae of dentists, well, there's three hundred dentists. There are three hundred dentists probably across a hundred different offices around the state, and they don't have to provide cost reports to us. So we don't know who they are. We don't know what their patient revenue is. They don't have and we it it just got this the administrative burden of trying to implement PACS is very complicated. So with EMS, same thing. There's forty, fifty EMS providers, but we work with the ambulance the emergency medical service provider agency at the time because they were, like, they were on board with it. And the idea was we raise this money, and then we'd use it to match up and then increase the rates. So we were able to work with them because they worked with us to sort of say, okay. We'll help you we'll help get the information out. We'll work with them. So they were involved, but it wasn't easy to do. [Speaker 6 ]: But overall, is there to their benefits? [Nolan Langwell ]: Yes. You know, the question is is it still to the benefit? Right? And that's where the argument is. No. When they pass provider taxes, they get the increases. No. It's a one time bump, but then you can't increase it again. So it just I won't get into the word of whether it's beneficial or not. But it it allowed us to increase their reimbursement rates. [Chair ]: I know that this isn't part of that presentation, but maybe and don't have to have the numbers now, but maybe it's just something that we can be thinking of regarding EMS. So last year, we we raised the rates, but we also allowed them to receive reimbursement for non transport. Correct? And is that in effect yet, or does that when did that start? July first? [Ashley Berliner ]: It was July first. I think it was July first. [Chair ]: New budget. Makes sense. So I'm wondering if we can be thinking about with EMS and the provider tax sort of along the same lines of the conversation we're having around hospitals, which is how much is being generated in the provider tax and how much is Medicaid paying to EMS throughout the state, what the claims are and also what the increase has been with the reimbursement for non transport. If they're seeing, you know, if they're seeing real dollars for that. Mhmm. Is that something we can think getting? [Nolan Langwell ]: I think we can [Speaker 5 ]: look into getting those numbers. Sorry. I don't have them on the top. [Speaker 2 ]: I have No. [Chair ]: That's what I I I knew that. But [Nolan Langwell ]: I wanna say it brings in about a million dollars a year. [Leslie ]: The the What is that? [Nolan Langwell ]: Says for EMS prices somewhere in that million dollar range. I mean, it's the first. I will say that, not every provider is happy with it. [Chair ]: Is there any provider? [Nolan Langwell ]: I'm not going there. Yeah. [Ashley Berliner ]: I didn't expect the That's [Chair ]: what I'm historical action. I'm sure we'll be [Nolan Langwell ]: We'll see. If you ever have a product, Drew Hadelton is a great resource. Yes. So with that, I guess we are done. [Leslie ]: We gave you four more times because we had it twice, and we need four more [Speaker 5 ]: to get it. Yeah. Uh-huh. [Nolan Langwell ]: Are you trying to match me? [Chair ]: Does it [Nolan Langwell ]: gross me up [Leslie ]: or gross me out? [Speaker 2 ]: Both. And I have [Nolan Langwell ]: some quest I have some answers for you. We can have them offline. Your question from yesterday about [Chair ]: get some questions for me, and [Nolan Langwell ]: I found answers for them. [Speaker 2 ]: Is it something that we in a rush to leak do we have other witnesses? [Chair ]: No. We don't, and we're on the floor at three o'clock. [Speaker 2 ]: Because I would say if it's not that long, maybe he could tell me I'm on the record so the public hears unless you want you know, unless it's like I don't wanna put you on the spot. [Ashley Berliner ]: No. No. [Chair ]: I'm I'm fine unless [Speaker 2 ]: I I would like for us to have a break. But, I mean, if it's, like, a five minute thing and you wanna tell us quickly on the record just so the Alright. Guys. But unless you're it's not ready for showtime and you wanna, like, polish it up a little because I wanna respect that, like, not putting people on the spot. [Nolan Langwell ]: I'm so used to saying stuff I shouldn't on the record. [Speaker 2 ]: Me too. I just accepted that. That's the nature of human existence. [Nolan Langwell ]: Okay. [Speaker 3 ]: Some [Nolan Langwell ]: So the first question was the number of active lives in Vehi, which is the Vermont Education Health [Ashley Berliner ]: Oh, yeah. Oh, yeah. Yeah. Yeah. Yeah. [Speaker 2 ]: So Active lives. What about, like [Nolan Langwell ]: active basically means it just means covered people. Right? Okay. Not just teachers. It's their kids. [Speaker 2 ]: It doesn't mean they're exercising. [Nolan Langwell ]: It's it's it's the family who who's covered under the plan. So it's about thirty four thousand five hundred. And then there's also thirty five thousand retirees, but that they're in a separate they're in a separate retirement system. And then for state employees, it's about seventeen thousand seven hundred forty one. [Speaker 2 ]: I'm trying to do math quickly. Is that, like, about eighty thousand people total? Seventeen seven. [Speaker 3 ]: About retired seven thousand something. [Speaker 2 ]: If you're doing the math, I could see it. [Chair ]: What about retired state employees before Medicare? That's first. [Nolan Langwell ]: Let me let me do this one first. Start this. And then That's about fifty two thousand when you do the state employees and the active. When I say active, they mean not retirees. So it's about thirty to fifty two thousand between the employees, the high active. And then you add retirees, thousand plus there are eighty six hundred covered lives, retirees in the state plan. We're talking ninety six thousand people between b high, the state employee plan, active, and retired. [Speaker 2 ]: And those are all technically private insurance? Correct. That's about a a sixth of Vermont's population. [Nolan Langwell ]: Ninety six thousand divided by six hundred and forty thousand. Yeah. I mean, it's It's about, [Chair ]: fifteen percent. And in our pie charts, they're all included in the self funded [Nolan Langwell ]: They're all in the private insurance, and then they'd be How much would that be? Employees would be in the self funded. The Beehive, it's a weird it's like I I don't know if it'd be probably in this fund, self funded. It's a weird not self insured, but Jen actually kinda explained it some kind of, I don't remember what it's called. It's not such a because it's like a because it's not a single employer. It's like a group of employers that are coming together. So it's not quite an associate, and it's so I don't know if that's considered self funded in the charter or not. I don't know how to [Speaker 3 ]: you know? [Speaker 2 ]: The point of me asking the question, though, is just trying to get a sense of because I know that there's talk about oh god. What's it called? That thing that new payment approach that [Nolan Langwell ]: A hedge? [Speaker 2 ]: No. No. No. No. No. So I didn't mean to have that kind of reaction. [Chair ]: Reference on the expiration? [Speaker 2 ]: Reference based. So yeah. So we there has been talk about using reference based pricing for that population, and I'm trying to get a sense of what percentage of the overall population. So if we were gonna do that, like, I don't know what if we're gonna take testimony on this at some point, we probably will because there was a report. But if we were gonna explore using reference based pricing for the that population, then it would be like a pilot project on fifteen percent of Vermont. [Nolan Langwell ]: If you do retirees too. Yeah. Okay. It's not retirees, and it's [Speaker 5 ]: A lead class. [Speaker 2 ]: But I'm just trying to get a sense of the scope because I think doing a test on like, testing it on a population of that size and seeing how it works makes sense than trying to roll something out for everyone. But I I guess I wanna hear what people are recommending about this. I just wanna get a sense of [Chair ]: the the scale. That's all. [Leslie ]: Leslie, did you so we did get the report on reference grace pricing from the Green Mountain Care Board. I've asked Erin to summarize it for us. So you will be getting a summary of that report. [Speaker 2 ]: Are you are you an intern? Reports. [Nolan Langwell ]: Okay. Thank you. And then the second question this committee asked was, what's in the other category? Remember, we were like, who are these others? Yeah. [Speaker 2 ]: Yeah. Yeah. We asked. Yeah. Who are we othering? [Nolan Langwell ]: We are othering mostly, it's Vermonters covered by out of state insurance. So we we regulate the large group market, the small group market, the individual market, but these are folks that are just sort of outside the scope of our regulation. That was, like, eleven thousand four hundred people. So that's most of that was the other category. An interesting sidebar that came up and said health and welfare, someone asked about these health ministries. [Speaker 2 ]: Mhmm. Oh, yeah. The faith based. [Nolan Langwell ]: They actually probably fall under uninsured because it's not an insurance product. Oh. So they're they're getting health care, but it's not insurance. [Chair ]: Let me forbid forbid those. [Speaker 5 ]: I thought so too. We forbid we forbid [Ashley Berliner ]: the product. Doubt I believe in. [Nolan Langwell ]: The understanding is that they're still existing in Vermont. [Speaker 2 ]: I don't think we forbade them, but I remember discussing this. Yeah. [Speaker 5 ]: We did look at it. [Speaker 2 ]: Yeah. I [Nolan Langwell ]: think when I first joined out here. Yeah. I'm not trying to spark four rabbit holes, but I'm just filling out the blank. [Speaker 3 ]: You're not [Nolan Langwell ]: trying to support a lot? It's digging more holes for us to dive into and get lost into, but I wanted to make sure that I remember to answer your question. And I think that was it. We have questions. You're not allowed to have anymore. But but just to get [Speaker 2 ]: some clarity, like, would would an example of out of state insurance be like, let's say, I get a client and they give me an insurance card, and I look at it and it's some insurance company I never heard of and I call them and they're like, we'll contract with you for this one case. Is this would they be in the other? Yeah. The other [Nolan Langwell ]: would be I work for a company that's based in Montana. Oh. I don't know. My insurance through Montana. [Ashley Berliner ]: I'll give you a perfect And [Nolan Langwell ]: I go to a local provider, but I'm getting my Montana insurance. I might be out of nowhere. [Chair ]: I happen to I happen to know, like, most of the airline in place. So if you work for United Airlines and you're working here in Vermont, I think there's UnitedHealthcare. They're all the self funded oh, the e word you didn't wanna use yesterday. Mhmm. Arissa. [Speaker 2 ]: Oh, wait. It's United that regularly. [Chair ]: No. I mean, it's it's, you know, large employers that have have employees throughout the US, and they may not necessarily be based in Vermont. [Speaker 2 ]: Yeah. [Chair ]: And when, Vermonters that are in compacts work in other states through an agency, the agency has health care in another state. [Nolan Langwell ]: Now it gets even more complicated because if I'm Blue Cross Blue Shield of Montana and I go to a provider in Vermont, and I'm a Vermonter, they have this thing called, like, what? It's called rental networks or something like that where so, basically, I still can it's still I'm still in network, which gets into the [Speaker 2 ]: Yeah. Yeah. That's what I was getting at is that sometimes, like like, if it's Blue Cross Blue Shield and it's from out of state, it's but you can you still have to build. [Nolan Langwell ]: You still get in network because they have these they have these they I think it's called a rental network or something where these they they have part of the same association. They can buy they have agreements with other states to be able to do that. But there's insurance have these. [Speaker 2 ]: But there's sometimes random insurance companies. And if I call and if I call them, because the person will say no one in Vermont will see my file, those companies will do a single case contract with me. Mhmm. That would be in the other category. That's what I was trying to figure. I think that would fit in the other. Now it makes sense [Speaker 3 ]: to me. [Ashley Berliner ]: I'm just trying to [Speaker 2 ]: put it into, like, actually what it looks like in practice, you know, and not just numbers on a page. I think that was helpful. Yeah. [Nolan Langwell ]: Yeah. That that's how it was a provider and you might experience it. [Speaker 2 ]: Yeah. Exactly. Yeah. Or how the patient might experience it is, I have this random insurance company that no one is accepting. It's there in the other. [Nolan Langwell ]: Okay. [Chair ]: Thank you, Nolan. Thanks for the last two days, and I think we're gonna see you back on Friday. Sort of dive into health insurance. Thank you, Ashley, for being here [Speaker 2 ]: as well. Thank you. [Ashley Berliner ]: Thank you. For these. I'll be on the stage. [Speaker 2 ]: Especially thanks for the info. [Speaker 5 ]: Oh, you all. [Nolan Langwell ]: Oh god. Careful.

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