Vermont Legislature SmartTranscripts:

[Robin Scheu (Chair)]: Good morning. This is the House Appropriations Committee. It is Wednesday, 02/04/2026. It's about 09:45 in the morning. We're continuing to go through the FY twenty seven budget, and we're delighted to have Diva with us, the Department of Vermont Health Access. The Vermont's at the middle, not the beginning. That's where I get confused. Anyway, welcome. I know you've been here before, so I think we don't need to go around and introduce ourselves. But if you all want to introduce yourselves and your friends in audience or on the screen, please go ahead.

[Kascionne Gross (Commissioner, Department of Vermont Health Access)]: Good morning, everyone. I am Kascionne Gross. I'm the DEFA commissioner.

[Alicia Cooper (Director of Managed Care Operations, DVHA)]: Good morning. I'm Alicia Cooper. I'm the director of managed care operations for Diva. Addison on the screen.

[Addison Stromle (Deputy Commissioner, DVHA)]: Hello. Addison Stromle, deputy commissioner at Diva.

[Kascionne Gross (Commissioner, Department of Vermont Health Access)]: And then we have a couple of Great.

[Robin Scheu (Chair)]: Welcome all of you. Okay, so we have information online and on paper and

[Tiffany Bluemle (Ranking Member)]: Yeah. On the screen.

[Kascionne Gross (Commissioner, Department of Vermont Health Access)]: And on the screen. Yeah. So today, I bring a whole crew of people. We are Stephanie Barrett Bliss. She retired two weeks ago.

[Robin Scheu (Chair)]: So it's Oh, that's right.

[Kascionne Gross (Commissioner, Department of Vermont Health Access)]: It may be a phone a friend situation as we go along. But just wanted to give you an overview of the plan for this morning. Just a quick overview of DIVA and how the agency approached I know the secretary wasn't here last week and approached how we did the community budget process differently this year. So we'll go over that and then dive into our FY 'twenty seven budget, both the admin and the program side, talk about our one time ask, and if time allows, talk about some key accomplishments that we had over the past year.

[Robin Scheu (Chair)]: Key accomplishments are pretty important so they don't have to go last. I mean, the ups and downs do not need to be the first thing we talk about.

[Kascionne Gross (Commissioner, Department of Vermont Health Access)]: I think we'll have time. I'm pretty sure we will have time to dive into those, the way that I planned it out or the way that I think I had slotted it Okay. Yeah. Just to remind you, the agency this year approached the budget process in terms of the executive leadership team. So we thought about ourselves as instead of six different departments, as a committee of six thinking about the interdependencies of each department. And Diva is one of those that sits there in that. And that we have identified key priorities. We looked at programs that were efficient, things that we were thinking about that may not be as the move forward, things that we needed to accomplish in the near term. Our four priorities this year were around housing, mental health and substance use, the health care in terms of affordability, quality and sustainability, and then also the workforce that works for us. It's very important there. So in Diva particularly, we view our mission is to improve this as something that has not changed. Our mission and values haven't. What has changed, though, is being new in my role, I've taken the time to listen and learn from different types of community partners, and they see themselves where Diva should go in the future. And what we have decided to do is move forward with what instead of doing a whole new priorities, these are what I like to call priorities refresh. We have three priorities around value based payment, operations, and modernization, and really thinking about how does Diva, to think about the health care landscape and the role that we play there, have identified five different priorities for the coming time. And that is really to champion our members and thinking about how our policies and programs really kind of how they become the center and what they and how do we communicate those changes and what they and how do we communicate in a more effective way there. Coverage. So the next one is promoting a high quality provider network. That means coverage is not enough. We need to have the providers in place. And so thinking about having adequate and appropriate rates, giving the providers the tools that they need to move things forward. The third is to advancing population health and quality improvement, really kind of thinking and focusing on the quality of care that we need to give our patients and thinking about how we tie that into our provider network. The last two are more kind of internal facing priorities, really strengthening the operational infrastructure and system modernization. So thinking about the systems that we need to be successful to achieve those kind of the three mentioned priorities there. And then lastly, we can't do any of this without the people in our department, and so we are looking at investing in now and how do we build our teams out and support from our app there. Diva really serves as a unique role, as you kind of think of the six departments. Medicaid, the Medicaid program runs through all six of them. Diva acts as both a plays a dual role in terms of the Vermont health care. And so unlike most states, DIVA serves not as kind of the Medicaid program, but also the health, the managed care plan. And in doing so, we have some poor Medicaid functions covered under federal law around determining eligibility, compliance, state requirements, setting provider rates, managing benefits. And then at the same time, as we operate the health plan, paying for claims, managing provider networks, looking at advancing value based payment model and monitoring the quality and outcomes. This dual identity allows us to more directly align financing and care delivery models in ways other states may not be able to.

[Robin Scheu (Chair)]: So I want get back to the eligibility for a moment. What parts of Medicaid are you determining eligibility for? Because I think doesn't DCF also do certain eligibility things, or do you do all the eligibility for Medicaid across the agency?

[Kascionne Gross (Commissioner, Department of Vermont Health Access)]: Addison, you want to answer that?

[Addison Stromle (Deputy Commissioner, DVHA)]: Sure. I mean, in general, we're kind of the front door for Medicaid. So the initial application that someone would file to see if they're eligible for any programs comes in through DIVA. There are some exceptions to that that I'm frankly not that familiar with over at DCF, but I think it's pretty small compared to, you know, we're the general application processing entity for the state.

[Robin Scheu (Chair)]: Okay. So when we go to six month determinations as opposed to twelve months, that's all landing in your shot?

[David Yacovone (Member)]: Yeah. Yeah.

[Addison Stromle (Deputy Commissioner, DVHA)]: So that's and we'll talk a lot about that, but that's I know I've testified with you all before about all of those changes. Those are all in DEBA.

[Robin Scheu (Chair)]: Okay, great. Thank you. Upgrading questions.

[Wayne Laroche (Member)]: Along the same lines of the question, the designated agencies or what agencies are in the field. You heard something about paperwork requirements for Medicare than Medicaid. Sometimes somebody may decide the wrong way and the providers and cause a liability that you might not be able to recover money from, what kind of controls do you have over time? Is that correct?

[Kascionne Gross (Commissioner, Department of Vermont Health Access)]: I'm not sure I understand the question. What kind of controls do we have under making sure that Medicare is paying their share or coordinating eligible for work that are

[Robin Scheu (Chair)]: And how do they determine eligibility for people who are applying?

[Wayne Laroche (Member)]: Yes, and it's all done in your shop or is any of that eligibility determination happening at the level of agency's or the whole department.

[Kascionne Gross (Commissioner, Department of Vermont Health Access)]: So how does the eligibility work for a designated agency is processing that?

[Robin Scheu (Chair)]: Do DAs determine eligibility as well, or does it all come through you?

[Wayne Laroche (Member)]: I don't think there's anything she said or anything to do with that.

[Robin Scheu (Chair)]: Yeah, I don't think so either.

[Wayne Laroche (Member)]: That's that. What our designated agency system does. This is the eligibility is a state function.

[Robin Scheu (Chair)]: Does that answer your question Wayne?

[Wayne Laroche (Member)]: You're on the right track, but I haven't gotten to the bottom of it yet. Keep

[Robin Scheu (Chair)]: Okay, let's keep going. Let's keep going.

[David Yacovone (Member)]: So

[Kascionne Gross (Commissioner, Department of Vermont Health Access)]: that concludes the overview of Diva. And the next, I was gonna turn it over to our our bucket recommendation. So in terms of salary and wages, it's really the the ask is for 1,600,000.0 for our general fund, which will turn into a 1.35 gross. This reflects the impact of the Pay Act and the annualization of the eight new positions in the BCCI program, which is handling justice reentry, and as well as some reclassification, some merit increases as well.

[Robin Scheu (Chair)]: So we're not worried about the Pay Act. We are interested in new positions. And you'll get to that later on in the

[Kascionne Gross (Commissioner, Department of Vermont Health Access)]: Yeah, we will.

[Tiffany Bluemle (Ranking Member)]: That's fine. Okay.

[Kascionne Gross (Commissioner, Department of Vermont Health Access)]: We'll get there, too. And so just as I really quickly, right. This is vacancy of savings, and that we're running a little just over 5% where we just expected it for for 3%. The next slide around our contracts, we are proposing that we discontinue the Vermont Legal Aid Medicare Advocacy Program contract. We in referencing the budget process that the agency took, we looked at programs and contracts that looked at efficiency. And this is one of the things that we saw as one of the proposals, that we were spending more on the contract than we were recouping into Medicare in terms of getting back from Medicare. And so this is the reason why we have decided to propose to put this on the table as a proposal to cancel this contract.

[Robin Scheu (Chair)]: Question on this. Yeah, go ahead, Dave, you can start.

[David Yacovone (Member)]: We heard from legal aid who said that I think in November they just signed a five year contract with you. So there's a little surprise in that a decision was made fairly long term. Was the performance that you just indicated whereby you were spending more than what you were collecting in savings, was that for one year or was that for many years? Several years?

[Kascionne Gross (Commissioner, Department of Vermont Health Access)]: So if you look back, so if you go back to 2020, we've looked at it from 2024. So looking back at it, we saw that it was about a 60% return on investment in 2024, about a 15% in 2025. And then looking at this current year through the December, we were looking at something around 46%.

[David Yacovone (Member)]: Did anyone have an opportunity to lift the hood on the engine, so to speak, and try to determine why there was a decline and maybe make a decision to address what might improve the results or was the decision just where we're not getting what we need, we have to move on.

[Alicia Cooper (Director of Managed Care Operations, DVHA)]: I think that this is one of those instances where it's a bit challenging because we were engaging in the contracting process and anticipating that there would be a longer period of performance, while also going through that agency wide process to review all potential savings opportunities across all of the departments in the agency. And across all of those departments, different options were put on the table and the executive leadership recommended a set that felt that there would be potential to move forward. And so I think this is an area where we would certainly be open to continuing to understand those moving parts under the hood in this arrangement if the contract were to continue. If the proposal is to remove the contract from operating in the future, then that wouldn't be something that we will do.

[David Yacovone (Member)]: And this proposal will cause the contract to cease to exist completely. So you'd have to do a complete rebuild, should someone decide they wanna look to see if there's more savings that can be achieved as there were in the past. Just wanna make sure I'm understanding the situation. So in November, decision was made, let's continue. And then under budget pressures, what can we come up with savings that was lost during that process? Yes, that's correct.

[Robin Scheu (Chair)]: Yeah, thank you.

[Wayne Laroche (Member)]: I have to step away, I'll put that.

[Robin Scheu (Chair)]: This sort of confuses me for a number of reasons, because you had to get your budget in by October 14. So was this in the original budget to eliminate it in the October you had to turn into finance and management?

[Kascionne Gross (Commissioner, Department of Vermont Health Access)]: Yeah, so the budget process for the agency started well into May. And so this was always on the table. We just didn't know what was going to be kept into the final budget until

[Robin Scheu (Chair)]: So you had it in as a cut in your budget that you sent to finance and management, and yet you were signing a contract in November? Yes. That doesn't compute for me. That doesn't make sense to me. Why would you sign a contract in November if you had cut it out of the budget that you were sending to finance and management?

[Kascionne Gross (Commissioner, Department of Vermont Health Access)]: Because what we have done is we've put it into a proposal, and we didn't know whether that would have been kept into the government's recommended proposal. So we

[Robin Scheu (Chair)]: Did VLA know that it was being considered for being cut? Had you talked to them about this?

[Wayne Laroche (Member)]: No. And

[Robin Scheu (Chair)]: knowing that for the previous two years, you were not getting your return on investment, and you went out to bid, I'm just wondering if there was anything in the RFP that talked about the need to get that return on investment. Did you change anything in the contract to help ensure that you were getting what you needed from it? Do you see what I'm trying to say? Because if it was a problem, then if you're going out to bid, you would want to change the contract to ensure that you were getting what you wanted, that your expectations were there. Was that in the contract?

[Kascionne Gross (Commissioner, Department of Vermont Health Access)]: So part of the contract did say that the state would notify the contractor if the monthly revenues totaled less than the amount invoiced during the twelve month period.

[Robin Scheu (Chair)]: Was that in there every year?

[Kascionne Gross (Commissioner, Department of Vermont Health Access)]: And that would trigger a corrective action plan from the

[Robin Scheu (Chair)]: So was there any kind of corrective action that was done before the decision to cancel this? No.

[Wayne Laroche (Member)]: Same line of thinking. Yeah. In the contract. You let them know if something's falling short, is there language in the contract that specifies corrective actions if such things happen? Yeah, was language.

[Robin Scheu (Chair)]: But it wasn't implemented. Correct. All right, I have to think about all that. Let's continue.

[Kascionne Gross (Commissioner, Department of Vermont Health Access)]: Okay. The next item under contracts is our two chief medical officer support contracts. They're to help provide support for prior authorizations on mental health approvals within the age of the department. The next section is around IT system contracts. We have our Medicaid Management Information System, which is held by Gainwell, which has updates and maintenance. We've talked about this in our BAA. So this is just that. And then the next two is our increase in our call center for Maximus this year of 52,000 general fund, which equates to 150 by 150 gross. And then we are also proposing to end our AQUIDAS contract because we feel that the Medicaid data warehouse and analytical solution can now calculate those measures, which we no longer need that standalone contract. So that was just an area where the executive leadership team found a duplicity in trying to improve efficiencies there. Moving on, we have the ADS health contracts. We have the Deloitte contract for the Medicaid warehouse, which is just what we talked about in BAA. We're just now annualizing that for maintenance and operation purposes. And that match will, once it's certified, go back in July. We have Oracle licenses, which have increased costs. We have those for technology purposes, and that Visa is a three year agreement, which we had to submit to CMS. And then lastly is our MMIS Gameball contract at 60,000 for our general fund. I'll hold there if you have questions about those contracts.

[Tiffany Bluemle (Ranking Member)]: I'm seeing any Dave,

[Robin Scheu (Chair)]: go ahead.

[David Yacovone (Member)]: Well, I don't know if this is the right place, if it isn't, push me to a different area. Do you have the capability to do with your management information systems, some type of predictive analysis so that you can look at the total, all the beneficiaries, there's a big number of them, and are you able to say, you know, I was 200,000, here's 15 to 20,000. That's what we're gonna spend 80% of our spend on. Let's go in there and wrap them with services or whatever the best practice might be to help with a better quality of life and could cause containment. Do we have that kind of capability?

[Kascionne Gross (Commissioner, Department of Vermont Health Access)]: I'm not sure if I would call it a predictive analytics, but one of the things that MD West does have is kind of the creation of dashboards in which we can then kind of dive into the different populations and see

[Robin Scheu (Chair)]: I could say the

[David Yacovone (Member)]: creation of what? Dashboard. Dashboard.

[Kascionne Gross (Commissioner, Department of Vermont Health Access)]: Thank you. And so that way we can kind of look at the different types of populations and see where they're using services, how much they're costing and kind of do that deep dive to kind

[David Yacovone (Member)]: of better populate and manage them in terms of population. So it's not a criticism, but it's after the fact these people are higher per member per month than others. Let's examine, do you have contracts with independent entities or state employees who provide services to those high cost populations? We have

[Kascionne Gross (Commissioner, Department of Vermont Health Access)]: I mean, so we have the BCCI, which does case management for some of those chronic care applications. And then there's the blueprint and some programs that are ran out of the central office of the health care reform. And is the VCCI where you're adding staff? So VCCI, so VCCI, last year or this year, hired eight new positions to afford justice reentry, and so where they can go into the jails now and help coordinate care before they have-

[David Yacovone (Member)]: Directions And does that VCCI pay for itself? It costs X, does it generate Y in savings or would we know?

[Kascionne Gross (Commissioner, Department of Vermont Health Access)]: I'm not sure if we ever looked at it that way.

[David Yacovone (Member)]: Thank you.

[Robin Scheu (Chair)]: Let's continue. I'll also just make note to welcome representative Houghton from the health care committee. And if you have questions or anything, just let us know.

[Kascionne Gross (Commissioner, Department of Vermont Health Access)]: Okay, perfect. And then for operating expenses, that's just net. And then we also have, as we discussed in BAA, the new leases, which should be analyzed for those seven months of $159,000 And I think last time, had a question of where or who we contracted with, and that's just and it's well, no, it's superior. Ultimately, it's where we have the lease agreements.

[Robin Scheu (Chair)]: So you didn't go through BGS. Maybe this is the BGS.

[Kascionne Gross (Commissioner, Department of Vermont Health Access)]: Yes, that's BGS.

[Robin Scheu (Chair)]: BGS did this. Okay. And so this is the annualized version of the lease space twelve months?

[Kascionne Gross (Commissioner, Department of Vermont Health Access)]: Ours for seven months for this year.

[Robin Scheu (Chair)]: Oh, seven months.

[Kascionne Gross (Commissioner, Department of Vermont Health Access)]: The Business of twelve. A lot. Sorry. Yeah.

[Robin Scheu (Chair)]: So FY '27 for twelve. Yeah. Moving again. No.

[Rep. Lori (Laurie) Houghton (House Health Care Committee, guest)]: That's okay.

[Robin Scheu (Chair)]: Sorry. Okay. Thank you.

[Kascionne Gross (Commissioner, Department of Vermont Health Access)]: And then to get at your HR1 questions, we do see HR1 driving our significant changes for Medicaid eligibility. In terms of changing health care eligibility for immigrants, the more frequent recommendations in the community engagement or the work requirements. We estimate that there are about eight we'll need 12 new positions needed for the eligibility unit to meet that requirement, which will be reassigned from the position pool there.

[Tiffany Bluemle (Ranking Member)]: I am wondering if you have considered instead of a whole new group of employees that you would need to train whether there are community partners that are already in contact with folks who could be doing some of this work.

[Kascionne Gross (Commissioner, Department of Vermont Health Access)]: And I'll let Addy.

[Addison Stromle (Deputy Commissioner, DVHA)]: Sure, yeah. Addy Stromlov for the record. I was in to talk with you all about these changes in-depth. Community engagement, not in the sense of the work requirements, but in terms of leveraging community partners is a huge part of this implementation. Under the Medicaid Act federally, only the state can do Medicaid eligibility. So we can't farm that particular function out in terms of actually processing someone's application or redetermination. But supporting people through that process, either through our sister program or general awareness in the community, again, is a big area of focus in the implementation, but not one that can replace the need for staff in our eligibility unit.

[Tiffany Bluemle (Ranking Member)]: Well, does that mean that needs to sign off, but in terms of paperwork, putting the pieces together that would then enable a state worker to sign off on something, is that allowable under the federal rules? Helping

[Addison Stromle (Deputy Commissioner, DVHA)]: someone put together their application, yeah, absolutely. Sure. Signing the application has to happen either by customer or an authorized representative and then doing the determination, the eligibility determination based on that information has to happen by the state.

[Wayne Laroche (Member)]: I

[Tiffany Bluemle (Ranking Member)]: I just think that there are folks in the community, there's a network of organizations that regularly work with all the same people. And could be, just as I know the Department of Labor has done this in the past, in terms of its own eligibility screenings back in my past, they'd allow providers to do some of that screening and eligibility work up front so that it is streamlined for the state. And just trying to figure out ways that we can streamline the effort, because I know that this is a heavy lift, to make sure that people don't fall through the cracks.

[Robin Scheu (Chair)]: Wayne? I'm sorry, Dave was up first and then Wayne.

[David Yacovone (Member)]: Just to augment tips questioning. Yeah, the area agencies on aging, for example, have a system whereby if I, as the senior citizen want to, I could specify that Mike's gonna get a notice when I get my notice. Because sometimes these things are confusing and it's hard for people to process them. But my buddy Mike down at the street might say, Hey, Dave, how are coming with that application? And so he becomes an assistor, not a brother assistant, but an assistant. I digress. So if I'm at the childcare center doing my childcare application for the bed and folks get help with that. It's a lengthy application. Expecting staff there to be able to say, Hey, Mr. Yacovone, your Medicaid is coming up in six weeks. Can I help you? And in the hope that the applications that are ultimately submitted to the state are clean or properly filled out and gives you a good return on things. Just that whole idea of investing in community providers to do that kind of work, Is that in this budget anywhere?

[Kascionne Gross (Commissioner, Department of Vermont Health Access)]: No, I don't think it is.

[David Yacovone (Member)]: Would you if you could

[Wayne Laroche (Member)]: have or is it

[Kascionne Gross (Commissioner, Department of Vermont Health Access)]: just I not think what we're looking at is the extreme amount of budget pressures that we had and did not come up with new initiatives to kind of or new ways to fund community outreach.

[David Yacovone (Member)]: If I just one quick one. If you could, I don't expect you to have it now, but your staff that do the benefits determination, you could tell me what your ratio is, 300 to one client to worker, what they're processing now, and what you expect that to be with the new six month requirement. At one time, that number was as high as one to 600. There were many errors then, so I'm not suggesting that they're that high, but just trying to see if there's some flexibility that might allow those 12 people to be deployed differently. Thank you.

[Rep. Lori (Laurie) Houghton (House Health Care Committee, guest)]: Wayne, go ahead.

[Addison Stromle (Deputy Commissioner, DVHA)]: Would it be possible for me to just jump in briefly on that?

[Robin Scheu (Chair)]: Yes, go ahead. Thanks, did wanna, when we

[Addison Stromle (Deputy Commissioner, DVHA)]: get to one times, you'll see that we do have an ask related to outreach and community engagement along with this implementation. That is mostly for purposes of awareness in this with all of the significant changes to the processes for this year. This figure is, you know, ongoing need because we have projected what the increase in our workload is going to be in our eligibility unit due to these changes. And I know I talked to this committee about it before, but it's about a 30% increase. We do it by transaction now. It's not kind of like a caseload scenario as I think it may have used to have been. And the just the sheer number of notices, new applications, new redeterminations that we will have to do with these changes represents a 30% increase, which is why we need these 12 new positions, although they're not all eligibility workers, some are for the noticing work, IT testing, and then also in our communications.

[Robin Scheu (Chair)]: Think I have Wayne and then Marty.

[Wayne Laroche (Member)]: Well, you've all heard my concerns about thickness of operations and the possibility that vets could come and look at things and things, find things not so right. I know that the auditor's report, he was in here not long ago, I think there was some audit findings along those lines. So it looks to me as if these 12 physicians would help with those kinds of concerns, is that correct?

[Kascionne Gross (Commissioner, Department of Vermont Health Access)]: Yeah, that's correct.

[Tiffany Bluemle (Ranking Member)]: So I'm confused in why the positions, you're certainly putting them into the annualized budget, but why this extra expense of making extra notices is not built into the base as well, and you're using one time appropriations instead.

[Kascionne Gross (Commissioner, Department of Vermont Health Access)]: We are It's

[Addison Stromle (Deputy Commissioner, DVHA)]: in the base.

[Kascionne Gross (Commissioner, Department of Vermont Health Access)]: Go ahead, Addy.

[Addison Stromle (Deputy Commissioner, DVHA)]: No, this is in the base also, Right? What's in the next paragraph? Yeah.

[Kascionne Gross (Commissioner, Department of Vermont Health Access)]: Yeah. So in the next paragraph here are in the next line, in the in the ups and downs, you do see an increase in the expected cost of $290,000 for outreach, for noticing for members. So it's doing outreach.

[Tiffany Bluemle (Ranking Member)]: But it's the second sentence. In the second sentence, you say you're going to fund them with one time appropriations and federal grants.

[Kascionne Gross (Commissioner, Department of Vermont Health Access)]: Oh, no. That's other system changes that need to happen.

[Tiffany Bluemle (Ranking Member)]: Not this extra note. Yeah, I

[Robin Scheu (Chair)]: apologize. Part

[Kascionne Gross (Commissioner, Department of Vermont Health Access)]: of that is to change our systems in order to be able to kind of enroll and add, you can go into more detail about that. But there are IT changes to the systems that we will need to change in order to do the six months and the additional work or the additional information.

[Tiffany Bluemle (Ranking Member)]: More frequently that needs to be done.

[Kascionne Gross (Commissioner, Department of Vermont Health Access)]: Addison, would you like to add anything else there?

[Addison Stromle (Deputy Commissioner, DVHA)]: No. We can expand on it when we get to the one times, but that's all of the work we talked about again last time I was in that needs to be updated in our eligibility system.

[Kascionne Gross (Commissioner, Department of Vermont Health Access)]: The other kind of the other additional item in our admin budget is the school based services. We are moving to ensure Medicaid compliance. We're recommending that the school based services program, inclusive of the administration, be restructured, consolidated and supported within Diva and AOE retaining responsibility for the alignment of the educational policy. And so within that, we are asking for one new additional position in our business office to help us with that, And then as well as the kind of the school based service, EHR system and the Random Motion Time systems will be implemented on in October. Those startup costs are covered by community based service grant and then other grant funding. And this will also have to require additional maintenance resources. And then lastly, it's continued payments to the school districts.

[Robin Scheu (Chair)]: So I think this may be a situation, know you've talked about the language and statutory amendments. If we decide to go this route, we may just put the language in the budgets, and instead of having to have a separate bill so the money in that language will go again. We're working on that, so something to think about, have to understand it a little bit better first, but sometimes we just do that. Go ahead, Wayne.

[Wayne Laroche (Member)]: So AOE was doing this in the past?

[Kascionne Gross (Commissioner, Department of Vermont Health Access)]: Yes, that's correct.

[Wayne Laroche (Member)]: So with the shift over, is that going to lighten the load over there? Any change in position to make up for that?

[Kascionne Gross (Commissioner, Department of Vermont Health Access)]: I believe that's the one that they're trans the official. Believe so. Allison, is that it?

[Rep. Lori (Laurie) Houghton (House Health Care Committee, guest)]: Yes. Okay.

[Tiffany Bluemle (Ranking Member)]: The AOE is coming in tomorrow maybe?

[Robin Scheu (Chair)]: Today? Today? So it shouldn't

[Wayne Laroche (Member)]: be a new position. There'll be

[Robin Scheu (Chair)]: a transfer. Might be. Don't know how they're looking at it. We'll find out. What was your question? So you're saying we're shifting this, you regardless need one new position to do this? Correct. May I? Yes, go ahead, Dave.

[David Yacovone (Member)]: And why is this being done?

[Kascionne Gross (Commissioner, Department of Vermont Health Access)]: For Medicaid compliance on the federal side. Thank you. And then our Medicaid policy staff can come in and talk more at Aye.

[Robin Scheu (Chair)]: Thank you. And so the other thing just explain the maintenance expense is a reduction in general fund, but an increase somewhere else? SBS IT systems?

[Kascionne Gross (Commissioner, Department of Vermont Health Access)]: Yeah. I Allison, do you remember? We can follow-up. That would

[Robin Scheu (Chair)]: be great to understand what that is. Thank you.

[Kascionne Gross (Commissioner, Department of Vermont Health Access)]: And then moving on to more of our program side of things, what we have seen for trends and baseline. I think some of these things have been we have talked about it in our VA testimony. So the consensus and caseloads that we have seen on studying of the caseload, but increasing those who continue to remain. And so the recommendation is at $14,930,000 in general fund. The other one, it's a buy in, you're seeing an increase in the Fed rate. And also, we are expecting a higher caseload for that population. And so we're asking for 0.702 general fund. Then the David, saw your hand. Do you want to I just Go

[David Yacovone (Member)]: ahead and it. And is that the buy in where people on Medicare, the dual eligibles? Yes. Used to be quimby, slimby, but it's not. And we did the Medicare program changes last year. Yes. The cost related.

[Kascionne Gross (Commissioner, Department of Vermont Health Access)]: Yeah. Thank you. So there's actually two costs. That one is around the caseload and the rate increase from the feds. And so that's the first one. And then the expand of the 150 where we expanded the expansion this year, that's the you'll see that as the fourth line down here. Thank you.

[Rep. Lori (Laurie) Houghton (House Health Care Committee, guest)]: There's a question. Laura? I apologize. I'm jumping to the bottom, if that's Okay.

[Wayne Laroche (Member)]: We don't

[Rep. Lori (Laurie) Houghton (House Health Care Committee, guest)]: have any question. My understanding from South Korea Committee is that there are ongoing conversations about that line item and how we can make it work. And so I'm curious why it's out of the budget for those conversations, maybe they have been and never been updated.

[Kascionne Gross (Commissioner, Department of Vermont Health Access)]: I think as we were putting together the budget in this recommendation, that this is something that we have proposed and that we have continued to have those conversations. But I think as language, Alicia, correct me if I'm wrong or kicking under that, the way that the budget language that we have now, we're not able to implement as needed. We can't draw down if the budget language requests that we do the enhanced match, we cannot do that right now.

[Rep. Lori (Laurie) Houghton (House Health Care Committee, guest)]: So are there no more conversations that have happening about this? You're saying it cannot be done at all?

[Kascionne Gross (Commissioner, Department of Vermont Health Access)]: We can't. As it is written in the budget language, no, we can't implement. But we can continue to have those conversations of how to change that.

[Robin Scheu (Chair)]: Okay, thank you. So these numbers don't mean a lot to me because I don't have any sense of relativity. Are these up or down from last year? What's the full amount? So, the consensus caseload, What was it before? What is it now? So, what's the difference? This is just a number, so I'm not understanding it. And that's true for all of them going down. Do we have the before and after information?

[Kascionne Gross (Commissioner, Department of Vermont Health Access)]: For the consensus and caseload number or I all of

[Robin Scheu (Chair)]: don't know what it means, because I don't know if it's No,

[Kascionne Gross (Commissioner, Department of Vermont Health Access)]: no, no. Let's continue to

[Robin Scheu (Chair)]: Maybe we can find that somewhere.

[Kascionne Gross (Commissioner, Department of Vermont Health Access)]: Yeah, that'll be up in the spreadsheet. I'm going do ups and downs. So in section b three zero seven?

[Robin Scheu (Chair)]: I see caseload and utilization, global commitment of 3,000,000 $33,000,003.75, so that doesn't even tally with 35,480,000.00. There's some other

[Kascionne Gross (Commissioner, Department of Vermont Health Access)]: Yeah. So what you see what you're seeing is the total number. So the 14.93 and the gross of 35, you will see that those numbers will add up once you look at Section B307, where the tax load is 33.375. And then in Section B309 for the Medicaid program only, we're seeing general fund of $429,000 and section B310, which is the non waiver expenses.

[Robin Scheu (Chair)]: But those we just kind of we all Into one. But is that an increase in case load utilization? And what does it mean? Why is it increasing or decreasing or whatever it's Yeah.

[Kascionne Gross (Commissioner, Department of Vermont Health Access)]: So that's an increase in case load and utilization. So on page 63 of the annual report, you see where we've identified each of the Medicaid eligibility groups whether we're seeing increases or the expenditures. And I can walk you through each of the mags, or we can

[Robin Scheu (Chair)]: I just want to understand what you're seeing, what the trends are, how it's comparing, what you're worried about, that kind of information?

[Rep. Lori (Laurie) Houghton (House Health Care Committee, guest)]: So that section of the case level immunization does outline the change year over year what we've had for actuals and are expected to change with the narrative for each one of them. So it does talk about the individual Medicaid eligibility groups and how it correlates to staffs that would previously have have the related to their consent numbers.

[Robin Scheu (Chair)]: Can you just tell me? What are you seeing?

[Kascionne Gross (Commissioner, Department of Vermont Health Access)]: Yeah, so what we're seeing is we're seeing a steady amount of caseload, but what we're seeing is those that who remain in the program are costing more. They have a higher PMPM, which is driving up the increase in our expenditures.

[Robin Scheu (Chair)]: So they're using the services more? Yes. And do you have any sense of why that's happening? We've been hearing that for the last couple of years, but I'm wondering what your thoughts are on why we have this increase in utilization.

[Kascionne Gross (Commissioner, Department of Vermont Health Access)]: There's a number of things. I think there's the increased pharmacy costs that we're seeing. We're seeing more people respond to care issues. And so I think it depends. I don't think we have gotten really dope deep down yet of what are the drivers of the cost that we're hearing it from other plants, Blue Cross and others, and with our other states too, that we are seeing an increase in utilization and the increased cost. But no one has a good handle on why this is happening.

[Robin Scheu (Chair)]: So are you planning to do a deeper dive to understand that better? Yes.

[Wayne Laroche (Member)]: Where is that? Is it still right, or is it certain demographics?

[Kascionne Gross (Commissioner, Department of Vermont Health Access)]: I don't have that information at this.

[Rep. Lori (Laurie) Houghton (House Health Care Committee, guest)]: Yes. To follow-up on that, as part of the analysis that you do, is it possible that you can provide the data based on services providing cooling or imaging, or so that we have specific categories where we're seeing the increase, and then to try it over the last three years would be helpful. MST, this is a program, Endocrine Surgery Program, that is definitely going to help to work on home trip

[Robin Scheu (Chair)]: syndrome. Is

[Rep. Lori (Laurie) Houghton (House Health Care Committee, guest)]: there any outreach that your office is doing, or AHS in general, to target the funds that could benefit from the program?

[Kascionne Gross (Commissioner, Department of Vermont Health Access)]: Addie, do you want to take that?

[Addison Stromle (Deputy Commissioner, DVHA)]: I think that obviously a lot of notices have gone out for those who became newly eligible for the higher level programs. I think we're in discussions with the healthcare advocate about some additional outreach through postcard or something that's a little bit more proactive for folks but that's the extent of it that I'm aware of.

[Rep. Lori (Laurie) Houghton (House Health Care Committee, guest)]: That's helpful, thank you.

[Robin Scheu (Chair)]: Any other questions on that page? May. Dave, go right ahead.

[David Yacovone (Member)]: It could be in your big budget book here, but what would be helpful, and I'm sorry, I hope this doesn't add a lot of work, but if you had to explain these to 150 people with varying levels of understanding, it would be great if somebody could give us written at the sixth grade level so that I can understand just a little late person's explanation. A couple of sentences. I know that's hard to do under each of these.

[Kascionne Gross (Commissioner, Department of Vermont Health Access)]: Yeah, and that is actually in our budget buff.

[David Yacovone (Member)]: Oh, okay. And if somebody, oh, okay, could just say page 28. Yeah, we could. That would help us too. Yep. Thank you. We could definitely do that. Yes, Wayne. Could you talk

[Wayne Laroche (Member)]: to us a little bit about the callback?

[Kascionne Gross (Commissioner, Department of Vermont Health Access)]: Callback, yes. So the callback is the Medicare Part D callback that is set by the Fed to determine how much for Medicare for the state pays. And then the feds decide in their formula how much the state owes in return. And so that's how for our dual eligible population.

[Wayne Laroche (Member)]: So again, this is something that would be less far back once you get this

[Kascionne Gross (Commissioner, Department of Vermont Health Access)]: Yeah, we have no control over how much the feds determine. No other questions. Turning to policy changes. We have one rate increase in our 27 AS. That is for the Northeastern Family Institute for their hospital diversion program, While NFI has received other provider rate increases, this is one of the things that as an agency, the program lives with the Department of Mental Health, but Diva has the rate in our budget. And so when we came together under the executive leadership team, we felt that the hospital diversion program was one of the items that needed an increase there, since they have not had an increase since 2021, I believe. The other kind of policy changes is we're recommending discontinuing the per diem rate for mental health extended stays in emergency departments effective July 1. The rate was implemented in July 2022 as a temporary crisis response. And we have seen utilization since decreased decline significantly. We have also sent this to the Clinical Utilization Review Board, which reviewed the policy and had also recommended discontinuing this and it will have little impact to the hospital providers. The second item under policy changes is the dental incentive program. We recommend eliminating these incentive payments. These payments were intended to encourage private dental practices to accept Medicaid patients. However, these modest payment amounts have not resulted in measurable increases in dental access. The third one is to increase prescription copays, and I think we can go to the next slide, Alex.

[Robin Scheu (Chair)]: So oh, you're gonna explain it.

[Kascionne Gross (Commissioner, Department of Vermont Health Access)]: The feeds are through. So with increase this is a HR one policy also requires cost sharing. So you're increasing the co pays for $4 for preferred and $8 for non preferred drugs. There are exemptions to the cost sharing and certain vulnerable groups such as children, pregnant women, And there is a limit of a 5% co pay cap that is in place that protects those that remain.

[Robin Scheu (Chair)]: That's an HR1 requirement? To have cost sharing, is, yes. And then you're deciding what the amount should be? Correct.

[Rep. Lori (Laurie) Houghton (House Health Care Committee, guest)]: Can you tell us what the companies were?

[Kascionne Gross (Commissioner, Department of Vermont Health Access)]: It was, I think, one to three. One and two? One and three.

[Wayne Laroche (Member)]: One, two, three.

[David Yacovone (Member)]: On Kio.

[Wayne Laroche (Member)]: No. Okay, it's back.

[Robin Scheu (Chair)]: Okay, I think I had Wayne Largo.

[Tiffany Bluemle (Ranking Member)]: No, you're set. Okay, answered your question. Martin? Well, I guess I'm confused. Are we paying an increased copay?

[Kascionne Gross (Commissioner, Department of Vermont Health Access)]: No, the beneficiaries will pay the increase.

[Tiffany Bluemle (Ranking Member)]: Beneficiary, okay.

[Robin Scheu (Chair)]: That was an increase

[Wayne Laroche (Member)]: to coverage. For the record, whole level is flat. So we have a one-two COVID, how is that not working class?

[Kascionne Gross (Commissioner, Department of Vermont Health Access)]: We felt that we needed to we have not updated that for a while and we felt and we decided to the pharmacy unit recommended that we increase that to the new amount of four to eight.

[Wayne Laroche (Member)]: But the reason I'm asking, you said you were required to do some of the HR1, but I'm hearing you say you're choosing to do it. We already had one to increase. So I'm trying to understand, was the increase because HR1 acquired us?

[Kascionne Gross (Commissioner, Department of Vermont Health Access)]: No. Okay, so we

[Wayne Laroche (Member)]: were already in compliance with one, two, three, the proposal is to increase it to four,

[Robin Scheu (Chair)]: Which is a choice.

[Wayne Laroche (Member)]: What I heard earlier that we're doing is to apply with HR1. I just wanted to clarify that that's not the case.

[Addison Stromle (Deputy Commissioner, DVHA)]: If I may, the HR1 cost sharing requirements go into effect in 2028, so this is completely independent of that.

[Wayne Laroche (Member)]: Okay, oh, that seems well. Thanks, Yacovone.

[David Yacovone (Member)]: Madam Chairman, so is it possible we increase them now, that we'll have to increase them again No. To comply in 2020? Unless

[Robin Scheu (Chair)]: the federal government changes the rules again.

[Kascionne Gross (Commissioner, Department of Vermont Health Access)]: Never know. Right.

[Robin Scheu (Chair)]: That's where we are.

[Wayne Laroche (Member)]: Okay.

[Kascionne Gross (Commissioner, Department of Vermont Health Access)]: The second item is utilization management. This is really, as I began to talk when I laid out the priorities of Diva, is look at our population health management and think about quality improvement. This is one of the things that the clinical units have put together and thought that they could have a decrease, some of the consensus. And so we took about a 2.3 reduction in the consensus number, thinking about how do we make the system more efficient and aligned with best clinical practices. And it's using and concentrating in areas of DME, special rate agreements, looking at different code, our coding review, and other items that we can use as terms of population health management.

[Robin Scheu (Chair)]: So I will confess, I pretty much don't understand anything you said in that section. It feels like a lot of lingo that I just don't understand. I don't know what DME means either. If you could

[Kascionne Gross (Commissioner, Department of Vermont Health Access)]: DME is durable medical equipment.

[Robin Scheu (Chair)]: Okay. So could you give examples of what you're talking about here or something so I can understand what you really mean by this?

[Kascionne Gross (Commissioner, Department of Vermont Health Access)]: Yeah, so for instance, for DME, it's kind of taking what we do in pharmacy and where we have a preferred kind of drug list, making a preferred kind of DME list of looking at what we can pay and what is needed. There is also thinking about prior authorizations of where we can use prior authorizations to reduce some of the unnecessary utilization.

[Robin Scheu (Chair)]: Go ahead, Laurie. And then David.

[Rep. Lori (Laurie) Houghton (House Health Care Committee, guest)]: And I apologize. I don't have

[Wayne Laroche (Member)]: the budget broken for

[Rep. Lori (Laurie) Houghton (House Health Care Committee, guest)]: a GC right now. The last statement concerns me, considering in our policy committee, we've tried really hard to ensure that we are helping consumers have access to health care by limiting fire authorizations when it's not So I'm curious, and it doesn't have to happen here, to understand that more and how the money equates to what you're saying that nuclear authorizations will be required.

[Kascionne Gross (Commissioner, Department of Vermont Health Access)]: Yeah, and Laurie, sorry, I misspoke. What I meant to say is to look beyond prior authorizations. What we have seen in health care is there has been a limit. There were a reduction in PAs across the board because of access. But to look at other kind of population health management tools of how do we better manage our population. So like as Representative Yacovone mentioned, can we do a deeper dive and look at concentrating case management or some other services and direct it there? Or is there some sort of preferred list that we can refer to them that's more cost effective than some other device that may not be tested.

[Rep. Lori (Laurie) Houghton (House Health Care Committee, guest)]: So that sounds fantastic. But it sounds like it's things that you haven't actually, a process that you've never come to conclusion on yet. So I'm curious why the money is showing downward trend, and we haven't done the analysis.

[Kascionne Gross (Commissioner, Department of Vermont Health Access)]: So the clinical units have done an analysis of what they hope to, nothing has been finalized yet.

[Rep. Lori (Laurie) Houghton (House Health Care Committee, guest)]: It would be great to

[Tiffany Bluemle (Ranking Member)]: see that.

[David Yacovone (Member)]: Dave? Currently, understanding is wheelchairs can be replaced once every five years. Will things like that change under this?

[Kascionne Gross (Commissioner, Department of Vermont Health Access)]: I don't think those will change. I think we might just see kind of are there certain types of wheelchairs that we prefer or think that need? How do we better meet the needs of our patients better and using our best practices and evidence base to do that.

[David Yacovone (Member)]: So time there were wheelchairs, for instance, that help people with positioning will move automatically and do things, uneven their legs. And that's best practice, I think, so that we would continue those kinds of things? Yes. Okay, I saw the word limits and I got concerned. Thank Yeah,

[Robin Scheu (Chair)]: I'm a little worried about that too, Dave, because if you're saving money, it feels like it is gonna be limiting choices and making things more generic that may not be in the best interest

[David Yacovone (Member)]: of On the size doesn't fit all. Yeah. This worked.

[Robin Scheu (Chair)]: Okay, and then your base funding reduction?

[Kascionne Gross (Commissioner, Department of Vermont Health Access)]: And the base funding reduction, this last slide. The base funding reduction comes from the that was 4.75 per member per month payment in one care of the ACO. The ACO ended in December 31. So we're not those payments will no longer continue. So that's what we're reducing our base because of that.

[Robin Scheu (Chair)]: So you don't have to pay. Right. Because there is no I understand that one.

[David Yacovone (Member)]: Dave? I just wanted to My understanding is the ACO payments, some of them went out additionally to help primary care. Now that the ACO is gone, will that kind of reimbursement stop or will it occur in some other way to primary care providers?

[Alicia Cooper (Director of Managed Care Operations, DVHA)]: The additional dollars that One Care was directing to primary care providers was through the structure of their contract with Medicaid and their contract with those providers. Without our having the one care arrangement, we do not have a separate mechanism for providing those additional payments to primary care at this time.

[David Yacovone (Member)]: Do you know the amount of that reduction, the dollar amount? Could somebody get it for us? We could follow-up. So is that, that can't be accommodated through some type of an add on to commonly use CPT codes that primary care uses and inflate the current Medicaid rate by some type of fraction to make sure the dollars go through? Or is it, I'm sure it's much more complicated than that, but.

[Alicia Cooper (Director of Managed Care Operations, DVHA)]: I think we could have a very long conversation about different ways that we could direct dollars to primary care. I won't say that the ultimate policy question would be around the objective and whether or not it's to mirror what One Care has been doing exactly, or to do something different. Depending on the goal,

[David Yacovone (Member)]: the tools might be different. There is a down associated with this. I think I can't find it right now. I just would want to know if it were X millions of dollars, if we would want to put guardrails around that so that it doesn't go to a bottom line savings. Although I appreciate if it needs to, to make your budget work, would tell us, but we would at least know what we wanted to fence off for some type of policy discussion by our healthcare committee, etcetera. Is that reasonable?

[Robin Scheu (Chair)]: Yeah, I understand that. You. Tip and then Wayne.

[Tiffany Bluemle (Ranking Member)]: This is not my budget area. What I'm trying, picking up on what Yacovone just said, are there other initiatives that Diva's pursuing to encourage primary care and primary to bolster that particular mid, this is a down in this area, Are there ups or is there something built into the base to support primary care?

[Kascionne Gross (Commissioner, Department of Vermont Health Access)]: Not particularly with Addison. Agency has the Rural Health Transformation Fund, which it's significantly invests in primary care, looking at how do we modernize Blueprint and other areas of the health care system. So there are thinking of more holistic, what do we do and how do we increase those costs or increase those payments through primary care through the Blueprint.

[Robin Scheu (Chair)]: Wayne, and then back to Dave.

[Wayne Laroche (Member)]: So essentially, my question is going to be, does the new rural health transformation enter into this, and does it perhaps perform the functions that the ACO might have

[Kascionne Gross (Commissioner, Department of Vermont Health Access)]: done or could have done? Or Yeah.

[Robin Scheu (Chair)]: No.

[Kascionne Gross (Commissioner, Department of Vermont Health Access)]: So the World Health Transformation Fund doesn't kind of supplant or kind of sub out the what the ACO does. It kind of looks at the health care system in general, doesn't pay for, does not reimburse for things that we already are doing, but looks at of like regionalization, paying for capital for mobile units and developing the workforce, looking at modernizing the different payments under the blueprint that could be used for primary care or mental health and other areas. What the actual function of videos, wouldn't that be the same? And it does pay for some technology and data analytics that the ACO did do.

[Wayne Laroche (Member)]: Helen, can I just offer a very high level David's example? That this is like a base funding change. The Rural Health Transformation grants are a series of one time initiatives. So that's the way you should think about it. One time program initiative, thinking well this is the base money, but this would not be really similar. Frank, intent seems to be, if they're one time, if using that one time money works to set up a new system, that carries forward time. Can think of it as something that's more not perpetual, but certainly more long term and could address some of the base problems that we have. My thinking is if we get this money, we might as well get the base bank for a buck out of it and set up things that are going to last through time, that will go beyond

[Kascionne Gross (Commissioner, Department of Vermont Health Access)]: I original base totally agree. And so the idea of the Royal Health Transformation Fund is not just one time, it's for over five years. And therefore, we're building out a system that can sustain itself and not just looking at one time plug in and then look at five years, oh, we can't do it again.

[Robin Scheu (Chair)]: There's a longer term look at it. But I'll remind the committee, we have no say over how the money is spent in the Rural Transformation Grant. It's going to be a cooperative agreement with the federal government. And our only role is for the Joint Fiscal Committee to accept the grant. So we cannot redirect any of the money. We can't say, can you tweak this program? It's going to be what it is.

[Wayne Laroche (Member)]: Is there any negotiation process with the state and the federal government?

[Robin Scheu (Chair)]: That's been happening. And I think it's done now. Not sure, but I think it's done because that's why we're accepting the grant on Friday. And so I think there were some. So we had something that Jill Mazza also presented to us in December, but that chart will need to be updated based on what their final negotiations are. So, we will see that at some point, but I'll just keep reminding us and the viewing audience that we have no authority or ability to change anything in that agreement. Thanks.

[David Yacovone (Member)]: Dave. Thank you. I promised our state auditor I would ask this question. I hope I get it right. He issued a report on Blueprint and I think his finding, and somebody will correct me if I get it wrong, but he was just saying, Blueprint doesn't indicate whether it's saving any money. And could you help us on that? Is the Blueprint saving money?

[Kascionne Gross (Commissioner, Department of Vermont Health Access)]: I think you would have to ask the Blueprint staff and central office for that. If you could help me. Yeah, I can help facilitate that.

[David Yacovone (Member)]: With the contact info as to who I should ask, because it would seem to me the management of chronic care, all care for that matter, but chronic care is critical for cost savings and good outcomes, how we manage diabetes, etcetera, all of that. And I'm wondering if we're making the right investments in that area. I'm not trying to be critical of the blueprint, I'm just trying to be inquisitive, just to know more. So, maybe I could meet with them on my own or maybe our healthcare committee will, if we ask them to-

[Robin Scheu (Chair)]: I bet they're on it.

[David Yacovone (Member)]: To do that kind of a deep dive.

[Robin Scheu (Chair)]: Yeah, and then if they're doing that, they can just let you know or you can keep an eye out for their agendas.

[Wayne Laroche (Member)]: Thank you.

[Robin Scheu (Chair)]: You can go hang out there.

[David Yacovone (Member)]: Place to hang out. Yeah, thank you.

[Robin Scheu (Chair)]: Goodness we have a healthcare fair. Okay, so I think we're done with questions on this page.

[Kascionne Gross (Commissioner, Department of Vermont Health Access)]: And now one time funding. So this is the HR one requires system changes. The total changes for '27 are expected to be around 5,000,000. Just under 2,000,000 of that is matched by the federal funds that were awarded to Vermont and from which was passed in the HR one that offset some of those costs. We were right If I could just talk, we are expected remaining costs to be matched at 90%. And then also our specific outreach activity will also need to be funded. And we're hoping that $340,000 of the gross costs can be covered by the federal grant. And that's a question that we have with CMS. And if CMS cannot determine that they outreach, then we'll need a general fund for about 50% of that cost.

[Robin Scheu (Chair)]: So what are the system changes about?

[Addison Stromle (Deputy Commissioner, DVHA)]: These are the three things that I've gone over with you all. There are three changes during 2026 that we need to make to update the way we do eligibility determinations for Medicaid, immigration changes six month renewals and work requirements.

[Robin Scheu (Chair)]: So that all has an IT impact is what you're saying. Yes. Thank you. Thank I'm not seeing any questions.

[Tiffany Bluemle (Ranking Member)]: So, Laurie, go ahead. So, I'm confused. Is this the number we see on page 14? Is that number duplicate what we just talked about back on page nine?

[Kascionne Gross (Commissioner, Department of Vermont Health Access)]: No, these additional. This is our one time. This is one time. Other questions?

[Robin Scheu (Chair)]: No, let's go to this page.

[Kascionne Gross (Commissioner, Department of Vermont Health Access)]: All right, and then the next one time request is for $2,000,000 for the provider stabilization to help support providers who have demonstrated stabilization need and have a plan to sustain that. Just an update of where we are in our 27 provider stabilization. We have seen a total of 28 applications that come in over the course of the year. We have seven outstanding applications and have awarded about eight of that for a total of 3.27. I will say that the budget requests or the ask from the remaining pending applications is around $12,000,000 And we have put out a a ledger report on the Provider Stabilization Fund of who's been applying it, what they've been applying for. That can be

[Wayne Laroche (Member)]: Is that

[Robin Scheu (Chair)]: what that link is down there?

[Kascionne Gross (Commissioner, Department of Vermont Health Access)]: That is what that link gets down there.

[Robin Scheu (Chair)]: Mike and then Dave.

[Wayne Laroche (Member)]: Just get lost a little bit on this piece of that. So the provider stabilization, is there any relationship between that and extraordinary financial relief?

[Alicia Cooper (Director of Managed Care Operations, DVHA)]: The two concepts are very similar. I think extraordinary financial relief is something that is explicitly available to nursing homes and private non medical institutions, and we are able to pay those funds using Medicaid matchable dollars. This provider stabilization fund was a one time appropriation last year that is making it possible for us to extend the same kind of financial support to other provider types, so non nursing homes, non PNMI providers, but this is all GF. Okay, got it, thank you.

[Robin Scheu (Chair)]: So this is all general, right? Because we can't eradicate this. So, it looks like there's still a bunch in the works that are pending. Correct. We don't know the outcome of this at this point. Dave?

[David Yacovone (Member)]: I think you just answered my question. There is 12,000,000 in need and we're requesting to appropriate 2,000,000, but the 12,000,000 in need is in FY twenty six. And that will go against the remaining funds of the initial 10,000,000. Correct. Of which is about 2,000,000 left? Of the 3.4. How much I could

[Alicia Cooper (Director of Managed Care Operations, DVHA)]: About 3,400,000.0.

[David Yacovone (Member)]: Still left. So you folks will work your magic and do your best to try to accommodate people. So the 2,000,000 for FY27 is a best case estimate or is it, this is what we got left in the budget, we'll put 2,000,000 up there.

[Kascionne Gross (Commissioner, Department of Vermont Health Access)]: Yeah, it was a governor recommended number.

[David Yacovone (Member)]: Somebody gave it to you. I wonder if they So have the applications for help stopped? Have they slowed down or are they still coming at a decent pace?

[Kascionne Gross (Commissioner, Department of Vermont Health Access)]: I would say that they have slowed down since. The initial.

[Alicia Cooper (Director of Managed Care Operations, DVHA)]: Last application was received on January 12.

[David Yacovone (Member)]: Well, it's fairly recent. Okay. So do you have any legal capacity? Let's say next year, a critical provider says help for whatever reason, I have no cash days on hand, etcetera. I can't pay my bills and 2 million's already spent. As a Medicaid commissioner, do you have any capacity to intervene in situations like that?

[Kascionne Gross (Commissioner, Department of Vermont Health Access)]: I mean, we could look at cash advancements that they would draw down against. Against potential. Could

[David Yacovone (Member)]: you do something and come in for BAA? I

[Kascionne Gross (Commissioner, Department of Vermont Health Access)]: would have to see. Yeah. There's a

[David Yacovone (Member)]: critical provider in this community, and if it goes away, we can't Exactly, yeah. Too big to fail or too little to survive. Thank you.

[Alicia Cooper (Director of Managed Care Operations, DVHA)]: Those conversations also typically involve full representation from the Agency of Human Services. So when you're thinking that this department doesn't have a funding source identified, there It's at least a review of other potential options. Okay, thank you. Yes, I've

[Tiffany Bluemle (Ranking Member)]: been looking at the report that you linked to, and I had heard earlier this in a session at Valley Vistas, which was, I think that their situation prompted, they asked for $10,000,000 last year, that you are still in negotiations with them, and that they have not agreed to an essential request that they remain in the state for a certain number of years as a result of getting the funding. And I think that there, it says that they have not engaged with you since the October. So I just am wondering what this means about this was such an emergency last year. Money has not been awarded. Now it's a year later. And I'm just wondering whether, well, whether you know whether Valley Vista is in decent shape or you have concerns about where they are right now. And second, will this money revert to the emergency fund if you apply? What date do you imagine making a determination about this request?

[Kascionne Gross (Commissioner, Department of Vermont Health Access)]: Yeah, I will say the negotiations with Valley Vista have been handled at the agency level. And so they have not been able to come to an agreement between the terms of what they're at, what's being asked of them. Part of that is to look at the whole system and what the role that ValueVisa is playing. And so there have been some negotiations back and forth between the agency and Valley Vista. And I think we're just waiting to hear back from the agency of whether or not what the next steps are. But we have reserved a pot of some reserved $2,700,000 for them because that is their request. I think it's just about the negotiation principle of the terms of the agreement.

[Robin Scheu (Chair)]: I think you make a good point that we don't want to give money to organizations that are going to close and move out of state. So I really hope that if we're and maybe Zeesh should put this in there, too. If it isn't, some sort of residency requirement. We do this for loans for professions when we send people to nursing school and things like that. And it would be unconscionable not to do something similar with giving things places, making

[Tiffany Bluemle (Ranking Member)]: that a requirement. Well, I'm just confused because last year when this was presented to us, this $10,000,000 emergency fund, it was presented really, I mean, It was known, but not probably articulated in oral testimony that Valley Vista was one of the organizations that was in dire need of this, and it's now been a year. And how dire was that need? I guess my question is, and I'm raising it just as a question since we have a member of the health care committee here, and I have raised it with human services.

[Kascionne Gross (Commissioner, Department of Vermont Health Access)]: And also to answer your point, part of the application process is to submit a sustainability plan. So we do look at making sure that they do not plan. So that's where I think the tension lines is making sure, ensuring that they can meet those agreements and whether they agree to that. But in other provider situations, their sustainability plan, they have actually showed other providers have shown in their sustainability plan that they are committed to staying where they are. And they have a plan to make sure that they're not asking for more money next year or the following year.

[Tiffany Bluemle (Ranking Member)]: So the start we see is last year's disbursements?

[Kascionne Gross (Commissioner, Department of Vermont Health Access)]: This current year, yes.

[Robin Scheu (Chair)]: I'm

[Rep. Lori (Laurie) Houghton (House Health Care Committee, guest)]: just curious on the stabilization plan. Is there then follow-up between DIVA and the organization three, six, nine, twelve months out, some time frame, to see where they are on that stabilization plan?

[Kascionne Gross (Commissioner, Department of Vermont Health Access)]: Yes. So for instance, there is one health center, a federally qualified health center, that had it scheduled to meet with the agency and Diva in March. And so we'll go over those, where they are in their plan, what they have been doing, and looking forward of how successful they are in achieving those benchmarks that have been laid out.

[Robin Scheu (Chair)]: David, you look like your Well, my

[David Yacovone (Member)]: thinking is painted from what happening at the national level. I want to be diplomatic, hope, but I don't know if we put any guiding language around the stabilization monies. People are only human, and I'm sure it wouldn't be this way in Vermont, but sometimes I don't want a room full of executives, you know, boy, you know, Mike's been a real pain in our yada yada yada, And decisions made on personalities when as opposed to, boy, here's a region of the state that if we lose ABC providers, there's a real hole for access, that kind of thing. And maybe I shouldn't worry about that in Vermont, but when I hear of these decisions being made, the executive level of criteria. Right. And they're all good people, I bet their hearts are right, but sometimes it's good to put it in writing so they can go back to that and say, we've got five of these other residential care homes here, we hate to lose ABC, but there are others and they're not completely full as opposed to, wow, here's a designated agency, we've got a problem, there's no mental health services. So can I noodle on that?

[Robin Scheu (Chair)]: Noodle on that, I'm wondering if that's something that the House Healthcare Committee will be taking up. So Laurie's nodding her head.

[Wayne Laroche (Member)]: We're giving them a lot.

[Kascionne Gross (Commissioner, Department of Vermont Health Access)]: I make that comment? So we actually do lay out the criteria that we have used in number four.

[Robin Scheu (Chair)]: Thank you. Okay. All right, I think we're done with this page for the moment.

[Kascionne Gross (Commissioner, Department of Vermont Health Access)]: All right, so ending on a positive note, key accomplishments. I think this year has been, if you look at it, it's been a little topsy-turvy. We started with good news of we were third in the nation and we had a great health care coverage. And then we had things happen on our federal landscape that were not so good. But Diva has weathered the storm, and I am extremely excited. And I could not be more thrilled to have the team that I have in place at Diva to help us there. Five areas of where I want to point your attention to is the marketplace ability. We completed open enrollment for the qualified health coverage for 2026 with solid enrollment despite the expiration of the enhanced federal premium assistance. And so that was kind of big for us. We looked at going back to our conversation, we distributed provider stabilization plan to protect access to care in areas and looking at provider insolvency. Last, another thing was around payment reform and system transition. We successfully managed the sunsetting of the ACO and launched the Voluntary Hospital Global Budget Model for 2026, where we secured six commitments from Vermont hospitals, ensuring that a population based payment reform can be made in the state. We expanded eligibility thresholds for Medicare Savings Program to improve access. And then we also kind of instituted a comprehensive refresh of the strategic priorities for Diva and how we will guide our decision making going in the future years. And then also, when you have time, or if you have time, The annual report lays out more detail on our accomplishments there.

[Robin Scheu (Chair)]: Thank you. So I'm just sort of in my head trying to think about new initiatives for this year seem to be related to eligibility, which is a requirement. Any other big events happening that are new this year?

[Kascionne Gross (Commissioner, Department of Vermont Health Access)]: Oh, I think we have

[Robin Scheu (Chair)]: our hands full with HR1 application. So you have 12 positions. Can you talk a little bit more about why you need 12 and what they're gonna do?

[Kascionne Gross (Commissioner, Department of Vermont Health Access)]: And I'll turn that over to deputy commissioner Addison.

[Tiffany Bluemle (Ranking Member)]: Okay. Sure. I can pull

[Addison Stromle (Deputy Commissioner, DVHA)]: up the list, but essentially, it's eight eligibility workers. So I mentioned before that we made a projection based on the 30% increase in our workload. So this represents essentially kind of a 30% increase in our frontline eligibility workers that process the applications and do the eligibility redeterminations to accommodate that increased work from HR1. There are two positions. One position is for the noticing team to accommodate the extreme increase in noticing based on the kind of doubling of the renewal sequence and cadence for the new adult population. There's a position for IT testing for the significant system changes that need to go in, and then two positions to do with communications and outreach to support that very fundamental part of the implementation work.

[Robin Scheu (Chair)]: Is it January '27 that everything goes into effect?

[Addison Stromle (Deputy Commissioner, DVHA)]: Yep, that's right.

[Robin Scheu (Chair)]: But you're assuming the 12 people for full twelve months?

[Addison Stromle (Deputy Commissioner, DVHA)]: Or did you We will hire them this summer if it gets approved and onboard them. We usually do training kind of late summer so that because the process of the redeterminations and the renewals has to start ahead of January 1 in order to comply with the deadline.

[Robin Scheu (Chair)]: Right. Okay, that's helpful. Thank you. Questions on that? Any other questions for Diva? Dave, go ahead.

[David Yacovone (Member)]: Well, do you believe if we had a more robust primary care throughout the state, that the number of non emergent emergency room visits, which I think Dartmouth, if you consider 30 to 35% of our emergency room visits are not emergencies, do you think it could be lowered? Is that a good investment? Somebody said, Diva, we wanna lower the cost of healthcare spending in Vermont, what do you think of this idea? Or do you have others?

[Kascionne Gross (Commissioner, Department of Vermont Health Access)]: Oh, so we're getting very philosophical here. No, do think there is a need for an investment in primary care. And I think that's what the Rural Health Transformation Fund does. I think there's also a need to handle care coordination and case management as well. And so I think there is a lot of things that, while primary care is important, I think it's important to look at the population in total and see where the needs are and where are there opportunities to control that. But if we're looking at how do you reduce PD visits, I think one of the things is having a robust primary care and care coordination system. Thank you. It

[Wayne Laroche (Member)]: seemed to me like if this rural transformation comes in, would be a good opportunity to collect data and see whether or not any of those activities actually decrease emergency room visits. But if you don't think about collecting the data ahead of time, the immune after the fact won't work.

[Robin Scheu (Chair)]: So I'm looking at your ups and downs and there's a couple of things. I just want a little clarification on the lines. In B306, you have vacancy turnover savings of almost $700,000 general fund and another $715 federal funds for 1,000,000 point dollars Are those positions that you're not hiring? How many positions are we talking about when you're using that to balance your budget?

[Kascionne Gross (Commissioner, Department of Vermont Health Access)]: I would have to go back and look, but we are hiring. I think there's a number of new vacant seats that we did not foresee coming. And so those are our open positions. And I think where we've used that 3%, I think what we're seeing now is we're closer. The vacancy rate is higher.

[Robin Scheu (Chair)]: And is this because there is turnover and that's how you're creating the savings between hires, when somebody leaves and somebody comes?

[Rep. Lori (Laurie) Houghton (House Health Care Committee, guest)]: You've had quite a number of folks leave, there are various reasons I should check

[Alicia Cooper (Director of Managed Care Operations, DVHA)]: to you, so we're actively trying to find.

[Robin Scheu (Chair)]: RTO being returned to office, and you've had some people leave as a result of that. Correct. Do you have a sense of how many?

[Rep. Lori (Laurie) Houghton (House Health Care Committee, guest)]: I can say from my business office, we have two folks in our analytics team, because previously a team of four, now it's a team of two that we will start to actively hire for. But in the business office specifically, we are 15 and we've had about two or three lead that we have just started. For that particular unit? For that particular can't speak for the rest the units, right? For my unit, that's effective.

[Robin Scheu (Chair)]: Yes, so return to office is impacting some of the work that's That would be good to get some more information about that. And then the other one, we sort of talked about it except I don't really understand it, sorry, is in B307, the applied behavior analysis coding for corrections is a decrease of 1,400,000. Just help me understand in plain English what that means.

[Kascionne Gross (Commissioner, Department of Vermont Health Access)]: Yeah. So in our applied behavioral health benefit, which is a benefit for children with autism disorder, have taken a look at there is a need to look at our concurrent billing practices. This comes from the federal compliance lens that they were looking, that there were, in their audits, in the federal audit, they were really looking at states with this benefit, and whether they had plans. And what we were seeing is a high number clawback from the Feds on that. And we viewed this as a risk. And so part of this is to have a now have a starting January 1 is a concurrent delete policy. And because of that, we're no longer allowing the billing of two codes at the same time. And we will see a reduction in spend there.

[Robin Scheu (Chair)]: So again, this is not my wheelhouse. So does that mean that families who have, let's see, heard you say children with will they not get the same services that they used to be asking, or will they have to pay more money as a result of

[Kascionne Gross (Commissioner, Department of Vermont Health Access)]: that? So neither one of those. So what we're saying is that you're paying for the patient's time and not for having providers at the same time of the billing. So the patients are expected to have the same level of service moving forward. We're just not allowing the providers to bill two codes at the same time. If the one of the providers, they're no longer allowed to pay, yes. And that's the reason why you see a

[Robin Scheu (Chair)]: reduction Someone's getting paid.

[David Yacovone (Member)]: Yeah. So Wayne and then Dave. So essentially, double billing.

[Kascionne Gross (Commissioner, Department of Vermont Health Access)]: Yes.

[Wayne Laroche (Member)]: Well

[Kascionne Gross (Commissioner, Department of Vermont Health Access)]: Well, not really double billing. No. No. No. It's too No. It's concurrent billing of where one billing was a supervisee and the other one was a supervisor. And so we're no longer allowing that billing to happen. So we're no longer paying for the supervisor, the train, the license. We're on. I

[Alicia Cooper (Director of Managed Care Operations, DVHA)]: heard

[Robin Scheu (Chair)]: about this. So if you're in training and you need a supervisor, there's a cost to the supervisor training the trainee, and now they can't bill The supervisor doesn't get paid for supervising the trainee.

[Kascionne Gross (Commissioner, Department of Vermont Health Access)]: During the same visit, yes, that's correct.

[Robin Scheu (Chair)]: So, Dave?

[David Yacovone (Member)]: New Hampshire did this, but then I was told New Hampshire pulled it back. Have you heard any more on the New Hampshire experience?

[Kascionne Gross (Commissioner, Department of Vermont Health Access)]: I would have to get back with our Medicaid policy. You say,

[David Yacovone (Member)]: Jeff, because when we met in December, as a small group, appreciate your help during that, we were told that New Hampshire was doing the same thing Vermont is doing, but then reversed it. So we said, well, good for the answer. And my understanding is also, correct me commissioner, I'm wrong, when the hands on worker is working with Dave in the school who has autism, concurrently at the same time, the supervisor and the hands on worker might be communicating and saying, I'm trying these approaches, what should I do differently? What's happening at the same time? My question is though, could the rate be increased for the hands on worker, the therapy person in such a way so that it's inflated to cover the ongoing supervision that they need. There is a possibility. And I also wanna say that there is a rate study for the ABA benefit, that

[Wayne Laroche (Member)]: it's due So from the

[David Yacovone (Member)]: that is possible? So it's possible.

[Robin Scheu (Chair)]: Wayne you look like you want to say something.

[Wayne Laroche (Member)]: I don't know if I should. I mean back to the services being provided to someone and you get another person that is being paid at the same time. But the billing is for, should be for, what's being received by the person. The training is something else.

[Robin Scheu (Chair)]: Yeah, I don't I think that requires a little more digging into it, Laurie.

[Rep. Lori (Laurie) Houghton (House Health Care Committee, guest)]: We have this on our agenda and the policy committee tomorrow.

[Robin Scheu (Chair)]: They may be spending a lot of time in your committee tomorrow. That's why we have the health care committees. We don't always understand it, and that's why I ask crazy questions because I really don't understand a lot of this stuff. Okay, was there anything else that anybody wanted to ask of Diva while they're here with us? I really appreciate you all coming in. More to come from the health care committee. Dave is our liaison. Thank goodness, Dave, you're the liaison. And we'll funnel questions through him, and then the health care committee will also know a lot more. So we really appreciate your time. Thank you very much. So committee, you have a few minutes to work on your budget areas or whatever. And then we're back at 01:00 with the Agency of Education, and the Secretary of the Agency of Education is actually going to come into our community this time. So we'll see you all at one.