Vermont Legislature SmartTranscripts:

[Val Taylor (Prospective Member)]: Hi

[Alyssa Black (Chair)]: everyone, welcome, welcome back. Today is Tuesday, January 6, it's 01:00, and this is the first meeting of House

[Francis McFaun (Vice Chair)]: of Hope

[Alyssa Black (Chair)]: Care of this session. So welcome back, everyone. I wanted to just spend a few minutes to, first of all, introduce a couple of new people. So we have, obviously, Representative Portis resigned and we have her replacement. So why don't you go ahead and introduce yourself to everyone in the committee?

[Karen Lueders (Member)]: Hello, committee. Delighted to be on this committee. Rep. Cornes was someone I admire and like very much, I

[Karen Lueders (Member)]: haven't just heard from her, she just

[Val Taylor (Prospective Member)]: talks to me and

[Karen Lueders (Member)]: says hello to everybody. This committee is doing really important essential work, I'm really, I'm just really pleased to be part of that. I live in Lincoln, I represent four towns, and I'm ready to get going. Great, what's your background, Karen? I'm a lawyer, I opened up my law practice in 1988 in Bristol when I started helping with families. And I've been doing that all that time since. I was briefly working with legislative counsel for one session, and before that I worked for the Supreme Court. I love the arts and music as well, so I have a very strong interest in those areas, and I play piano, and yeah, that's about it.

[Alyssa Black (Chair)]: Well, we are thrilled to have you. Yes, are. We make it happy. And if anyone was paying attention today on the floor, there was a game of musical chairs. And if anyone was taking note, there was one empty chair left at the end of all the changes that happened. And while technically the speaker has not introduced our other newest member to take the empty chair, I've asked that Val Taylor come in and introduce herself and spend a little time with us.

[Val Taylor (Prospective Member)]: Yeah, I'm Val Taylor. I represent, I actually was appointed in Jim Harrison's position, so District 11. I'm a room owner, I'm self employed since I was 12. I'm a house painter. And when we started our family, was assisting my husband in his business. He's an arborist. An arborist? An arborist. I

[Brian Cina (Member)]: know. You ever painted the trees?

[Jill Mazza Olson (Medicaid and Health Systems Director, AHS)]: I never painted a tree.

[Val Taylor (Prospective Member)]: Thank you. Thank you for having me. I'm excited to

[Alyssa Black (Chair)]: meet everyone here. Excited to have you. Sound welcome. And I've actually asked our stellar JFO, Nolan Langwell, over the next ensuing days, weeks. I'll have Nolan sit with both of you, trying to give you some healthcare 101 because you're going to be jumping into some things really quickly that are going to go right over your head and that's okay. I'm not worried about it. So please don't be worried about it. Well, of all, everybody have a good off session.

[Brian Cina (Member)]: Yeah. What's the definition of good?

[Alyssa Black (Chair)]: What was the most exciting thing you did this obsession that you want to share that the whole public has come out of? You want me to start? Make bread?

[Brian Cina (Member)]: There's a lot of things that were exciting, but I would say the most exciting thing that I'm ready to share publicly right at this moment is we took my friend who was very sick and who we thought was gonna die, but he he's not gonna die anytime soon that we're aware of, hopefully. But when we thought it was gonna happen, we took him to do this lifelong dream of visiting Paisley Park, which is Prince's music studio. And so we got to go to Minneapolis, which is a city I'd never been to. So I studied the architecture there as part of my opioid policy fellowship. Then we went to Paisley Park. That was really exciting. And then Prince has appeared in the pop culture in ways that were even more exciting recently, for those who might know what I'm referring So to without spoiling that was a real treat.

[Val Taylor (Prospective Member)]: Next. I'm trying to think of the movie now.

[Brian Cina (Member)]: What Purple Rain?

[Alyssa Black (Chair)]: Yeah. What's the movie? I can't think.

[Brian Cina (Member)]: Oh, what show? Yeah. You're gonna spoil it.

[Jill Mazza Olson (Medicaid and Health Systems Director, AHS)]: I'm sorry. I'm sorry.

[Brian Cina (Member)]: Critchlow played a pivotal moment in the finale of a a Great. Cult

[Allen "Penny" Demar (Member)]: Wait, hope

[Alyssa Black (Chair)]: hold on one second. Since we have twenty minutes to kill, everybody all day today has been asking me what my legislative priorities are. And frankly, what my priorities are, are not nearly as important as what our priorities are. So thing, just something that you want to work on this year.

[Brian Cina (Member)]: So we're rewinding. I'm gonna okay. So my name's Brian you know what? Maybe you say our name and our district too. So I'm Brian Cina from Burlington, Chittenden 15, which is the old North End and most of the East District. I already shared my highlight of the day of the year, which is visiting Paisley Park in Minneapolis. And I'm an Aquarius. Like sunsets and gardening. My priority, that's what it is, one of my priorities that's relevant to this committee is artificial intelligence in the healthcare sector. And I'll be sending all of you a bill to look at and consider co sponsoring by the end of the day.

[Val Taylor (Prospective Member)]: He's way ahead of us in all of this, but

[Alyssa Black (Chair)]: we're all good working to learn. Right?

[Val Taylor (Prospective Member)]: Wendy Critchlow from Colchester, that would be chitting at 19.

[Karen Lueders (Member)]: What did I do that

[Wendy Critchlow (Member)]: was fun? I did nothing that was fun. I had two weddings, yeah, and I have a new baby, but that didn't come until after,

[Alyssa Black (Chair)]: but yes. I had to work and

[Wendy Critchlow (Member)]: I worked for Vermont Health Connects and I just would like to say Thank you for your work. It's good. I don't know how we can do this. I want to

[Alyssa Black (Chair)]: say universal healthcare. That would be nice. Because

[Wendy Critchlow (Member)]: I don't see any way out of it. I'm sorry, I'm

[Alyssa Black (Chair)]: not going to be found like

[Wendy Critchlow (Member)]: a defeatist, but I'm watching what's going on

[Alyssa Black (Chair)]: at the state level, and it's, people are dropping left and right right now. They just don't want insurance, and it's very sad. That's it, okay, didn't mean,

[Wendy Critchlow (Member)]: something, I do have a new grandbaby that

[Alyssa Black (Chair)]: was just That's hard what for looking like beautiful. A Christmas present. And going down Saturday to go see the entire fall. Yeah. I think I'll skip over Mel, because you've already introduced yourself, and I don't know if you have any legislative priorities on healthcare, since you I'm gonna get my feet wet. That's good.

[Val Taylor (Prospective Member)]: Ask them to get an amount there.

[Allen "Penny" Demar (Member)]: That's great. Allen Demar, representing Montgomery, Neenah Spur. And I only have one priority, healthcare affordability. What? Healthcare affordability. Healthcare affordability.

[Brian Cina (Member)]: Affordability, thank you. That's what I said.

[Allen "Penny" Demar (Member)]: That's my only priority.

[Alyssa Black (Chair)]: Anything fun, Charlotte?

[Allen "Penny" Demar (Member)]: No, did I do that? I'm always having fun.

[Alyssa Black (Chair)]: Everything was fun. Was What

[Val Taylor (Prospective Member)]: was your fun thing you did to someone? One highlight.

[Allen "Penny" Demar (Member)]: Well, I got a granddaughter that's 18 years old that had her pilot license at 17. And she wanted to take me for a ride and I chickened out. Now she's in Florida at college or whatever it is she does. It's pretty impressive to see a 17 year old piloting her own airplane. And

[Karen Lueders (Member)]: I think I shouldn't.

[Allen "Penny" Demar (Member)]: But I still won't ride. Did

[Brian Cina (Member)]: you catch any deer? That's the question.

[Allen "Penny" Demar (Member)]: I didn't hunt this year. My family had some issues, and I just got some health issues in the family. Too much. Everything's fine, I'm happy.

[Alyssa Black (Chair)]: Oh, good. Good.

[Lori Houghton (Member)]: Lori Houghton. I represent the city of Essex Junction, And I spent a lot of time in Maine this summer with my family, which is really fantastic. And my son is

[Jen Carbee (Office of Legislative Counsel)]: a senior, so we're in the midst of waiting to hear from colleges,

[Lori Houghton (Member)]: which is pretty exciting. And I think what I want to work on and continue working on is kind of gets to the affordability piece, and that is still continuing the work on the transformation we're trying to do of the health.

[Alyssa Black (Chair)]: Yes, I'm Leslie Goldman. I represent the Bells Falls area. My biggest adventure this summer is I took a medical mission to Papua New Guinea, which was an enormous adventure. And I was working on a thread with village birth attendants. So these were women who had no education and learned their craft being handed over by their peers and older people.

[Leslie Goldman (Member)]: And what was really moving to me was the universality of a woman's experience of birth. They were asking the exact same questions about how to manage birth that we ask here at the infant hospitals. So I was just really fucked up. What am I interested in? I'm interested in making healthcare affordable, accessible, having better outcomes, stabilizing our hospitals. I'm from the South, we are hearing a lot about Brattleboro, I'm worried about that. How do we support that? So those are the questions I'm entering. It's very broad, and it's a bit of a mystery. I know it's only been

[Addison "Addy" Strumolo (Deputy Commissioner, Department of Vermont Health Access)]: a few hours.

[Alyssa Black (Chair)]: Any priorities, or did you do anything come summer? Winter, summer? That's a

[Karen Lueders (Member)]: good question, I mean, it was a good summer, I don't really, ever since mid October, it's kind of a blur.

[Alyssa Black (Chair)]: But as to healthcare, everything everyone has said is really important. I think making sure we

[Karen Lueders (Member)]: have access to primary healthcare and that those resources are available because not only is it more cost effective, at least to better outcomes, it's a better use of money. And having people in the hospital when they shouldn't be there is a more use of money. And so I'm glad that the legislation passed last year has some mechanisms, so I'm glad about the federal award and just wanting to be really thoughtful and careful systemically about how that can improve affordability. It.

[Alyssa Black (Chair)]: Deb, our new clerk. If you recall at the end of the year, since Mari had previously been the clerk of House Healthcare for many years, Deb is going to take over that role.

[Francis McFaun (Vice Chair)]: She's a big, loosely folded hesitation on her.

[Alyssa Black (Chair)]: Thank you, Deb. You, Deb.

[Debra Powers (Member)]: I might have got a little untold. Debbie Powers, I represent Waterford Burnett Reggate, and I do want healthcare to be more accessible and affordable.

[Val Taylor (Prospective Member)]: And health insurance also.

[Ashley Berliner (Director of Medicaid Policy, Agency of Human Services)]: Okay.

[Francis McFaun (Vice Chair)]: My name is Chagra McFaun. I represent Barrytown and parts of Williamstown. I've been in the legislature for twenty one years. I should be 22. No objection to that?

[Allen "Penny" Demar (Member)]: No,

[Francis McFaun (Vice Chair)]: I did not have a good summer. My wife is injured and we spent most of the summer in either the hospital or the rehab center. So she is doing okay now. What am I interested in? Reconstructing the healthcare system so that it's more accessible, keep the quality and it costs less. And I have to tell you, I've been working on that for all the time I've been in the legislature, it's starting to come to fruition now. My buddy over here and over there, have helped it come that way too. So, that's essentially, what I'd have to say, you'll get to know me, you're gonna have some fun with me, for sure, and I'm gonna have fun with you as we go through this process. Because you get a lot on the table this time, And I'm hoping that we're gonna move the right way. And we're all gonna be involved in that.

[Alyssa Black (Chair)]: I'm gonna skip over myself and go to

[Lori Houghton (Member)]: see when the best for last. I'm Daisy Berbeco. I represent Windham.

[Francis McFaun (Vice Chair)]: Let's

[Jen Carbee (Office of Legislative Counsel)]: see. I had a

[Daisy Berbeco (Ranking Member)]: great break. Although I'm gonna be totally honest, and I suspect that similar to some of you, it wasn't much of a break. I worked with a lot of our stakeholders over the summer. There were multiple health care emergencies that don't wait for us to get back in session to fix. I mean, we're a citizen legislature, but we represent our communities three sixty five days a year. So I had a great time back in my community and really reconnecting with them and especially two of my favorite constituents, and Cambria, my kids, who all of you have met. And Val and Karen, you'll meet them too. My priorities for this year is I want to help facilitate better communication among the committee. So us getting together and doing breakfast more, supporting Alyssa and coordinating things like that. And my policy priorities remain rooted in making sure that we don't forget mental health care, and especially youth mental health. And right now, our providers really could use our support. They're barely making ends meet. So helping to make sure that we're always remembering them is my goal this session, and just getting to know everybody a little bit more deeper so we can do good work together.

[Francis McFaun (Vice Chair)]: And I forgot something. And the chair, as usual, allows me to speak once in a while. Whatever you want.

[Alyssa Black (Chair)]: I love that.

[Francis McFaun (Vice Chair)]: Since I talked about a negative thing about the summer, after the summer was over and Christmas holidays and all that came around, I had one of the most wonderful Christmases I've ever had in my life. I have six grandchildren and they are all over the world. And my wife and I got a call from one that was on the ski lift in Jackson Hole, going up on the ski lift and he says, I just wanna tell you that I love you too. I had another kid call from Mexico and he said the same thing And at a, he and his wife, new wife, went back to the place where they met. And I remember the Christmas that he didn't come home. I was sitting there and his mother was there, and his mother said, What's her name? And that's what it was, so they went back to there. One of my grandchildren came from Belgium and she was present, the two youngest grandchildren were present. And of my grandchildren, she was in the hospital, she called from the hospital bed said, because she was planning to be there but she got sick. So my wife and I had a wonderful Christmas. So the whole year wasn't ruined by that summer, we had some good times. Thank you, madam chair.

[Alyssa Black (Chair)]: I'm glad you had a wonderful Christmas,

[Jill Mazza Olson (Medicaid and Health Systems Director, AHS)]: because I

[Alyssa Black (Chair)]: do know that you had a good, You were intimately acquainted with our healthcare system. I sure was. So I'm Alyssa Black, I represent Classics. January 6 is obviously a date that you remember. So I was sworn in exactly five years ago, 2021. I was kind of reflecting on this a little bit in the last couple of days. I had a pretty good off session. I really prioritized some things in my life. I did some great travel. I went to new communities. I was recently in London, but I actually got to go to Istanbul, which has been number two on my lifetime bucket list. And I just absolutely thoroughly enjoyed that. So I've gotten some great travel. I've gotten to spend some wonderful time with family and friends. I took down, I think the highlight for me, strangely enough, which is a little sad, was taking down my Christmas tree on Sunday. And I was so sad that I was taking down my Christmas tree because my house had just looked beautiful with it. And I had all these decorations that I've been accumulating over the last eight years, and they have never seen the light of day. It's the first time I put up a Christmas tree in eight years. It's the first time I've decorated, and it's frankly the first time I've actually really celebrated Christmas. So, Christmas for me was the highlight of my year. But now we're back here in the trees out on the curve, waiting for the town of Essex to come pick it up.

[Brian Cina (Member)]: Very small.

[Alyssa Black (Chair)]: Priorities. We have a ton of priorities. I'm going to cite Nolan every single time I just did a radio thing with VPR. Vermont Public, I'm sorry. I still call it VPR. And last year, we dealt with so many emerging crises. And if you went through our YouTube and you stacked up every single person that sat in this witness chair and said things like crisis heading off the cliff. Mean, what we dealt with Blue Cross Blue Shield of Vermont, what we dealt with UVM Health Network, what we did around 340B and the price cap, reference based pricing, all of the things that we dealt with. First of all, we did amazing work last year, just absolutely amazing work. The house was on fire. The house is still on fire. It's still on fire. It's incumbent upon us to ensure that what we do here sitting around this table for the next five months is that we have oversight and accountability for all the things that we've put in place. We had a couple HRAC meetings this session, and we set some very, very tight timelines last year. And to Lori's point about hospital transformation, keep them till 2029. And I am deeply concerned that if we don't move quickly and move forward on hospital transformation, we might not have any hospitals to actually transform. So we're still on fire. A family last year at 400% of the poverty level, which is solidly middle class, paid over $10,000 a year for a family of four. And this year on the exchange, they're paying $52,000 a year. That, under any definition, is not affordable. That's what we need. Everybody around here has a theme of affordability, and we will be continuing the work that we started last year and building upon that work. So that is my hope. Yes.

[Brian Cina (Member)]: I just realized that the new members told us what they did besides being a legislator, but I don't know if anyone else said to them what they do besides being a legislator. And I wondered if maybe we can quickly each do that so that they know that this isn't just all we do.

[Alyssa Black (Chair)]: Oh, well, speaking of that Speaking of what I did this summer, I spent an enormous amount of time in the business that I now work in as I'm calling myself the CFO, it's really not that big of a CFO. And I am learning all sorts of new, fun, fascinating things about automotive repair. And a couple of people sitting around this room, it got to the point where I was having to leave so often and my business partner would give me a shifty eye about where. So I believe three separate people in the last month, and I'm going to cite a former senator, they're like, Oh, it's just like Dick Mazza. Because now I'm making everybody come to the automotive repair to have babies. You want to talk to me?

[Val Taylor (Prospective Member)]: We're going upstairs.

[Alyssa Black (Chair)]: Dick Mazza famously would only meet people at the store. That's what I do in the off session. In charge of the financials of an automotive repair business. Yeah, but we've got to get moving here. Jen, I put one thing on the table? Because I'm based from you guys, I'm looking at the guiding principles, so we may want to talk to our new members about those at some point. Actually, let's get more information about each other throughout, because there were a couple of things I wanted to say, just really business wise. First of all, yes, our guiding principles. And I famously am the person that had a meltdown over why are we spending all the time on this? This was years ago. And I said, when Lori sat in the seat.

[Jen Carbee (Office of Legislative Counsel)]: But you embraced it. I embraced it.

[Alyssa Black (Chair)]: Embarrassingly, and I've actually used some of them in floor reports, I look up to them all the time and I think, oh, yeah, that's what we're doing. Couple of housekeeping things. All I ask from you is that you be on time. Our witnesses deserve the respect of us being on time. Their time is important. Please, please make an effort to be on time in committee. If you're not going to be here, if you're going to be late, let someone know. Tasha. Oh, oh my gosh. Yeah. Oh, I'm the worst. Forgot. We need to introduce our new committee assistant. Hi everybody, I'm Tasha Kaffner, I'm the new committee assistant. It's nice to meet all

[Val Taylor (Prospective Member)]: of you and I look forward to working with you over the next few months.

[Alyssa Black (Chair)]: We are so thrilled to have you. So thrilled, despite the fact that I just spent thirty minutes we're really thrilled to have you. Looking forward to it. So everybody get Tasha's number if you're going to be late or if you aren't able to make it, please let somebody know so we're not waiting on you. Again, I find it a respect thing for our witnesses. Their time is important, just like our team is important. Also, wanted to mention something, two things about respect. And I said this at the beginning of last year, and I just want to set a reminder that we have in our committee were served by our staff. And in particular, we have Nolan from JFO. We have Jen Carby from Legislative Counsel, and we oftentimes as well have Katie McLennan from Legislative Counsel. Our staff works for all of us, But please be respectful of our staff's time. And if there are things that you can find out on your own, find them out on your own. Don't burden them, because they're really, really, really busy. I mean, heck, you saw all the bills they had to write. I was thinking about you on the floor today because every other bill, it seemed like healthcare, healthcare, and I'm like, She's been busy. She hasn't been traveling all over the world in the last. So please be respectful of our staff, even though they work for all of us. And I do appreciate that. The other thing I want to say is we had a couple incidents last year, and I really want people to reflect and think on this a little bit. We deal with some topics in here that are deeply, deeply personal to all of us. I mean, we're dealing with the health and the lives of Vermonters. And I want us to remember that the witnesses that sit in our chair are people too, and they deserve our respect. And we did have a couple incidents last year of which I take full responsibility. But there were some times when we were not respectful and we turned a few of the things that happened with some witnesses, we turned them into personal and almost in a way personally attacking the witness. We should never ever do that. And I just want you to know that I'm going to be very, very cognizant of that this year. These people are here to give us information and help us, but we do not need to ever attack anyone personally or make comments personally. And I'm not going to go into the specific situations, but I just want us to remember that the people that they're doing their job and they're here doing their job and they deserve respect. And so let's try to keep our comments professional and not get into the personal rep. I think that was it.

[Francis McFaun (Vice Chair)]: I'll add one thing too.

[Alyssa Black (Chair)]: Of course, you always definitely

[Francis McFaun (Vice Chair)]: ask me.

[Alyssa Black (Chair)]: No, no, no,

[Francis McFaun (Vice Chair)]: no, no. That, what she's just talking about, that goes for all of us too. We have to respect each other, we have to work together. We may have different ideas, we may feel differently about a particular subject or the way we are going to solve a problem, but remember, it comes from the heart from everybody. And just work together and respect each other, and we'll get a lot of good things done. Thank you. Yeah. You've got the last word.

[Alyssa Black (Chair)]: Well, I was going say, you know, the speaker asked for my input, she didn't actually, frankly, she didn't ask for my input, but I did know that I was going to be getting two new committee members, And my only directive to the speaker was, I don't care if anyone has healthcare experience. I can teach or I can't, staff can. People will learn. I'm not worried about that at all. And I think that it goes for every single person that sits around this table that I just want people who have a core set of values and I always want you to follow your core set of values, even if they are at odds with someone else. That is your job and that is why you're representing your constituents and that's why they've elected you. So always do that. Okay. Let's have Jen come up.

[Addison "Addy" Strumolo (Deputy Commissioner, Department of Vermont Health Access)]: Sorry, I

[Alyssa Black (Chair)]: didn't get into your time. Oh, wow, I really got into your time. I'm so sorry. So I wanted Jen to do an overview of what we did last year and updates of things that have happened, because I think even I sometimes forget what we did.

[Jen Carbee (Office of Legislative Counsel)]: Well, good afternoon. Jen Carvey from the Office of Legislative Council. I see those of you who are returning, and welcome to those of you who are new. Look forward to working with all of you. So I am one of the two attorneys who spends the most time in this committee from the Office of Legislative Counsel, and I'm going to take you most of you on a walk down memory lane, all the exciting things you worked on last year. And there were a lot of things, even some of them I didn't remember because you were quite busy. So put together a presentation. Hopefully, we can

[Val Taylor (Prospective Member)]: easily make work. Can we have this posted on our page? It's not yet, but I will post it on my face now.

[Alyssa Black (Chair)]: Okay. Realizing we have no date for today. Dates. Okay.

[Jen Carbee (Office of Legislative Counsel)]: So what did you pass in 2025? And by which I mean, what bills that went through this committee became law? And there's one in here that spent a little time in your committee, but has some relevance, so I included it as well. I need these controls somewhere else because they're blocking my contact. Alright. So the first thing you did and became act two, so very early on in the session was to permanently unmerge the individual and small group health insurance markets. And that took effect just a few days ago on January 1. These markets had been merged as part of the implementation of the Affordable Care Act. They had been temporarily unmerged on a year or two basis since 2022. And last year, after testimony from many different stakeholders who advised this courts of action, permanently unmerged those two markets. So now they have separate separate premiums, separate risk pools. Act three, you did some sort of cleanup work on a bill you had worked on the year before or some of you had worked on the year before on claim edit standards. So health insurance claim edit standards and prior authorization requirements. There have been a couple of issues that came up after the 2024 session. There were some recommendation to address, again, pretty early in the 2025 session. So the first one was dealing with what happens when there are health services delivered outside Vermont and how do Vermont's requirements on claim edit standards apply. And so language was added to specify that those out out of state services are exempt from our required claim edit standards that health insurers have to follow unless the insurer and the out of state provider agree that one or more of them will apply. The second was to define primary care. So there was an exemption from prior authorization requirements added in 2024 for services ordered by a primary care provider. And there was a definition that wasn't providing sufficient clarity. So this added a definition saying a primary care provider for purposes of the exemption from prior authorization requirements is a provider who is contracted and enrolled with the health plan as a primary care provider. So if they meet the health plan standards to be a primary care provider, then they will be exempt from that carrier's prior authorization requirements for most services. Act six dealt with the Office of the Healthcare Advocate. So there was some language throughout the bill that expanded the scope. The Office of the Healthcare Advocate language had dealt really primarily with health insurance, and this broadened it to reflect the role that they have assumed over the years, which is addressing affordability and access to care for all Vermonters and not just those on health insurance. It also expanded the Advocate's ability to ask questions during the health insurance rate filing process. It requires the Green Mountain Care Board. So even though it's in the Health Care Advocate bill, this is requiring the Green Mountain Care Board to make the whole record of a health insurance rate review available to the public. They have to redact confidential information, but otherwise, the whole file becomes public. It also enlarged the role of both the healthcare advocate and kind of their counterpart for long term care, the long term care Ombudsman's office. When they intervene in an application for a certificate of need, we'll see more about certificates of need coming up. It has some fairly broad language requiring state agencies to seek input from the healthcare advocate when they're developing policies affecting healthcare access and affordability and to provide I keep having to move my arm to provide access to the health care advocate to confidential or proprietary information when appropriate as long as the health care advocate's office does not further disclose that information. That was Act six. Act nine, this is the only one in this slide deck that I didn't draft. So you will all have more familiarity with it than I do. This is one that Katie worked on with you. But this requires hospitals to develop and implement security plans for preventing workplace violence and managing aggressive behaviors, and that had to be based on the results of doing it of having a security risk assessment done for each hospital. Then hospitals must use a workplace violence incident reporting system to document, track, analyze, and evaluate any instances of workplace violence. It excluded from certificate of need requirements hospital expenditures that are necessary to implement the security plan, and it requires hospitals to report the costs of implementing their security plan as part of the hospital budget review process so that the board can take those costs into account when establishing hospital budgets. Hopefully, this looks familiar to you.

[Alyssa Black (Chair)]: When did that go into effect, Jen, that that required updating the Green Mountain Care Board?

[Jen Carbee (Office of Legislative Counsel)]: That's But I I I don't know. I don't know if anybody in the room was following this enough to know. Pull that

[Alyssa Black (Chair)]: up. Yeah.

[Addison "Addy" Strumolo (Deputy Commissioner, Department of Vermont Health Access)]: I can I know they're already working on

[Alyssa Black (Chair)]: I only I tried to put in the effective date if

[Jen Carbee (Office of Legislative Counsel)]: it was something sort of unusual? But for the most part, these were, I think, effective, like, 07/01/2025, but I can take a look. I think the idea was just that these costs should be accounted for in the hospital budgeting process, and hospitals shouldn't be dinged on their hospital budgets because they were having to

[Francis McFaun (Vice Chair)]: implement them.

[Brian Cina (Member)]: I just looked at your act some I'm assuming you would be act some way.

[Jen Carbee (Office of Legislative Counsel)]: Did because this is Katie's bill.

[Brian Cina (Member)]: And it says 07/01/2025.

[Karen Lueders (Member)]: Great. Alright, now

[Jen Carbee (Office of Legislative Counsel)]: we're back to my bills. Act 11, very large bill, very short write up. This was updating and reorganizing the health insurance statutes in APSA chapter 107. This is my labor of love project.

[Brian Cina (Member)]: This is mine too?

[Alyssa Black (Chair)]: My my Yes.

[Jen Carbee (Office of Legislative Counsel)]: This was yours.

[Alyssa Black (Chair)]: Think it was yours.

[Jen Carbee (Office of Legislative Counsel)]: And so this has been great. We overhauled the chapter. In this committee, we talked about the effective date, which you changed to 09/01/2025, which worked out great because I was able to get it incorporated into the brand new, hopefully up there, title eight part one book. So going forward, it will always be the same book as the new version. All right. Act 14. This is the one that did not spend a lot of time in this committee. It was mostly my asterisk there. It mostly down the hall in House Human Services. But because it deals with, among others, the designated and specialized service agencies, I wanted to make sure to point it out. So this is Medicaid rates for community based service providers. And this act requires the Secretary of Human Services to calculate payment rates for providers of community based services, and it specifically includes the DAs and SSAs, in the Medicaid program that are reasonable and adequate to achieve the required outcomes for the populations they serve. And then it directs the secretary to establish a methodology for calculating those rates that includes a schedule for conducting Medicaid rate studies. So they're continuing to kind of do a deep dive on different provider type Medicaid rates, set out a predictable timeline for redetermining base rates, and come up with a process for calculating an annual inflationary rate adjustment. So the important piece to remember is this next bullet, which is it directs the secretary to recalculate, do the math, at least annually, and report those rates and the cost of funding them annually as part of the agency's budget presentation, but it doesn't automatically commit the legislature to funding them. So this is really an effort to have you have at least from the agency's perspective, kind of the official word on what they should be getting paid and how much less if it's less they are being paid and what that gulf looks like so you can make decisions on how you want appropriate money. It also directs the Secretary to establish a process for providers to request stabilization assistance from the agency if they're at imminent risk of closure. So this is sort of analogous to the nursing home extraordinary financial relief, but there was interest from the agency in not using that same terminology here. So it's provider stabilization, but same idea if they're at imminent risk of going under. And it requires the agency to provide an implementation update on this act by January 15. So next week, you should be getting, right, an update on this. That report has not come in yet to my note. Great. Next is act 15, which is again, can't see the title, but something having to do with certificates of need. It increases the monetary thresholds for when a certificate of need, a CON, is required. So you might remember it also and it aligned the triggers for hospitals with those for other healthcare facilities. Remember, for those of you who were here last year, we used to have two sets of triggers that were a little bit different if it was a hospital or a healthcare facility other than a hospital, and you significantly increased the monetary thresholds and left most of the non monetary thresholds in place, but just have one set of rules for all facilities. And in addition to some new CON exclusions added in some other bills from last year, including the hospital security plan and the freestanding birth centers we'll see coming up, you added new CON exclusions in this bill for fully depreciated medical equipment, ground ambulance services, and emergency medical equipment and supplies, and new services or projects for facilities that are owned or operated by the state or funded by contractor grant from the state, but you did put in a notice requirement. The Green Mountain Care Board would have to get notice that this new project is happening. But the discussion in this committee was if there has been a decision made by another part of state government that a particular service or construction project is appropriate, it shouldn't have to go through a certificate of need process, but there should still be that awareness for the board. So far, so good. Hopefully, these are sounding familiar to most of you. Alright. Act 19 was the licensure of freestanding birth centers. You created licensure requirements for freestanding birth centers and directed the Department of Health to adopt rules, including the requirements for operating a birth center, what scope of services a birth center can offer, and requirements for written practice guidelines and policies that include transfer procedures if a patient needs to go to a hospital, in collaboration with other providers who would be providing services to the same patient. Here we have another exemption from the CON requirements for these birth centers and the language required health insurance plans that cover maternity services to cover those services when they're provided at a birth center. And you also directed the Agency of Human Services to seek federal approval for Medicaid coverage of services provided at a birth center. Section 20, dealing with what I've termed certain legally protected healthcare services. Some of you may remember from twenty twenty three that term legally protected health care services deals with access to reproductive health care services and gender affirming health care services. And so there was an Act 15 of 2023 along with Act 14 that went through the judiciary committees, did a lot of work on that topic. The one that went through this committee was really focused on the health care side of things. Act 20, S 28 from last year, made some updates and additional provisions. The first was to create some reciprocity language with other states that protect access to reproductive and gender affirming care, basically saying if a provider that we have a lot of protections in Vermont law for providers who deliver these services in Vermont. If a provider from another state who was acting under that state's similar legally protected health care kind of laws provided services there that would have been permissible if they were provided here by a licensed provider. If that provider comes to Vermont, Vermont will extend the same kinds of protections, including not cooperating with extradition proceedings for that provider as though they were a Vermont provider.

[Brian Cina (Member)]: I can look it up, but I think the group should know the answer to your question. Can you remind us of how it expanded the scope of conduct that violated the Consumer Protection Act? If it's not easy to do, I'll look it up and we can talk about it.

[Jen Carbee (Office of Legislative Counsel)]: Yes, but let just get to that first. It's still just on bullet number one.

[Brian Cina (Member)]: Oh, think you read through them already. No. That's funny. Read through them and she's talking and

[Addison "Addy" Strumolo (Deputy Commissioner, Department of Vermont Health Access)]: then I'm like, okay.

[Alyssa Black (Chair)]: She's still on the reciprocal.

[Brian Cina (Member)]: My bad. My bad.

[Jen Carbee (Office of Legislative Counsel)]: I'm talking about reciprocal.

[Val Taylor (Prospective Member)]: Okay, sorry.

[Jen Carbee (Office of Legislative Counsel)]: It's okay. So the second bullet here is to exempt records that are held by the state's professional licensing entities from disclosure under the Public Records Act if they contain personal contact information for the applicant or licensee other than an address that the applicant or licensee designated as a public address. So this is to keep their personal home and, and phone number, home address, phone numbers, things like that from being disclosable under the Public Records Act. It amended the unprofessional conduct laws for several health care professions to as unprofessional conduct advertising that has that is misleading or has a tendency to mislead and for letting someone's name or license be used if they are not actively overseeing the services that are being provided in their name or under their license. The act allowed a healthcare provider to prescribe medication to terminate a pregnancy based on an adaptive questionnaire that will allow the provider to ask follow-up questions if needed. A lot of discussion in this committee on that. Is the bullet that that representative Cina was asking about. So the Act expands the scope of healthcare related conduct that violates the Consumer Protection Act. Previously, the language had been specifically around limited services pregnancy centers. This expands that to apply to anybody offering health or doing advertising relating to health care services in this state, so regardless of setting. It also added federal investigations and proceedings to non cooperation language. The 2023 legislation, particularly on the judiciary side, had language in it directing state employees and officials not to use any of their time or resources to assist in an out of state investigation into somebody who is providing legally protected providing or receiving legally protected health care services if that was in in order to impose civil or criminal liability on them. This is adding federal investigations as well. So directing that nobody in state employment should be dedicating time or resources to cooperating with a federal investigation or proceeding that's seeking to impose liability for legally protected health care activities. Modified the limits on disclosure of protected health information related to legally protected health care activity, including, again, adding some limits on disclosure to the federal government that otherwise would be permissible under HIPAA. But this would say under Vermont law, is not. And finally, it allowed prescribers and pharmacists to have their names removed from prescriptions for medications for reproductive and gender affirming health care services.

[Alyssa Black (Chair)]: That is the discussion I remember the most. Yes. For bringing that back.

[Jen Carbee (Office of Legislative Counsel)]: Sure. We'll move on. Slide 21. This was medical debt relief and removing medical debt from credit reports. This act, this is a proposal from the treasurer's office. They requested and you approved appropriating a million dollars to the treasurer's office to contract with a nonprofit entity to acquire and repay certain medical debts incurred by Vermonters. If you remember, those of you who are here, they were going to be because they were old it was old debt. They were going to be acquiring them for significantly less than the original debt. And so that's about a million dollars would would go significantly further than just a million dollars in debt. To be eligible, there were certain requirements around the debtor. They must be a Vermont resident. They must either have household income, if not greater than 400% of the federal poverty level, or owe medical debt that is 5% or more of their household income. And their patient account still has to have an outstanding balance even after the provider has done their normal collection efforts. This act also added a definition of behavioral health to Title I of the statutes for certain purposes, which wasn't all that relevant to this bill, but it's in there. It allowed nonprofits to request a consumer's credit report without the consumer's permission, so to pull credit without permission in order to determine their eligibility for abolition of medical debt, usually have to get the consumers permission to pull their credit except for certain purposes. This added determining eligibility for abolition of medical debt to those purposes. It prohibits credit reporting agencies from reporting medical debts or maintaining medical debt information in a consumer's file. And it prohibits large health care facilities, hospitals, ambulatory surgical centers, things like that, and medical debt collectors from reporting medical debts to consumer reporting agencies.

[Alyssa Black (Chair)]: Just an FYI, we're asking the treasurer's office to come in late next week to give us an update on this, to see how it's going, what they've been able to accomplish so far. So looking forward to that. Yes.

[Jen Carbee (Office of Legislative Counsel)]: All right. I'd say we're almost done, but we're not almost done. Partly because I have a lot of slides on Act 68, which was the health care reform one you spent a lot of time on. Act 49 is the Green Mountain Care Board's authority over to to change hospital reimbursement rates and appoint a hospital observer. So this act allows the Green Mountain Care Board to reduce a domestic health insurer, which is really statute state for Blue Cross Blue Shield of Vermont. So it allows the Mountain Care Board to reduce Blue Cross Blue Shield of Vermont's reimbursement rates to one or more Vermont hospitals if that insurer faces an acute and immediate threat of insolvency. And some of these are terms that are defined in existing statute. There are certain parameters, and the board can only reduce rates to hospitals that meet certain fiscal criteria, so they have to be in relatively good fiscal health. And they can only reduce rates to the extent necessary to address the threat of the insurer becoming insolvent. So you put some safeguards around it, but that is a new authority for the board. You directed the board in setting hospital budgets to account for any significant deviation in the hospital's revenue during the previous fiscal year in excess of its approved budget. So they can do some kind of truing up in future years. You allow the Green Mountain Care Board to adjust hospitals' commercial health insurance reimbursement rates at any time during the year to ensure the hospital stay within their approved budgets so they can make more changes than just at budget time. And at least for a few years, you've allowed the Green Mountain Care Board to appoint an independent hospital observer under certain circumstances. And this is really to go in and look at and work with a hospital that may have made a one of the criteria is made a material misrepresentation in their budget filings, or I think has made a material deviation from their approved budget. This authority is repealed on 01/01/2030, unless you extend a concern, particularly from the hospitals, about this being an open ended authority. And so this would at least require a revisiting.

[Alyssa Black (Chair)]: I should know this since I actually reported this bill. Were there any other circumstances that we allowed for an appointment? Did it have to be material misrepresentation? Was that an and or an or?

[Val Taylor (Prospective Member)]: I need to get out

[Jen Carbee (Office of Legislative Counsel)]: of this for a second to look, so give me a second. See if I can look things up here. It was an or. You didn't have to meet multiple criteria, but let's see. Eight forty nine. So the language on this is the board may, upon finding the hospital has made a material misrepresentation in information or documents provided to the board or that a hospital is materially noncompliant with the budget established by the board, appoint an independent observer. So those are the two the two permissible criteria, either material misrepresentation and something provided to the board or materially noncompliant with their budget.

[Alyssa Black (Chair)]: Okay. Thanks.

[Jen Carbee (Office of Legislative Counsel)]: Act 50, Certification of Community Based Perinatal Doulas and Medicaid Coverage for Doula Services. This created a voluntary certification process for community based perinatal doulas through the Office of Professional Regulation and required the Department of Vermont Health Access to reimburse certified community based perinatal doulas for providing services to Medicaid beneficiaries during pregnancy, labor, delivery, and postpartum. The reason, as you may recall, that it's a voluntary certification process, it's not required. You could still be a doula, a perinatal doula, or even a community based perinatal doula without getting certified, but only certified community based perinatal doulas could be reimbursed through the Medicaid program. So that was the rationale for the voluntary certification. You expressed legislative intent that the reimbursement rates for these doulas should be reasonable and adequate for the services provided and consistent with rates set by other states' Medicaid programs for doula services. And you directed DIVA to seek a federal state plan amendment by 07/01/2026 to allow Vermont Medicaid to pay for doula services. Act 55.

[Alyssa Black (Chair)]: Just a quick question about, so they have to seek it, but it doesn't mean that we'll get it. And I that process may be think that they're going be updating us on this.

[Val Taylor (Prospective Member)]: Okay. Yes.

[Jen Carbee (Office of Legislative Counsel)]: Next we have Act 55, which is the 340B prescription drug pricing program. And we never changed the title, so I just gave you the parenthetical reminder that this is where the cap on outpatient administered drugs lives. So this restricts certain actions by prescription drug manufacturers regarding 340B contract pharmacies, 340B drugs, and patients of 340B covered entities. It creates a private right of action for anyone who is injured or harmed by a manufacturer's failure to comply with the provisions and requirements. And we may be hearing a bit there's some active litigation. You may recall getting a litigation hold notice through maybe me from the attorney general's office, and there is active litigation on many parts of this. So this may be part of a future conversation as well. The Act required hospitals to report information about their participation in the 340B program to the Green Mountain Care Board by January 31 annually through these reports through 2030, it directs the Green Mountain Care Board to post those reports on its website. So we still have a few weeks. I didn't see anything up there, but hopefully they're making space for that on the Green Mountain Care Board website. And then the cap part that I think is getting the most attention is that it caps the amounts that hospitals can charge health insurers for prescription drugs that are administered in an outpatient setting. And that cap is set at 120% of the 04/01/2025 average sales price. So if you remember, to those of you who were here when we worked on this, it was after 04/01/2025. That's why we picked a pass date certain so that we knew what those numbers were. If a hospital was already charging less than 120% of the average sales price on 04/01/2025, then the cap was the actual percentage of average sales price on that date. So it didn't allow them to go up to 120%. It capped it at whatever it was on that date. There were some additional provisions. A hospital can ask the Green Mountain Care Board to increase its reimbursement rates for other service lines if it can show that the price caps are negatively affecting access to care, quality of care, or the sustainability of rural health care services. It's specified that the price caps will remain in place unless and until the Green Mountain Care Board sets a different reference based price that applies to these drugs. And we're going to talk more about reference based pricing in a moment. And it carved out certain types of hospitals. These price caps do not apply to independent critical access hospitals that are not affiliated with another hospital or hospital network. So these are only non critical access hospitals. I'm sorry. Yes, it applies only to non critical access hospitals and critical access hospitals that are affiliated with another hospital or hospital network. Alright, I think we're down to the last two. Act 62 was an act relating to modifying the regulatory duties of the Green Mountain Care Board. It changed or eliminated some Green Mountain Care Board duties, including those having to do with health information technology and vital Vermont information technology leaders. The Board had been responsible for approving the state health information technology plan for reviewing and approving Vitals budget and some other HIT related standards that have largely shifted to other entities in state government. It eliminated the 8% allocation for accountable care organizations and the Green Mountain Care Board's bill back formula. The Green Mountain Care Board is able to bill back the entities it regulates for a portion of the cost of regulating them With One Care winding down at the 2025, there was not going be a lot of action on the accountable care organization front. And so there really was not 8%. Having an 8% allocation for ACOs didn't seem to make sense anymore, so you took that out. It significantly modified the ACO certification and budget review processes, including recognizing the need to certify Medicare only ACOs and the less need to do budget review except for potential future ACO that would contract with Medicaid or commercial insurance or both. Also set fees for ACO certification and budget review processes. It specified that the board's regulation of hospital budgets does not constitute a contested case under the Vermont Administrative Procedures Act. Remember some lively testimony on that. And a reminder that aggrieved parties have the existing ability to appeal under the Green Mountain Care Board's appeal statute, which is an appeal directly to the Vermont Supreme Court. They've modified the scope of some requirements around meetings of an ACO's governing body to apply only to ACOs that contract with Vermont Medicaid, which I think few or none as of now. And it eliminated some language requiring the Green Mountain Care Board to do an annual advisory rate case. So kind of doing a rate case as if Medicaid was an insurer for the all inclusive population based payment arrangements between DIVA and an ACO. This was really sort of more timely in the all payer model time and had had the Remed Care Board doing nothing binding, but sort of giving its 2¢ on whether the rates were appropriate. So that was eliminated. I like to call this the articulatable nexus.

[Val Taylor (Prospective Member)]: I think that was the

[Jen Carbee (Office of Legislative Counsel)]: HCA bill. It was, I think it had to do with insurance rate review.

[Alyssa Black (Chair)]: I'm

[Jen Carbee (Office of Legislative Counsel)]: still trying

[Alyssa Black (Chair)]: to it out of my mind. Still can't say articulate a word.

[Jen Carbee (Office of Legislative Counsel)]: Good reason in many. Alright. Lastly, but five slides worth, we have Act 68, which was S-one 126. And we have to get used to the new numbers, Act 68, and this is the Health Care Delivery and Payment System Reform Bill. This one did a lot of things, and I think you'll be hearing some, particularly on this one, some follow-up in the next days and weeks. So the first thing it did was to require the Green Mountain Care Board to establish reference based prices. And these are prices that represent the maximum amounts that Vermont hospitals can accept as payment in full for items or services delivered in Vermont. And the reference based prices are based on a percentage of the Medicare rates for the same or similar item or service or a different benchmark as appropriate. So the term reference based pricing is using a reference, in this case, Medicare rates or something else, as the basis for whatever the price is. So it could be 120% of Medicare. It could be 250% of Medicare if they're using Medicare, but something based off of kind of a known constant, which in this case could be the Medicare rate or something else. So the Green Mountain Care Board is supposed to start. They were supposed to start as soon as practicable, but not later than hospital fiscal year 2027, which actually starts 10/01/2026. So start as soon as practicable, but not later than sometime in that year that begins 10/01/2026. The board will review once it sets them, it will review reference based prices for each hospital annually during their annual budget review. So this does mean that reference based prices may not be the same for each hospital for each item or service. Specify that balance billing is not permitted, so the hospital can't get the reference based priced amount from the insurer and then bill the patient for some additional amount. That would be balanced billing. And it requires the Board, in collaboration with the Department of Financial Regulation, to monitor implementation of using these reference based prices. This is really to get some control over prices, over what's being paid to ensure that decreased payments to hospitals result in decreased health insurance premiums. It's not necessarily a one to one, but the idea was to be monitoring this to make sure it's having the intended effect. There's also, oh, it does say this in here too. So it allows the board to, in consultation with the agency of human services and others, to look at setting reference based prices for services delivered outside a hospital, like primary care services. There had been conversation last year perhaps making those reference based price amounts higher in order to incentivize more care in the community or if that's the appropriate setting. That's some of the work that they will be doing in the future. And it does specify that the board's reference based pricing authority does not apply to rates paid by Medicare or Medicaid. For Medicare, we don't have the authority. For Medicaid, we have a whole separate process through the Agency of Human Services and Diva for paying providers. So this is just Marvin Space Bryson. Doctor. This

[Francis McFaun (Vice Chair)]: thing no later than twenty seventh fiscal year. What is the fiscal year of the hospital? Is it July 1?

[Jen Carbee (Office of Legislative Counsel)]: No, it's October 1 to September 30 for all of the general hospitals. And then as of last year, you've allowed Brattleboro Retreat more officially to keep a calendar year. But for the rest of them, they follow the federal fiscal year, which kind of makes sense since they've used a lot of Medicare.

[Alyssa Black (Chair)]: But then the real This date?

[Francis McFaun (Vice Chair)]: Yeah. Do we put that in there?

[Jen Carbee (Office of Legislative Counsel)]: By week of this committee as opposed to the downstairs committee, I don't recall. I think it was I think it started downstairs. Not that date. Not that date?

[Alyssa Black (Chair)]: Not that date. Okay. There was a lot of

[Jen Carbee (Office of Legislative Counsel)]: talk about dates. I think there was there was the tension between wanting to get this reference price pricing going as soon as possible, and the board saying we need time to figure out how to do it first. So it's still a little squishy with the soonest practicable, but not later than over a course of a year. But you'll get an update from them on how that's going. But it does say in there, we'll start. Yes. Yes. That's true too. Doesn't mean they have to be setting all prices for all services at all hospitals. Start. They gotta start. Also in this act, the language requires the Green Mountain Care Board to establish global hospital budgets if resources to do so are available for one or more noncritical access hospitals by, again, hospital fiscal year 2027 and for all Vermont hospitals by hospital fiscal year 2030. Again, this is I I think I was trying to find some middle ground between wanting to keep moving forward toward global hospital budgets and recognizing that the resources may not have been provided to the board to do that work in addition to the reference based pricing and other, other responsibilities. Then separately, the act requires a hospital that is proposing to reduce or eliminate a service to comply with its hospital budget order must provide a notice of intent to the Green Mountain Care Board, the agency of human services, the office of the healthcare advocate, and the legislators who represent the hospital service area at least 45 before they actually reduce or eliminate the service. And it allows the board to modify a hospital's budget or take other action to preserve access to necessary services. The Act gave the Green Mountain Care Board the authority to oversee hospital networks that derive 50% or more of operating revenue from Vermont hospitals. There had not been specific authority to regulate or oversee hospital networks. The board can recommend, but not require actions necessary to, that it finds necessary to correct aspects of the network or its financial operations that are inconsistent with the principles for healthcare reform, sometimes called the Act 48 principles, or the statewide health care delivery strategic plan once that's established. Coming up, I think, on the next slide. And then also unrelated, but I sort of went through in the order in which they appear in the Act. The act requires payers and providers to provide an unredacted copy of an executed or proposed health care contract between payers and providers to DFR or the Agreement Care Board upon request, so to give them more insight into what is in these contracts. Could you just say what a global hospital budget is?

[Lori Houghton (Member)]: Is that a

[Alyssa Black (Chair)]: Vague question. Happened. Well, it was asked a million times.

[Jen Carbee (Office of Legislative Counsel)]: Yeah. And and also, Well, it sort of depends. I think there are different ways of defining it. And so I think some of that is going to be what the board will be determining.

[Alyssa Black (Chair)]: Did it stay through a conference committee that we actually have in there to find what a global budget is?

[Jen Carbee (Office of Legislative Counsel)]: Think that is part of what's in there. Yes.

[Val Taylor (Prospective Member)]: It's in the eye of the beholder.

[Jen Carbee (Office of Legislative Counsel)]: So yes, needs defining before it really happens, but it is not a specific thing. All right. The act also directed the agency of human services and collaboration with stakeholders to lead development of that statewide healthcare delivery strategic plan. The plan is due to you all by 01/15/2028. And there are some interim steps in there as well specified. And then the agency has to update the plan every three years with the first updated plan due by 12/01/2030, so not quite three years so that you have it before the session begins. The Act created an 18 member Health Care Delivery Advisory Committee and a 16 member Vermont Steering Committee for Comprehensive Primary Health Care. We can revisit all of these in more detail if you want. It directed the Agency of Human Services to collaborate with the existing Health Information Exchange Steering Committee to develop or continue to develop the unified health data specified some elements of the development process, including determining whether it makes sense to integrate clinical and claims data, and if so, how to do so in a way that protects proprietary information. This is definitely one that was hashed out in conference. Integration of clinical and claims data if it's going to happen cannot begin before next January, and then only if a majority of the steering committee votes in favor of proceeding. There's a report on integration of clinical and claims data and whether it makes sense and how it would work, all of that due to you by sometime next week with annual updates on the development and implementation of the unified health data space due beginning next year. The act authorizes the Green Mountain Care Board to share any material. So a different topic again, it receives pursuant to subpoena and has subpoena power. If the act now authorizes the board to share anything it receives pursuant to to its subpoena power with the agency or of human services or Department of Financial Regulation as appropriate to the agencies or DFRs work, So they don't have to go through a duplicative process. Alright. And then I think finally, the act directs the agency to facilitate oh, no, we're not doing it. Second to last slide. To facilitate healthcare provider response to the urgent financial pressures that are facing the healthcare system and identify opportunities to increase efficiency, improve quality, reduce prescription drug spending, and increase access to essential services while reducing hospital spending by not less than 2.5% for hospital fiscal year 2026, which is the one we're in right now. They required the agency to report monthly on the well, to report on the proposed reductions it had approved by 07/01/2025. And there's a report I linked to. And then to provide monthly updates that would be due from monthly from 10/01/2025 through 09/30/2026. So, basically, during hospital fiscal year 2026, AHS has a lot of those on its website. So I just put it there, but they're also on the legislative website. It also directed the agency of human services to identify specific outcome measures for meeting the healthcare system transformation goals from Act 167 of 2022. So for new folks, we talk a lot about Act 167. That's act one sixty seven, and we'll probably do an over or a reminder of some sort on that. And report those measures and related information monthly from October I'm sorry, from 08/01/2025 through 01/01/2027. And you can see, again, the AHS website for reports. It also appropriated $2,000,000 to the Agency of Human Services to provide incentive grants to hospitals to encourage them to engage in transformation work. And it required the agency to report by December 1 on the amounts that had been obligated or disbursed as of November 15. That report has also been submitted. A couple of other reports. The act required DFR to provide a plan by November 1 for preserving the sustainability of domestic health insurers. Again, Blue Cross Blue Shield of Vermont. That report has come in. Lot A of these reports came into the health reform oversight committee and sometimes the joint fiscal committee as well. And it directed the agency of human services to report by December 1 on opportunities to retain useful capabilities developed by or on behalf of the ACO and funded with public dollars. There's a thought that there might be some resources that we wouldn't wanna lose when One Care wound down at the 2025, and that report is available as well. Alright, this is the last slide on this, and then afterward I have a link to all of Nolan's fiscal notes for Acts that had fiscal notes. So the Act requires some reporting. Requires the Green Mountain Care Board to report on its implementation of this Act 68 by February 15 this year. It also requires starting next year that the Green Mountain Care Board's annual report include updates on reference based pricing and global hospital budgets. The Act requires the Agency of Human Services to provide an annual update by February 15 on the status of the statewide healthcare delivery strategic plan, the activities of the Healthcare Delivery Advisory Committee and other initiatives it's working on. The Act created three new positions at the Green Mountain Care Board in fiscal year twenty twenty six, our current fiscal year two related to reference based pricing and one devoted to operations, procurement and contracting. In addition to the $2,000,000 to the Agency of Human Services for the incentive grants, the Act also appropriated an additional $2,200,000 to the agency for the transformational work, creation of the statewide health care delivery strategic plan, and its development of alternative payment models. And finally, the act appropriated $1,212,500 to the Green Mountain Care Board for its three new positions, contracts related to its work, and standardizing. This is a small piece in the act, standardizing electronic hospital budget data submissions so that the board can more easily compare expenses across hospitals. And if you would like physical notes for any of those, Nolan wrote them, I just linked to

[Alyssa Black (Chair)]: them. And that's it.

[Lori Houghton (Member)]: That's amazing.

[Alyssa Black (Chair)]: We barely saw Katie at fall last night. I know. It's because you saw a

[Jen Carbee (Office of Legislative Counsel)]: lot of me eyes barely in concert as you.

[Alyssa Black (Chair)]: Taffer.

[Francis McFaun (Vice Chair)]: What's in my mind, and it may be wrong, did we not talk about incentivizing the nurses, something about supporting the workforce? Hospital violence? Hospital violence? No. No. No. It was providing incentives

[Jen Carbee (Office of Legislative Counsel)]: I'm thinking it might have been that might have been something in the budget. Budget. The budget.

[Francis McFaun (Vice Chair)]: So we did do

[Alyssa Black (Chair)]: it then.

[Jen Carbee (Office of Legislative Counsel)]: I don't know. I'd to I'd have to look at what it was.

[Francis McFaun (Vice Chair)]: Okay. Think Alright.

[Addison "Addy" Strumolo (Deputy Commissioner, Department of Vermont Health Access)]: If

[Alyssa Black (Chair)]: I recall, we were doing our budget priorities and there was extending around something with nursing. I'll be honest with you, I'm not sure.

[Jen Carbee (Office of Legislative Counsel)]: There's not much. Yeah, I'm not sure it made it through either. I'm not sure it made it through. There's only two mentions of nurses in the budget and they have to do with reducing reliance on tribal nurses. Also important. And the skilled nursing facility context, so I don't think it's something

[Francis McFaun (Vice Chair)]: to do with building that workforce to try to reduce the cost of the traveling nurses and all that stuff.

[Jen Carbee (Office of Legislative Counsel)]: I mean, is some of that in this, but again, what actually passed in the budget was specifically in the context of the Department of Disabilities Aging and Independent Living as part of its budget presentation this year to the Appropriations Committee's reporting on grants to skilled nursing facilities made through an earlier appropriation earlier budget appropriation and looking at the impacts of the grants, including whether they reduce reliance on travel nurses and increased workforce retention and expansion. Thanks.

[Alyssa Black (Chair)]: Maybe if anybody is following this or watching this

[Jen Carbee (Office of Legislative Counsel)]: and follow-up. Because sometimes there's money built into the agency's budgets that fund initiatives that we don't specifically call out in here. So it's possible there's there's stuff we can you can ask about when you hear from the agencies during budget adjustment too.

[Alyssa Black (Chair)]: Did you want to weigh in? Do you want to introduce yourself?

[Diane Ledford (Green Mountain Care Board staff)]: I missed the beginning and I wasn't sure if you were at all. Hi, Diane Ledford, Green Mountain Care Board. Thank you, great start of this session. One of the things I want, I don't know this for sure, but representative, the in ARPA, the ARPA money that's still out there, there was an update at the December when house appropriations met from Doug Farmer on where and what's left of the upper body and there's something sparkling in here, don't want to dare say it, I'd love to learn how much, but I felt there was something in there around workforce development and emergency but that might be another place that we all think about. But that dollars are still active, they're still working.

[Francis McFaun (Vice Chair)]: Because that's a big deal.

[Jill Mazza Olson (Medicaid and Health Systems Director, AHS)]: It is a big deal.

[Alyssa Black (Chair)]: Thanks for following all of that. I know you can't get away from appropriations. Always helpful to get a bit of Karen, did you? Yeah, I just had a

[Karen Lueders (Member)]: couple of questions. I don't need to take time now if it's just, if it's a big ask. So one, there's a mention of critical care hospitals and some distinction made about those, I can understand it. I don't want to take a lot of time, but I'm curious about that. And then also about the development of the reference based pricing going forward, not just the drugs, but the other things, and how that actually gets implemented. Those are my two questions.

[Alyssa Black (Chair)]: Why don't we, your 101, you'll go over what hospital types there are, Brett?

[Francis McFaun (Vice Chair)]: Let me say there are many hospitals that don't get into the weeds

[Alyssa Black (Chair)]: about that. Maybe we'll get It's

[Jen Carbee (Office of Legislative Counsel)]: a federal designation as critical access hospitals.

[Karen Lueders (Member)]: And it impacts the control one can have over those hospitals? Or?

[Jen Carbee (Office of Legislative Counsel)]: Not necessarily. I think they're often smaller hospitals. They're sort of the only care available in the area. And so I think sometimes there is concern about doing things that, and they may have smaller margins and they're maybe concerned about doing things that affect their financial health in ways that are maybe less of a consideration for areas that are more urban. And they get paid different rates from the Fed.

[Alyssa Black (Chair)]: There's different types of federal designations for hospitals and they all sort of have different payment mechanisms. And we had exempted from one of the bills that she

[Jen Carbee (Office of Legislative Counsel)]: held there. I think there's a couple of places you've carved out critical access hospital. And the other question was about reference based pricing and sort of who owns it going forward. It's all in the Green Mountain Care Board, so it's a pretty broad provision. Arguably could have existed or existed harmoniously with their rate setting authority that they had not exercised, but it was directing them to start implementing reference based pricing, starting with the hospitals, but looking at potentially going more broadly to other types of providers and provider settings and services.

[Alyssa Black (Chair)]: And we're going to get an update from the Great Mountain Care Board very soon how that's going. All right. Thanks Jen. Thanks for all your work last year. Look forward to on it.

[Jen Carbee (Office of Legislative Counsel)]: I totally forgot about those things. Right? I know. I didn't

[Alyssa Black (Chair)]: talk I have a confession. We were at a meeting the other day and Jen was there and I said something about, well, with

[Francis McFaun (Vice Chair)]: the

[Alyssa Black (Chair)]: markets merged, and Jen looks at me and she's like, you unmerged them last year permanently.

[Karen Lueders (Member)]: There's no revelation. We sunset the sunset or something like that.

[Alyssa Black (Chair)]: Same as that when we just We just got rid of the sunset. Yeah, there was no sense. Just Alright, just to unravel. Nolan, you want to come on up?

[Francis McFaun (Vice Chair)]: Talk about what?

[Alyssa Black (Chair)]: Oh, I know you've been doing

[Karen Lueders (Member)]: a miracle here at the hospital.

[Francis McFaun (Vice Chair)]: Anything you want.

[Alyssa Black (Chair)]: I guess you don't need to, if you don't want to. I thought we had to do an agenda for What were we talking about? Economic changes?

[Francis McFaun (Vice Chair)]: We're talking about tomorrow.

[Alyssa Black (Chair)]: Yeah, we're going to talk

[Val Taylor (Prospective Member)]: about it tomorrow. But today I think was just there, but I don't have anything specific.

[Alyssa Black (Chair)]: Alright, well we can take a long break, or we can take a break until, I don't know, is people at AHS going to be joining us remotely or? Cheryl's going be

[Val Taylor (Prospective Member)]: in person, but the rest are over soon. Alright, so they're

[Alyssa Black (Chair)]: scheduled at three, but maybe if they're able to come a little earlier, and they happen to be here, then we can start earlier. So, I'll be checking the committee room at 02:50, maybe? Alright, we can go off the fly.

[Val Taylor (Prospective Member)]: So, if I can just say really quick,

[Alyssa Black (Chair)]: Okay, now everybody can hear me.

[Jen Carbee (Office of Legislative Counsel)]: There you go.

[Alyssa Black (Chair)]: Wait, you haven't heard a second. Sorry, we're

[Addison "Addy" Strumolo (Deputy Commissioner, Department of Vermont Health Access)]: just gonna get a sec.

[Alyssa Black (Chair)]: There we go. Okay, So we're back and we're still up. You'll be able

[Val Taylor (Prospective Member)]: to see them on stage when my parents sign. Okay.

[Jill Mazza Olson (Medicaid and Health Systems Director, AHS)]: They are there.

[Alyssa Black (Chair)]: Okay. So we're going to get started. And we have with us the new what is your title now? Have you Good morning. Can you introduce yourself?

[Jill Mazza Olson (Medicaid and Health Systems Director, AHS)]: Okay, sure. Good morning. I'm Jill Mazza Olson. I am the Medicaid and Health Systems Director. So I've been in the role since about October. Thank you. Excited, my son. I know many of you. I, for the past about twenty five years, have been working in health care policy, but on the provider advocacy side. So this is a big change for me. I know a lot, but I don't know a lot. And so I'm really excited to be here today. I do have subject matter experts who are joining us today. And today, I'm going to be more in your wizard of Oz mode, sitting in the chair while they do most of the talking. Tomorrow, I'll talk about rural health transformation,

[Alyssa Black (Chair)]: and you'll hear more from me. Karen, do you want to introduce yourself? Because I think everybody here would know everyone else. I know,

[Karen Lueders (Member)]: because I was on Addison County Home Health and Health. Was our fearless advocate when I

[Alyssa Black (Chair)]: was in that position. So I worked. Yes, it's nice to be here. And I think we have actually Addy now. Hi. Hi. Welcome, guys. All

[Jill Mazza Olson (Medicaid and Health Systems Director, AHS)]: right. And I think it's Ashley who's running the slides. Is that our plan? Okay. Great. We do have a series of slides. And shall I let them introduce themselves? And

[Alyssa Black (Chair)]: also just to let you know, I've asked them to come in because I don't know if you remember last year, we had the joint hearing with Human Services. This was before HR1 passed, and if you recall that there was so much stuff, and I'll never forget, actually, your spreadsheet, and it was just one form after the next. So I figured we should have an update from what actually came to fruition out of all of that.

[Francis McFaun (Vice Chair)]: Who can I get

[Alyssa Black (Chair)]: caught? It's on web.

[Francis McFaun (Vice Chair)]: Is it? I'm

[Val Taylor (Prospective Member)]: checking. Oh,

[Francis McFaun (Vice Chair)]: oh, it's a Tuesday.

[Alyssa Black (Chair)]: Okay, go ahead,

[Jill Mazza Olson (Medicaid and Health Systems Director, AHS)]: I'm sorry. So can I let Addy and Ashley introduce themselves? Absolutely. Okay, great. Ashley, do you want to introduce yourself? Oh, she just shared her slides and then I said introduce herself, but that's okay.

[Alyssa Black (Chair)]: She's gonna do all the talking.

[Ashley Berliner (Director of Medicaid Policy, Agency of Human Services)]: Hi, yes. Ashley Berliner. I'm the director of Medicaid policy for the agency of human services. Good to see And you

[Addison "Addy" Strumolo (Deputy Commissioner, Department of Vermont Health Access)]: Addy? Hi, everyone. Addy Stromolo, I'm the Deputy Commissioner at the Department of Vermont Health Access or DEVA.

[Jill Mazza Olson (Medicaid and Health Systems Director, AHS)]: So these are two of the most competent people I have ever met, And really the right people, I think, to give you the overview of what I think this committee needs to know and the primary changes that happened in HR1, which passed in July.

[Alyssa Black (Chair)]: I just want to be clear, of you and Ashley, you're actually housed in the agency. You're in the central office.

[Jill Mazza Olson (Medicaid and Health Systems Director, AHS)]: I am in central office, exactly. I work directly, just if this is helpful to you, I work directly for the secretary. So I report secretary and sit in the secretary's office. Ashley's team, the Medicaid policy team, is actually also in the AHS office. So that's separate from Diva, where Addison works for Diva. There is some separation there, which is sometimes actually useful and helpful within our Medicaid world. So Addison is in charge of Medicaid policy. Ashley's in charge of Medicaid policy. Addison is in charge of our enrollment. And I also have responsibility for health care reform. So Ashley Berliner reports directly to me. And the director of health care reform, which is actually a vacant position right now, who's an interim leader, reports directly to me. The idea is to try to make sense of all of this across the agency. But it is certainly a large portfolio, which is why I rely on subject matter experts when there's this much detail. Sorry, just to clarify before you begin.

[Brian Cina (Member)]: Sure. I was very confused at first by HR1 because it's a rules resolution in our house, but then I realized, is that HR1 in Congress?

[Alyssa Black (Chair)]: Yes, ugly Ugly good.

[Brian Cina (Member)]: But it's so like you maybe clarifying. The reconciliation bill. Federal HR1. Federal HR one. When I looked up H1 and HR, I couldn't find it. Then I was like, oh, this is federal. Yes. And maybe everyone would eventually figure that out. But I

[Val Taylor (Prospective Member)]: just thought we should clarify.

[Jill Mazza Olson (Medicaid and Health Systems Director, AHS)]: Thank you. I appreciate that. This is how we talk about it internally. So it's sometimes hard to remember what it sounds like externally. So thank you. I appreciate that. Okay. So I'm going to just sort of give a very quick overview of what we're going to talk about, and then I'm going to essentially turn it over to the team. So we're really looking at the major provisions that impact either Medicaid or health care as a whole. So we're going to talk about Planned Parenthood, provider taxes. And I'm not sure Ashley heard you say this, Madam Chair, but it sounds like the committee is going to get a full primer on what provider taxes are so we don't have to go too deep. But there are impacts to provider taxes we'll want to talk about. It's essentially a revenue impact. State directed payments, cost sharing, and then eligibility. And there are multiple elements under that. And we'll switch to Addy at that point. You. All right, I'm going to turn it over now to Ashley Berliner.

[Ashley Berliner (Director of Medicaid Policy, Agency of Human Services)]: Thank you. So the very first thing that was in effect when HR one or the big beautiful bill passed on 07/04/2025 was a prohibition of federal Medicaid funding for Planned Parenthood or Planned Parenthood like entities. One for one year. Can you guys hear me?

[Alyssa Black (Chair)]: There's a phone bang. Yeah.

[Jill Mazza Olson (Medicaid and Health Systems Director, AHS)]: Not mine. Sorry about that, Ashley.

[Ashley Berliner (Director of Medicaid Policy, Agency of Human Services)]: No problem. That several impacts the state of Vermont is about $1,100,000 gross for this one year, about 600,000 in federal financial participation. We have decided to backfill that lost federal revenue with general fund for this one year period. You might hear in the news there have been many, many lawsuits related to this ban on Planned Parenthood funding. There have been injunctions that have been overturned and then reestablished and then overturned again. So we are just holding steady at general fund. When the final decisions shake out ultimately likely in the Supreme Court, then we will settle up if federal funding can in fact be used. If not, we'll be all set with our general fund backfill. So we're just waiting on final court decision there.

[Alyssa Black (Chair)]: And just to be clear, so 1,100,000 is the total that loss of that and the state out of general fund is having to make up the 600,000, which would have been matching federal funds?

[Ashley Berliner (Director of Medicaid Policy, Agency of Human Services)]: That's right.

[Alyssa Black (Chair)]: Okay. Thanks.

[Ashley Berliner (Director of Medicaid Policy, Agency of Human Services)]: So moving on to provider taxes, this is a provision that goes into effect immediately in terms of states cannot create new provider taxes after the effective date of HR1. And then in November 2027, for states that have existing provider taxes, you are required to reduce those provider taxes by half a percentage point per year for five years until you get down to 3.5% in 2032. So this is kind of a slow burn impact where in the first year, if we reduce our provider tax from 6% down to 5.5%, it's a loss of $18,000,000 in general fund revenue per year. Cumulatively over five years, that adds up to a loss of $87,000,000 in today's dollars for general fund revenue. So you can see that this has the potential to be a really significant financial impact for Vermont. We're looking at this from a lot of different angles and are grateful that the deadline for this is not until the end of next year.

[Jill Mazza Olson (Medicaid and Health Systems Director, AHS)]: So this is not a this year budget problem, it's a next year budget problem.

[Alyssa Black (Chair)]: But we're thinking $87,000,000 We'll get to $87,000,000 by the fifth year, and it'll be essentially the equivalent or whatever that date, that time period, 87,000,000 is actually real that will be each and every single year. Yes. $87,000,000 per year that we are foregoing Total. Total.

[Ashley Berliner (Director of Medicaid Policy, Agency of Human Services)]: That's what the reduction would be if we do in fact have to reduce our provider taxes down to that 3.5%. And we're looking at this from a lot of different angles and working with tax and Department of Financial Regulation on it as well. So definitely an ongoing conversation, but that is how it would shake out financially by 2032.

[Val Taylor (Prospective Member)]: Okay. I have a visual on this, so be helpful. Okay, great. I'll save my question for that. Alright.

[Brian Cina (Member)]: Super. I think you're gonna answer my question.

[Alyssa Black (Chair)]: Alright. Thank you. Sorry.

[Ashley Berliner (Director of Medicaid Policy, Agency of Human Services)]: I'm moving right along on these, please, I'm glad you're stepping in with questions. Addison is going to have most of the real meat of this bill, but I wanted to make sure we had a chance to talk about some of the other provisions that impact Vermont. So this one has a direct impact for you all in your seats as state legislators. We have something, it's a term of art in Medicaid called a state directed payment. And it's essentially where states, or in your case, the legislature require a plan to pay healthcare providers in a very specific way. So in Vermont, the plan is DIVA. And anytime the legislature is requiring DIVA to set Medicaid rates on a certain place in manner, that is considered a state directed payment under the provision of this bill. So what that means is that effective 07/04/2025, state directed payments that exist today are not able to grow and new state directed payments must be capped at 100% of Medicare fee schedule. Existing state directive payments above Medicare rates will need to be reduced by 10% per year beginning in 2028 until that state directed payment is no greater than the 100% of the Medicare payment level. That's a lot.

[Alyssa Black (Chair)]: This like, for an example, we pay primary care in advance, is it that we have to phase down that till it meets 100%? Because I think right now it's around 110.

[Ashley Berliner (Director of Medicaid Policy, Agency of Human Services)]: So primary care is an example where the legislature has said DIVA has to pay at 110% of Medicare rates, and that would be something that's implicated under this provision. We also have two federally known state directed payments where we actually have had to call them out as state directed payments, and that is the Blueprint for Community Health Team payments and patient centered medical home payments. Those are also above Medicare rates. None of this would be impacted until 2028, so again, not a this year budget problem. This would be something that we'd be looking at next year. And we're really digging into this and exploring our options. There are ways to make sure that we have the money the DIVA has the money to pay for these things without the legislature or AHS specifically directing them to pay it in a certain way. So we're really just like putting our thinking hats on and thinking about how we can work through this problem and want to just raise it to this committee in particular. When you're building your budgets this year, we need to be really careful about not specifically directing Diva to pay in a certain way. The money can be available, it can be in their budget, but to say you have to pay primary care 110% Medicare rates, or you have to pay $2.5 per patient per month for Blueprint, or you have to pay the Medicare rate for this treatment non transport code, that's where we get into state directed payment land and need to just be really careful about the implications of this bill.

[Alyssa Black (Chair)]: Are we worried about losing the federal match when we pay, or are we worried about the impact to providers? Where's

[Ashley Berliner (Director of Medicaid Policy, Agency of Human Services)]: I think right now we're worried about how to make sure we're in compliance and really making sure that we're doing everything that we need to do to be in compliance while still making sure that providers are getting paid the way that aligns with our values in Vermont. So there are some administrative things that we think will have flexibility to do. We don't have them all sorted out yet and we'll certainly, you know, be in communication as we figure out the guardrails, but that's where we are right now. I don't think that this isn't something to be alarmed about this year. It's just something to be aware of, particularly as you're setting the budget going into the session and just staying away from some of the language that's going to put a spotlight on some of this. Hopefully that helps a little bit.

[Alyssa Black (Chair)]: It doesn't stop us from the legislature mandating that certain rates be raised to 100% though, do they? Does

[Ashley Berliner (Director of Medicaid Policy, Agency of Human Services)]: It doesn't, no. The major factor here is 100% of Medicare rates and not going above that. There are some other strings attached when it is a state directive payment that we just want to make sure everyone's aware of and we're still working through. But right, raising rates to Medicare levels is not going to be hampered by this bill.

[Alyssa Black (Chair)]: Okay. Thanks.

[Ashley Berliner (Director of Medicaid Policy, Agency of Human Services)]: And just to provide a little bit of context because it's kind of a obscure thing that got raised nationally and became a huge deal on this bill. A lot of states are using state directed payments as a way to infuse their healthcare system with federal Medicaid dollars or kind of artificially. That's not happening in Vermont. Just don't run our Medicaid program that way. But when you're looking at national politics, that's really what they were trying to prevent, was having a lot of states kind of artificially infuse their Medicaid rates with federal dollars at the savings of state budgets. And again, relevant to us, but just so you have a little bit of context for where this is coming from.

[Alyssa Black (Chair)]: Do have a question, Karen? I do. So if we don't use the words state directed payments, what words might we use?

[Karen Lueders (Member)]: Are you still thinking about that to achieve?

[Jill Mazza Olson (Medicaid and Health Systems Director, AHS)]: I think we're still thinking about how we meet the policy goals and how we can do that and be at compliance. But we are, I think, feeling as though there are paths forward, but we just need to do some more work. So

[Ashley Berliner (Director of Medicaid Policy, Agency of Human Services)]: the last piece before I hand it over to Addy to talk about eligibility is around cost sharing. And the top line here is that in October 2028 for the new adult group or the expansion group that became eligible under the Affordable Care Act. For individuals who have incomes up to 100% of the federal poverty level, we will be required to impose cost sharing in the form of co payments on all services, except for specific lists of exempted services like preventative care, emergency care. There are some carve outs for categories of service. We will have a flexibility to decide what those co pay amounts are. There are still some federal protections like pharmacy copays can't be above $8 There are still things in federal law that apply. But we are, in this particular one, awaiting regulatory guidance because we need all of more information around what the federal administrators want before we can think about how we would administer this. But just something to be aware of that our co payments will be having to increase broadly in 2020.

[Alyssa Black (Chair)]: I'm sorry, I keep interrupting you, I have so many questions. So for expansion adults up to 100, those are the people who are going be required to pay co payments. Our expansion adults go up to 138% of FPL. So are you telling me from 101 to 138, those people don't have to pay co payments?

[Ashley Berliner (Director of Medicaid Policy, Agency of Human Services)]: You know, that was a great question. Let me get back to you.

[Alyssa Black (Chair)]: Because that sounds a little backwards.

[Ashley Berliner (Director of Medicaid Policy, Agency of Human Services)]: It might be backwards. It might be above, and it might be a typo there. I don't have I can't say that with a 100% confidence right this second, but let me get back to you. It's a really great point. And I'm gonna assume it's a typo.

[Alyssa Black (Chair)]: Either that or it's a really, really bad

[Ashley Berliner (Director of Medicaid Policy, Agency of Human Services)]: policy. It could be that.

[Addison "Addy" Strumolo (Deputy Commissioner, Department of Vermont Health Access)]: Okay. Alright. You can go and I can take over.

[Ashley Berliner (Director of Medicaid Policy, Agency of Human Services)]: Okay. Thanks, Addison.

[Addison "Addy" Strumolo (Deputy Commissioner, Department of Vermont Health Access)]: No. Unless there are other questions for Ashley, which is fine. Okay, so as I think you all know, in my role as Deputy Commissioner at Teva, I oversee eligibility and enrollment into both Medicaid and the qualified health plan marketplace. So we, our teams are kind of the entry point for people to get and then maintain healthcare coverage in our state. And this eligibility process is really one of the major levers that was used in the budget reconciliation bill, HR1. So a lot of the near term work is with us and with our teams. We began work right on passage this summer, including some small pieces that had to happen during for open enrollment for this year. But right now we're focused on three major provisions requiring implementation in late twenty twenty six and then 01/01/2027. And then there's a fourth provision for 2028. So we can go to the next slide. The first major provision is, are you guys seeing the next slide?

[Alyssa Black (Chair)]: We're still on the four work streams slide. There. Thank you.

[Addison "Addy" Strumolo (Deputy Commissioner, Department of Vermont Health Access)]: So the first major provision are changes to healthcare eligibility based on immigration status. These changes apply across Medicaid. They're not limited to certain eligibility groups and are effective for 10/01/2026. And then the commensurate change happens for the marketplace as of 01/01/2027. So this effectively blocks eligibility for asylees, refugees, and other non citizens who currently are eligible for coverage. This one is a little bit hard for us to quantify because people do not have to provide this level of detail in their application process as it relates to their immigration status when coming through the door into Medicaid. So a major area of focus for us is just identifying the scale of the impact. We think it's in the hundreds, but so that we will be able to effectively outreach them ahead of the change and ahead of actually making the adjustment to our eligibility process for next fall.

[Alyssa Black (Chair)]: Do we have any sense yet? I know that you said you're having difficulty identifying. Do we have a sense yet how many of these hundreds might be under might be children. I'm concerned because that population will automatically qualify for IHIP and that's all state dollars.

[Addison "Addy" Strumolo (Deputy Commissioner, Department of Vermont Health Access)]: The short answer to question is no, I don't know the breakdown by age, and we will work hard to get more information about this to you all because I think it will be a consideration, because yeah, as you said, probably a small subset may become eligible for IHIP and the rest will not have access to full healthcare coverage in our state anymore.

[Alyssa Black (Chair)]: Do you mind listening to that acronym? I have. It is

[Addison "Addy" Strumolo (Deputy Commissioner, Department of Vermont Health Access)]: immigrant health insurance program.

[Alyssa Black (Chair)]: Thank you. First bit, I can't believe I can't remember. Essentially what it is, is that if you're a child or a pregnant person and you're eligible for it's state only dollars, if you have an immigration status that doesn't allow you to qualify for Medicaid. So now that this population won't qualify for Medicaid, they would roll into that if they're children or pregnant people. Thanks, we can go on.

[Addison "Addy" Strumolo (Deputy Commissioner, Department of Vermont Health Access)]: Okay, sounds good. We can go to the next slide. So the next major provision is we refer to as six month renewals. Renewals or redeterminations are those mandated rechecks of eligibility in order to maintain coverage. This change, unlike the prior one, applies to a subset, which is that Medicaid expansion population that Ashley described. The expansion population are non disabled adults eligible for Medicaid based on income up to 138% of the federal poverty limit. And we refer to this generally as the new adult population. So this change is effective also for 01/01/2027, and it increases the required redetermination frequency from every twelve months to every six months. It's a really significant change, as everyone will remember from our experience unwinding or restarting redeterminations. This process can be onerous for people and having to do it twice a year instead of the annual on the annual cadence will be a big change. There are currently about 55,000 new adults in our system that will be subject to this new requirement.

[Alyssa Black (Chair)]: 55,000. Addy, I don't You don't have to give like just sort

[Karen Lueders (Member)]: of on a high level.

[Alyssa Black (Chair)]: I don't think we've ever, all the times we talk about redeterminations, what exactly does that involve? Like what is the onerous process like? I honestly don't know. I mean, it applications? What kind of income proof? How do you do a redetermination?

[Addison "Addy" Strumolo (Deputy Commissioner, Department of Vermont Health Access)]: Yeah, kind of all of the above. And our job

[Jill Mazza Olson (Medicaid and Health Systems Director, AHS)]: is

[Addison "Addy" Strumolo (Deputy Commissioner, Department of Vermont Health Access)]: to make it less onerous, but I don't want to kind of hide the ball on that. So the process is we'll outreach, everyone's assigned a redetermination date based on when they originally came into coverage. They get outreach through notices and different modalities starting a month or so ahead of time. And then we do our best to check the information that we have on file against electronic data sources. And if we can verify all that information using those data sources, we then send a notice that says, okay. You're good for another in in the new case, it will be six months. Currently, it's a year. If we can't check it with data sources, then we basically ask the customer to validate all their information again, using paperwork. They can submit it through different modalities, but they have to validate all of the eligibility factors like income. And then we make a determination about whether they still meet the criteria, get another notice that says whether or not they're good. And that back and forth with the paperwork can take a lot of time.

[Alyssa Black (Chair)]: What sort of human resources does it take right now to do twelve months? What would you anticipate increased need?

[Addison "Addy" Strumolo (Deputy Commissioner, Department of Vermont Health Access)]: Overall, these changes that I'm going through here are going to reflect about a 30% increase in our workload. We will talk more about the resource needs when we start talking about the budget, but it is definitely a big increase.

[Alyssa Black (Chair)]: Thank you. Oh, Brian has a question.

[Brian Cina (Member)]: I feel bad because I just zoned out the last few sentences. So, if this was just answered, forgive me. I just got an email that distracted me. My question is, how much does it cost the state to do this extra work that we're not doing now? Do we know? Or is that something covered by Medicaid? The cost of the renewals is extra labor that we're not doing now. Is that covered by the feds, or do we have to cover those renewals to get the federal money? Is that going to cost us more besides the stress and emotional labor in terms of just the actual financial expense? If you don't know, it's okay.

[Addison "Addy" Strumolo (Deputy Commissioner, Department of Vermont Health Access)]: No, there's definitely a yes. The specifics of how much are, again, something that we'll talk about in our budget recommendation, but there are various administrative costs, IT, operational staffing, as I just mentioned, that are absolutely a shift to the states to do these processes to make the process slightly more strict for people to maintain coverage.

[Jill Mazza Olson (Medicaid and Health Systems Director, AHS)]: And I think, Addy, I heard you say it's a 30% increase in workload. Thank you. Not cost, but workload.

[Alyssa Black (Chair)]: Do we currently receive a federal match on the expense of administering state Medicaid program? Do we? Yes, we do. Will that continue?

[Addison "Addy" Strumolo (Deputy Commissioner, Department of Vermont Health Access)]: Yes. Yeah, the administrative match is not changing.

[Alyssa Black (Chair)]: Okay.

[Addison "Addy" Strumolo (Deputy Commissioner, Department of Vermont Health Access)]: We get an enhanced match for things

[Alyssa Black (Chair)]: that Because I Leslie, can you say what that match is based on?

[Addison "Addy" Strumolo (Deputy Commissioner, Department of Vermont Health Access)]: I might defer to Ashley on that. Is it just fiftyfifty?

[Ashley Berliner (Director of Medicaid Policy, Agency of Human Services)]: Yeah, it's a fiftyfifty match for Medicaid administrative costs.

[Alyssa Black (Chair)]: If our costs go up by 30%, then does that mean the match goes up 30% or some percent?

[Ashley Berliner (Director of Medicaid Policy, Agency of Human Services)]: They'll pay 50% of the increased cost.

[Lori Houghton (Member)]: So they will pay more anyway?

[Addison "Addy" Strumolo (Deputy Commissioner, Department of Vermont Health Access)]: Yes. Same rate.

[Val Taylor (Prospective Member)]: Okay.

[Addison "Addy" Strumolo (Deputy Commissioner, Department of Vermont Health Access)]: So I think we can move on to the final piece for this year, which is Medicaid work requirements, or these are being referred to as community engagement requirements. This also applies to the Medicaid expansion population that we just described and is also effective for 01/01/2027. This is a brand new requirement, and it asks members to demonstrate that they are either working, engaging in community service or education minimum of eighty hours per month as a condition of maintaining their Medicaid eligibility. There are a number of exceptions and accepted populations built into the legislation like pregnant individuals, medically frail individuals, those with children 14. So this one is also a little bit of a moving target in terms of the impact, but if you take the exceptions into account, we think this change will impact about 30,000 members just in terms of needing to provide additional verification around work requirements in order to maintain eligibility. It's a big, big change. And then coupled with the enhanced frequency of the renewals for the same population, this is kind of the essence of the increased work that we'll be facing and the increased requirements for Vermonters coming up next year.

[Alyssa Black (Chair)]: If you have to do this every six months, how do you prove that for each of those six months you've been working for eighty hours?

[Addison "Addy" Strumolo (Deputy Commissioner, Department of Vermont Health Access)]: There's Sorry, I didn't mean to cut you off.

[Alyssa Black (Chair)]: Well, no. And I'm also thinking about I'm thinking about ways that people actually end up having to apply for Medicaid. And isn't a lot of our sort of new adult population that's on Medicaid, aren't they people who have recently been impacted by loss of a job? I mean probably can't I'm thinking about friends who have become unemployed and when they become unemployed, they lose their insurance and then they qualify for Medicaid and they're only on it for you know, until they're able to find it. How do you have a work requirement for somebody who just lost a job?

[Addison "Addy" Strumolo (Deputy Commissioner, Department of Vermont Health Access)]: Yeah, I mean, it's absolutely a kind of philosophical change in the program. I'm trying to remember, your original question was not specific to the loss of, oh, how do you prove it every six months? So we're working through that now. We have some flexibility and we think what it's going to be is demonstrating that you meet the standard for one month within that coverage period prior to your renewal. And we're working really hard to add data sources to our system to hopefully, you know, reduce the paperwork burden of having to demonstrate that. But that, yeah, that's kind of the bread and butter of this implementation is figuring out if there is data that can support for monitors and maintaining coverage and how we can get it into our system so that we can do that.

[Alyssa Black (Chair)]: Doctor. Houghton, did

[Val Taylor (Prospective Member)]: you have a question?

[Alyssa Black (Chair)]: I do.

[Francis McFaun (Vice Chair)]: Keep using the term Vermonters. What does that mean?

[Addison "Addy" Strumolo (Deputy Commissioner, Department of Vermont Health Access)]: I'm just using it to mean people who reside in the state, but then there are categories of eligibility including this expansion population that's based on their income level. So those are the specific Vermonters that would be impacted by this change.

[Francis McFaun (Vice Chair)]: Thank you.

[Alyssa Black (Chair)]: Of course. You can go on.

[Addison "Addy" Strumolo (Deputy Commissioner, Department of Vermont Health Access)]: The next slide touches on the fourth work stream, which is actually in the marketplace space, qualified health plan renewals. Yep. So this is a really significant change, but one that we actually haven't started working on yet because it doesn't come into effect until the 2028 plan year. So open enrollment will take place in the 2027. This is a new requirement that instead of automatically renewing people into qualified health plan coverage, which is something that we do now and that happens kind of everywhere in the insurance world, there will be a requirement to validate people's eligibility every year. And we're still working on what that looks like, but it is definitely a sea change in terms of what the process of open enrollment will look like. I guess the good news is that we do think that CMS will issue implementing regulations around this in the next year and so it may be that they can find a way to do it in a way that doesn't come out to be as onerous as it appears on paper. But this is something that we have on our docket for to start as the next phase of the project once we finish the three that I just went through.

[Alyssa Black (Chair)]: What sort of information would somebody even have to verify on their application that would mean that they can't qualify for something that pretty much anyone qualifies for because they're purchasing insurance.

[Addison "Addy" Strumolo (Deputy Commissioner, Department of Vermont Health Access)]: Thank you. Yeah, I should have clarified that. It's really focused on eligibility for the premium assistance. As you know, it's a large percentage of our Marketplace population qualify even with the expiration of the enhanced subsidies. So if someone just wanted to come in and not even apply for assistance and just buy a full cost qualified health plan, they wouldn't have to go through this new process. But most people go through the steps of providing information to see if they can get some of the tax credit. And so that's the typical information like household size, income, and then of course citizenship Vermont residency, social security number.

[Alyssa Black (Chair)]: Isn't your income so all just trued up with your next year's tax return?

[Addison "Addy" Strumolo (Deputy Commissioner, Department of Vermont Health Access)]: It is, but this this policy is to not allow people to take that tax credit in advance until they have documented their eligibility.

[Alyssa Black (Chair)]: Got it. There's no more five year agreement into automatic renewal then

[Jill Mazza Olson (Medicaid and Health Systems Director, AHS)]: on these applications? Yeah.

[Addison "Addy" Strumolo (Deputy Commissioner, Department of Vermont Health Access)]: That'll be interesting to see what they do with that that five year requirement for accessing the IRS data. It may be that they keep it in place. They just require that to happen ahead of enrollment rather than as part of the enrollment process.

[Karen Lueders (Member)]: Brian has another question, go ahead.

[Brian Cina (Member)]: Yeah, and we can come back to this another day because this is just the beginning, but do states Do we have to do all this? Can we just say, never mind, we don't want your money anymore, we're going to do our own healthcare system, we don't want to participate in health exchanges and renewals and all that? Are we forced by federal law to engage in this?

[Addison "Addy" Strumolo (Deputy Commissioner, Department of Vermont Health Access)]: I think I don't know if Phil wants to answer that, but I think it's a matter of money. Would be seriously damaging the state budget if we left those federal dollars behind.

[Jill Mazza Olson (Medicaid and Health Systems Director, AHS)]: Yeah. I think what's important to remember is there are still premium subsidies available to people that we really that we care about. Even without the extended the expanded subsidies, there are still subsidies that we're receiving. So to just say we don't want to do this, I think would have a pretty big impact on

[Alyssa Black (Chair)]: the federal budget that we're federal dollars that we're bringing to the states. So

[Brian Cina (Member)]: would it be correct to say that there's a lot of benefits associated with these extra barriers, and if we didn't jump through these hoops, we would lose a lot? You're talking

[Addison "Addy" Strumolo (Deputy Commissioner, Department of Vermont Health Access)]: about all of them? All of

[Alyssa Black (Chair)]: these provisions?

[Brian Cina (Member)]: Well, I guess this one particularly triggered me, but it just feels like they're throwing up all this bureaucracy. They talk about efficiency and improving the efficiency of government, and then they're asking you to do all this extra stuff. That's going to be inefficient. So it's just confusing to me.

[Jill Mazza Olson (Medicaid and Health Systems Director, AHS)]: Yes, I think we can leave that. I'm not going to editorialize on that.

[Alyssa Black (Chair)]: Can I ask just a question in general about the exchange? Is I really don't know because I don't know the history What of is the advantage for Vermont having its own statewide exchange? Why? What is the difference between if we just were on the federal, if Vermonters just were on the federal exchange?

[Addison "Addy" Strumolo (Deputy Commissioner, Department of Vermont Health Access)]: Yeah, I'm happy to spend a lot of time on that. The short answer is that we wouldn't be able to have our state subsidies. We wouldn't be able to have a Vermont specific call center, for example. Wouldn't it would just become we would go into the kind of federal machine and have a lot less control over what we're providing to our state.

[Alyssa Black (Chair)]: But we wouldn't be administering it.

[Addison "Addy" Strumolo (Deputy Commissioner, Department of Vermont Health Access)]: Right. The website would be a federal website instead of a state website.

[Alyssa Black (Chair)]: I'm not threatening to do that, don't worry. I just wondered what that is. Just to temper everybody. I don't think I ever really knew what the advantage is to having a statewide versus, you know, half the states seem to be on the federal, half have their own. Anyways, let's move on.

[Addison "Addy" Strumolo (Deputy Commissioner, Department of Vermont Health Access)]: No. Happy to have that conversation, though, maybe when we're we're talking about the affordability challenges in the marketplace right now. But yeah, on this topic, I think we're toward the end. I had one more slide just kind of describing we are, this is just what we are doing this year, all of these various implementations that I described. So it's kind of a big IT project but then we're really importantly working to try to mitigate resulting coverage loss among eligible Vermonters. And as I mentioned before, focused on things like IT updates, data sharing to do as much as we can without requiring paperwork from members. It's very much underway. We are partnering with entities throughout state government that's going smoothly, although it's not a very long runway. Once the systems are updated, as I mentioned before, we were expecting a very large uptick in our enrollment transactions that we processed during 2027. So increased redeterminations, verifications, reinstatements that we think is about a 30% increase to our workload. And then I also got at this little bit, There's a little bit of an analogy here to the restart of the Medicaid redeterminations that we went through after the years long public health emergency pause. And we did learn a lot from that experience and hope to leverage it in this implementation, things like system updates to support those automatic redeterminations, member communications through different modalities, other outreach and partnership to make sure that people have access to resources to retain their coverage. I just wanted it to be very clear that as we enter this work, we are focused on keeping people on the roles. That is our goal. And then finally Oh.

[Alyssa Black (Chair)]: No, I wanted to Just because it wasn't addressed in your slides, and I don't know if it actually happened or if I'm imagining because there's so many things that we were trying to keep track of. Are you going to be able to backdate anymore? Or did they put in there that you were unable to backdate? I know at a certain point I thought that that was in there that you couldn't backdate Medicaid.

[Addison "Addy" Strumolo (Deputy Commissioner, Department of Vermont Health Access)]: It wasn't a blanket. So there is a piece about limiting the availability of retroactive coverage. That's right. So instead of a standard three month retroactive availability, it's reduced to one for certain populations. And that is a piece that made it in. Was not, I think maybe at one point it was more of a blanket, there can never be any retro and that is not what passed.

[Alyssa Black (Chair)]: And I just want to be clear because what that would mean is that if somebody missed in this onerous redetermination process, if it was a month, over a month, they then would not be eligible because they're not during open enrollment, they wouldn't be eligible until next year's open enrollment because they wouldn't have

[Addison "Addy" Strumolo (Deputy Commissioner, Department of Vermont Health Access)]: a Medicaid, qualifying we don't have the open enrollment period. So it can happen at any point during the year. And this gets a bit technical, but there's something, there's a different policy around when someone is eligible for reinstatement. So if they were on coverage and they drop it because they weren't able to send us the paperwork in time, they still have ninety days to send the paperwork in and then get their coverage reinstated. So that availability still exists, But you're right that there is a reduction in the availability of retroactive coverage, which is a slightly different scenario where someone fully is disenrolled and then has to restart their application process.

[Alyssa Black (Chair)]: Okay, thanks. Sorry to derail you there.

[Addison "Addy" Strumolo (Deputy Commissioner, Department of Vermont Health Access)]: No. Thank you. We just have one more slide, is a visual depiction of the IT and project work that we are doing over the course of this year and how it interacts with things like open enrollment that dictate the schedule, the typical schedule. So happy to take any other questions you may have.

[Alyssa Black (Chair)]: I have one but tougher, and then Lori?

[Francis McFaun (Vice Chair)]: Could I go back to that previous slide? Because I am confused about the last sentence there. A note. Explain what that means by an example maybe?

[Addison "Addy" Strumolo (Deputy Commissioner, Department of Vermont Health Access)]: Yes, so when we restarted Medicaid redeterminations, one of the most important pieces is that when someone came back and realized that they were no longer eligible for Medicaid, we were able to transition them to qualify health plan coverage. So say their income had increased over the course of the pandemic, they were able to transition to another program. In the case of work requirements, if a Medicaid enrollee can't meet their eligibility for Medicaid because they don't meet the work standards, they can also not go to the marketplace. That's a prohibition that's built into the rule, the law rather.

[Francis McFaun (Vice Chair)]: Lori?

[Alyssa Black (Chair)]: Addy, I apologize. I had to step out

[Lori Houghton (Member)]: to deal with the health insurance issue.

[Jill Mazza Olson (Medicaid and Health Systems Director, AHS)]: I'm just She'll be calling you later. I know. I'm sorry if this question was asked. But so

[Lori Houghton (Member)]: is there any pending federal litigation on any of this that could affect not

[Jen Carbee (Office of Legislative Counsel)]: having to do any portion of it in the future?

[Addison "Addy" Strumolo (Deputy Commissioner, Department of Vermont Health Access)]: That's a good question. Not to my knowledge, not on these pieces. Thanks. I think it's possible that we've seen some litigation around the implementing regulations coming from CMS and it's possible well, for one, it's possible that's a reason why they might be delayed in putting them out. But if they do, that might be a moment when we would see more action in the courts. Okay, thank you.

[Alyssa Black (Chair)]: Other questions? I had just one, which is sort of unrelated to HR1, but I wanted to ask either Addison or Ashley or Jill while I've got you here. I distinctly remember the joint hearing that we had with Human Services and Ashley going through her spreadsheet of possible things. And I just remember getting to the eleven fifteen waiver. Aren't we in negotiations right now for the renewal of our and I'm wondering how that's going. I think I remember your face getting really white.

[Ashley Berliner (Director of Medicaid Policy, Agency of Human Services)]: Might be getting really white next year. So we are spending this year, twenty six, drafting our application, and then we will spend 2027 negotiating with CMS. So the waiver expires at the 2027, and we have to submit it by December 31 this year and then spend that full year really negotiating the terms. So next year is gonna be the really insightful point in time where we figure out what our waiver looks like going forward.

[Alyssa Black (Chair)]: Have we seen any experiences with other states in this past year?

[Ashley Berliner (Director of Medicaid Policy, Agency of Human Services)]: We've seen waivers get renewed. There is nothing like our waiver out there. And I think what I said last year and what still is true today is our investments are at serious risk. Like, that is the piece that we are really on an island with in terms of there's no other precedents in the country for those eleven fifteen investments. And so that feels like it's gonna be a really hard fight. I think other pieces of our waiver, there's a lot more reason optimistic, but we haven't seen any like one for ones and we don't expect to. New York and Massachusetts will negotiate ahead of us. So we'll get about a six month lead time on how their negotiations are doing, but hoping that we can kind of hide behind them and then not draw too much attention to ourselves while they're dealing with much bigger fish.

[Addison "Addy" Strumolo (Deputy Commissioner, Department of Vermont Health Access)]: One of the items at risk is the Vermont premium assistance. Just I think that's of interest to this committee as our state subsidy for the marketplace.

[Alyssa Black (Chair)]: And how much is that a year? Do we know? I know it's been different because we've had the enhanced, but do we have any idea how much

[Addison "Addy" Strumolo (Deputy Commissioner, Department of Vermont Health Access)]: is I know you've asked me this before and I still don't have the number off the top of my head. Do you Ashley? We might need to wait till the budget presentation too because like you said, it's different.

[Val Taylor (Prospective Member)]: Yeah, it's like 5 to 6,000,000, that range.

[Alyssa Black (Chair)]: Okay. And that's what it currently

[Addison "Addy" Strumolo (Deputy Commissioner, Department of Vermont Health Access)]: reduction because of the enhanced subsidies. It'll

[Alyssa Black (Chair)]: We're go

[Brian Cina (Member)]: going to have time with Nolan to really look at the numbers tomorrow, right?

[Val Taylor (Prospective Member)]: I'll do a Friday tax tomorrow.

[Alyssa Black (Chair)]: Oh, that's

[Brian Cina (Member)]: just one element of the

[Val Taylor (Prospective Member)]: numbers. Okay. It's a big one.

[Alyssa Black (Chair)]: Dive into Yeah, the

[Karen Lueders (Member)]: weather of Friday taxes,

[Alyssa Black (Chair)]: make sure we all understand that. Thanks. Thanks. I really appreciate you coming in to give us this outlook. Opening day outlook.

[Val Taylor (Prospective Member)]: Yes, there we are. Thank you. And

[Alyssa Black (Chair)]: thank you for all you guys are doing because I know that this has just been this is a lot. It's a lot. So I really appreciate it.

[Karen Lueders (Member)]: Thank you very

[Francis McFaun (Vice Chair)]: much.

[Alyssa Black (Chair)]: I think we're

[Val Taylor (Prospective Member)]: all