Vermont Legislature SmartTranscripts:

[Alyssa Black (Chair)]: Hi, everybody, welcome back. Elna Clark from Dulce Healthcare, and we have in with us the Commissioner of Diva and Sify Barrett, of course, finance, and we're pivoting to budget adjustment. So thanks for coming in.

[Stephanie Barrett (Joint Fiscal Office)]: Thanks for having me. Short notice. No

[Deshaun Perez (Commissioner, Department of Vermont Health Access)]: problem. I'm Deshaun Perez. I'm the Diva Commissioner. So today, we'll go over our Diva BAA, the admin budget, the program as well. And then we'll give you a couple of updates on some of the one time funding requests that we had and then also a status update on the past one time funds, which included the provider stabilization fund as well. Great. And with that, I will turn it over. That's my quick and easy

[Stephanie Barrett (Joint Fiscal Office)]: to do.

[Leslie Goldman (Member)]: Thanks for coming in. I'm

[Deshaun Perez (Commissioner, Department of Vermont Health Access)]: turning over to the person behind me on the screen. So I

[Stephanie (DVHA finance official)]: I was going to this presentation, this PowerPoint was presented about a month ago to the House Appropriations Committee, and we'll just walk through it the same way we did with that committee. Alex is going to be the slide mover forward person.

[Alyssa Black (Chair)]: So

[Stephanie (DVHA finance official)]: as the commissioner explained, we'll just walk through our admin budget, has several adjustments, our program budget, which has some significant adjustments, and then go through updates on one times and a new funding request one time in the BAA. So starting with our admin budget, there are several adjustments to Diva Health contracts and ADS health contracts that Diva pays for. There's a modest adjustments to the contracts with a couple of physicians that support our Chief Medical Officer. You see those at $39,400 for the fiscal year. And you'll see these again annualized in big bill request. Our main MMIS Gainwell contract had amendments for interoperability and development coming in at just under $200,000 of GF, about $2,000,000 of total spending. These are mostly the ninetyten match development funds. Over at ADS, they hold the Deloitte contract for the MDWAS, the Medicaid Data Warehouse and Analytics Solution. And that project has successfully gone live. There's more sort of ramp up and certification work that's happening over the next next few months. Beginning in January, we're moving to the what's called the maintenance and operation phase. And so that's a different match rate. That's the development of the MDWIS program was done with one time money, but the maintenance and operation is ongoing funding. You see a partial year addition to our budget for that and it's significant at about $2,300,000 and 1.4 gsf.

[Alyssa Black (Chair)]: Can either you or Daisy, can you remind us what MDWAS is, what it's supposed to do? It seems as though MDWAS is on every single BAA and every budget with unanticipated costs. Frankly, how much have we paid for this so far?

[Deshaun Perez (Commissioner, Department of Vermont Health Access)]: I'm not sure. Do you know?

[Stephanie (DVHA finance official)]: We can we can get that information for you because there's actually a whole infrastructure, and steering committee across the the central office, ADS, Diva, and any other participating agencies where we track the funding we can very closely. Purpose of the MDWAS, which is making, pulling all of the data related to all of Medicaid into one location where it can be accessed and analyzed and utilized for management. We're also hoping that it will have some benefits to the financial reporting processes. That work has to be done first before we can move to the procurement, you know, because of the MMIS system, the next cycle of MMIS system procurement. The funding was one time funding that was initially provided three years ago, and then there was an adjustment the next year for the development side of this. There has been a bit of pressure on our Gainwell contract as a result of MDWAS because work also, concurrent work has to happen in the MMIS system. So there has been some pressure there, but we have that including all the staff time work that has gone into it in our total budget, and we can provide that to the committee.

[Alyssa Black (Chair)]: When you say all the Medicaid data, are we talking about more like claims data or are we talking about eligibility data? Is it really just programs expenditure data?

[Deshaun Perez (Commissioner, Department of Vermont Health Access)]: I would say it goes beyond that. I of it as we're creating a data lake. So we're pulling in all the Medicaid resources that we have and other data sources as well. So social determinants background. And so we're able to pull that together and provide a more analytical tool for us instead of always having to run the same report. We can automate that now. And that frees up our staff planning to dive into the data and take a deeper dive of what does the population look like, where are they coming from, what are the specific needs that they're having. So it increases our analytical capacity on trans menace tremendously.

[Stephanie (DVHA finance official)]: Yes. And it also is going to have the benefit of replacing another contract for the data that we have to report under something called to the federal government on how our programs spend and what we are spending in granular detail, we're spending on. So we're meeting that's been a very onerous process to meet that. And that is the sort of the first benefit of this is that it's looking like that will be the ability to provide that reporting functionality in a more streamlined and less burdensome way.

[Alyssa Black (Chair)]: Thank you. Thanks for that explanation. Looking forward to not seeing any.

[Stephanie (DVHA finance official)]: Yeah, it should be in the background, you know, once fully certified and up and fully operational. The other ADS held contract is Oracle licenses. They also have a small Gainwell contract. And the Oracle license cost went up in July. That wasn't known when we built the budget last year, and that's supporting the Vermont Health Connect work. And then we have a few operating expense increases. Basically one, which is DIVA is one of the agencies that's moving out of the main building at the Waterbury Complex over to leased space. And those leases are in place, and we have a cost coming into our budget midyear. And you'll see this annualized when you see the big bill request from Diva in a few weeks. And also in the admin budget are a couple neutral changes. One is fiscally neutral, which is moving money from one place in the to DIVA's budget to pay the ADS bills that are not related to These are the statewide overhead system support costs.

[Alyssa Black (Chair)]: So can I go back to the lease space?

[Deshaun Perez (Commissioner, Department of Vermont Health Access)]: Sure.

[Alyssa Black (Chair)]: So has the lease begun already?

[Stephanie (DVHA finance official)]: The leases were signed in December. Yeah.

[Alyssa Black (Chair)]: It was in December. It's And

[Stephanie (DVHA finance official)]: work has been started. This

[Alyssa Black (Chair)]: is lease space through the June.

[Stephanie (DVHA finance official)]: No. It's I think it's

[Stephanie Barrett (Joint Fiscal Office)]: a four year, Yeah. Five year

[Deshaun Perez (Commissioner, Department of Vermont Health Access)]: It's a multiyear contract.

[Alyssa Black (Chair)]: This 252,000

[Deshaun Perez (Commissioner, Department of Vermont Health Access)]: Oh, this goes until the June.

[Stephanie (DVHA finance official)]: Yes. This is for the cost through the June. I'm sorry.

[Deshaun Perez (Commissioner, Department of Vermont Health Access)]: Yeah.

[Alyssa Black (Chair)]: Okay. So the return to the office is now costing half $1,000,000 a year in leased?

[Stephanie (DVHA finance official)]: In our budget, think it's about $440,000 annualized.

[Alyssa Black (Chair)]: For just the lease, of course.

[Stephanie (DVHA finance official)]: For just the cost of the lease itself.

[Brian Cina (Member)]: Yeah. Brian, what was the cost of people working from home compared to working?

[Stephanie (DVHA finance official)]: The baseline cost of individuals in terms of their salary doesn't change. There is a cost to these leases, and there will be a one time cost to the fit up of the space.

[Deshaun Perez (Commissioner, Department of Vermont Health Access)]: Well, we

[Brian Cina (Member)]: were reimbursing people for their expenses at home. So now the state's paying for electricity, gas, water, utilities, and leased space for workers that we weren't paying when they were working from home?

[Stephanie (DVHA finance official)]: I'm not sure I follow your question. When you say the utilities, are you talking about

[Brian Cina (Member)]: When people were working from home I'm sorry, there might be a glitch because I heard you talking and I didn't mean to interrupt you. So I'm sorry if I did.

[Stephanie (DVHA finance official)]: If you could just be clear on the expenses that you're asking about.

[Brian Cina (Member)]: Yes, so when people work in an office, the state's paying a lease and we're paying utilities for operating the office. When people were working at home, was the state paying anything for their expenses besides their salary? Like, we paying their rent? Were we paying electricity, water, gas, cable, or anything for them at home?

[Stephanie (DVHA finance official)]: For the individual? Were we reimbursing the individual for their home expenses?

[Brian Cina (Member)]: Well, yeah, but they're home We're

[Stephanie (DVHA finance official)]: providing them with a laptop computer that they took back and forth, and we still will be doing that. That's not changing.

[Brian Cina (Member)]: And

[Stephanie (DVHA finance official)]: so that's why I'm struggling to understand the exact question you're asking.

[Brian Cina (Member)]: Okay, I think because when the legislature was remote, we got a daily stipend for our expenses at home, and then that was eliminated when we came back in person. So the state was paying the cost of operating a building with people here and remotely. And then we were all we all have to come back to work here, and there's no more stipend for people at home. So the state saved money from paying us at home and focused the investment on operating things from here. And what I'm hearing is that when workers were working from home, that it wasn't costing the state anything extra for them to work from home. Now that they have to be in the office, we have to lease the space and pay all these utilities for the next five years. There's one other question I had related to this, which is how did the state acquire the office spaces? Was an RFP process, or did they just go out and pick a space? What

[Stephanie Barrett (Joint Fiscal Office)]: was

[Brian Cina (Member)]: the process for selecting where the offices would be?

[Deshaun Perez (Commissioner, Department of Vermont Health Access)]: Yeah, I think that question may be best answered by the administration of the agency administration. Thank you. They would have more answers.

[Brian Cina (Member)]: We don't need to sideline it with this either. So thank you. I just wanted to understand it.

[Alyssa Black (Chair)]: I do have an additional question on this. So is this just the cost of the new lease? Or does it include all

[Leslie Goldman (Member)]: of the supplies that are now needed for these people who are now in the building three days a week? We were working

[Alyssa Black (Chair)]: from home. So

[Leslie Goldman (Member)]: is it electricity? Is it is it toilet paper? Is it whatever?

[Deshaun Perez (Commissioner, Department of Vermont Health Access)]: Everything. I I think somebody, I'm not sure.

[Stephanie (DVHA finance official)]: This this line item is just is just lease the lease expense that we are getting a bill for and have to pay. We do have in our base budget amounts that are for supplies. Diva's supplies will go with them to the new space.

[Leslie Goldman (Member)]: And will there be an increase in line item?

[Stephanie (DVHA finance official)]: We have not budgeted an increase in that line item. I think that remains to be seen. There's going to People being in the office, do you actually use more supplies? But it is a hybrid, still a hybrid standard. So we are not anticipating at the moment an increase. People come in one day a week or one day a month now, and they may be utilizing or taking home the supplies they think they need from what is currently in our baseline.

[Daisy Berbeco (Ranking Member)]: That's fine. Thank you.

[Alyssa Black (Chair)]: The Waterbury State Office Complex currently or December, who did Diva share space with? I guess why did we have to lease space? Didn't we have space in the state office?

[Stephanie (DVHA finance official)]: The main reason is several years ago, the Cherry Street Building where the health department was moved to the Waterbury Complex, the remote standard was lower. So there's enough room for people currently under the lower standard, but with the people being in more, there's not enough room for everyone to have a desk for every day. And that's the reason for the the lease space. It

[Alyssa Black (Chair)]: would be really how if can you remind me how many people actually work for people?

[Deshaun Perez (Commissioner, Department of Vermont Health Access)]: There's about 350.

[Alyssa Black (Chair)]: 350 people.

[Stephanie (DVHA finance official)]: It's actually about 380.

[Stephanie Barrett (Joint Fiscal Office)]: Or that. Yep.

[Deshaun Perez (Commissioner, Department of Vermont Health Access)]: Give or take a few.

[Stephanie Barrett (Joint Fiscal Office)]: So How many

[Stephanie (DVHA finance official)]: But it's it's it's heavy. The the these questions on actually the space design are are better directed to the administration because they they've been doing all the work on it in terms of, you know, who who could how how that can be accommodated. And the lease space is a part of that accommodation in terms of having everyone being able to have a desk.

[Alyssa Black (Chair)]: I guess, you know, I'm just

[Stephanie (DVHA finance official)]: On the days that you with the standard that is now in place.

[Alyssa Black (Chair)]: I mean, obviously, it's just one area, but it's nice to know how much Vermonters are now paying that they would have not been paying for the past few years and how much money It would be really nice to know how much the state of Vermont has saved that they otherwise would have paid because people were working remotely. Was prior to the return to office, what was a basic week? How many employees actually did work in the office at Diva?

[Deshaun Perez (Commissioner, Department of Vermont Health Access)]: That really depended on the units kind of priority setting. So it varied from week to week on how many people were in the office or not.

[Alyssa Black (Chair)]: So like on a given day, was there like an average of 50 people there, 100 people there?

[Deshaun Perez (Commissioner, Department of Vermont Health Access)]: I couldn't say how many people were were there or not because it just fluctuated.

[Stephanie (DVHA finance official)]: Okay. And it fluctuates on the needs of the business that's at hand. I know from my unit, people would come in once a month, but also as needed. And then some people in my unit previously would be in every day. So within each unit, it varies as well.

[Alyssa Black (Chair)]: I just think it's really important that we understand this, particularly since it's coming in the BAA. Has Diva instituted the return to office? Is that now in place? Because I know that for a time you had gotten an exemption because you had to lease a space. Is everybody now in the office?

[Deshaun Perez (Commissioner, Department of Vermont Health Access)]: So we are waiting for this space to become available, and we're still working on those three the the three office locations before we we bring everybody back.

[Alyssa Black (Chair)]: Okay. How's morale? It

[Stephanie (DVHA finance official)]: it has it has suffered.

[Deshaun Perez (Commissioner, Department of Vermont Health Access)]: It it has taken a hit. Yeah. Okay.

[Brian Cina (Member)]: Thank you for being honest. Yeah.

[Alyssa Black (Chair)]: At a time when we're really, really going to need to rely on Viva with the upcoming challenges that you're going to be facing.

[Brian Cina (Member)]: And when the workers are going to be faced with these impossible situations to manage.

[Alyssa Black (Chair)]: Oh, thanks. Okay. I think Val, did you have a question? You asked. Okay. And Leslie, we have a hand and we'll move on.

[Leslie Goldman (Member)]: Okay. I'm just curious to know who the leases are with because in the earlier ones you're saying Gainwell and Oracle, but you're not mentioning anyone.

[Stephanie (DVHA finance official)]: Those are IT contracts. This is how

[Leslie Goldman (Member)]: we like I'm asking about who the leases are for the buildings that you're mentioning for operating expenses. Where it is?

[Deshaun Perez (Commissioner, Department of Vermont Health Access)]: Who is the property manager?

[Leslie Goldman (Member)]: I'm saying you mentioned people above, so I'm wondering about mentioning people here as well.

[Stephanie (DVHA finance official)]: Yeah, the buildings are on the Pilgrim Park. I don't remember the name of the I've seen a copy of the lease because this is the source of the need for the ask. And it's all the same property owner and management company that we are leasing them from. And the agency of administration can provide that, I'm sure, or we can. It's off the tip of my tongue. I can't remember the name of them.

[Leslie Goldman (Member)]: Yeah, think that I would appreciate that in this line item.

[Stephanie (DVHA finance official)]: Okay. And

[Alyssa Black (Chair)]: I know I said I promised to move on, but Daisy has one question, and then we really will, we will move out.

[Daisy Berbeco (Ranking Member)]: Stephanie, what happens if Diva doesn't get the money to pay for this five year lease?

[Stephanie (DVHA finance official)]: The lease is a contractual obligation. We will get the bill. We will actually pay the bill. And how we close out the year is a question of whether or not we would need to seek additional resources if it's not provided directly as a line item in this budget adjustment. I don't know. I'm trying to I'm struggling with whether or not we have another recourse. If we don't have the funding, that's a question for the administration as well, if you don't provide the funding for the additional lease cost here that we face. That's not a very concise answer, but those are the two paths that I can see.

[Daisy Berbeco (Ranking Member)]: Well, something to contemplate because the BAA is something that the legislature passes or doesn't.

[Alyssa Black (Chair)]: Would it be accurate to say that DEBA would need to find that money that's somewhere already in their budget and it would maybe come out of programs and services?

[Stephanie (DVHA finance official)]: Well, it wouldn't come out of the program budget because it's in the admin budget.

[Alyssa Black (Chair)]: But

[Stephanie (DVHA finance official)]: it's a sort of philosophical question about the budgeting overall, but the contract has been entered into.

[Alyssa Black (Chair)]: Nolan actually For wanted

[Stephanie Barrett (Joint Fiscal Office)]: the record, Nolan's right, Crystal. Can I just provide some clarification? EVA doesn't need legislative approval to sign a real estate contract. They need legislative approval to pay for it. So they signed the contract, they don't need approval for that. What they're coming to you now is they're asking for spending authority to pay. You do not give them the money for that. They will have to either come back again and ask for it or find it elsewhere, but they have to pay the bill. Just to kind of help clarify. Just

[Stephanie (DVHA finance official)]: to be clear, it's not Diva that signed the lease, it's the administration that signed the lease, but Diva is the occupying space. So we it's our budget that that cost is falling into. And and this is a recommended expenditure addition in the BAA from the administration.

[Alyssa Black (Chair)]: Okay, let's move on.

[Stephanie (DVHA finance official)]: Just the last two small pieces in our admin budget are those net neutral moves, ABS overhead costs, like statewide overhead costs that fall across all the departments needs an adjustment upward. And then the HR1 bill had a restriction on Planned Parenthood funding for a year. And so we are switching the funding source. We're not defunding Planned Parenthood, but we're switching the funding source for the year from the matched federal dollars to fully state dollars.

[Alyssa Black (Chair)]: Thank you. Thank you. Yeah.

[Stephanie (DVHA finance official)]: You'll see that in the programmatic side as well. Now we'll move to the program budget. So this is pretty typical. It's a very large budget adjustment for our consensus update, primarily driven by just higher cost per case. And our caseloads continue to decline, but our cost per case, meaning the folks that are left in the declining caseload, are higher cost per case folks. And we just didn't get the trend line on that correct when we built the budget last year. And we're not alone in that. I have sat in on many NAMD finance calls, very similar experience in other states where you try, you understand that that's what's going to happen and you try and project the trend as we came out of the PHE and that rolled out. You try and project that trend of who's remaining and what their cost structure will be. But we are always a little bit lagged on data when we're building the budget. And so this $33,000,000 increase is catching up with the most recent experience of our expenditure on claims through our system. And we also have some adjustments.

[Alyssa Black (Chair)]: You're talking about per case and caseloads, who are we talking about here? Is this So

[Stephanie (DVHA finance official)]: we're talking about the enrolled population in every month its Medicaid expenditure eligibility group, and then what is expended on average across that caseload and how that cost per case, that PMPM, that per member per month expenditure, what does that look like compared in actual what it looks like actually with expenditure, more recent expenditure compared to what we thought it was going to be when we made a projection last year at this time when we asked for the 'twenty six budget.

[Alyssa Black (Chair)]: Right. So your caseloads are down, meaning you have fewer people enrolled and yet the acuity and the per case has gone up.

[Stephanie (DVHA finance official)]: It's higher than we thought it was going to be, even with the lower caseload. Also, this isn't a 100% cost per case. There are also adjustments for clawback and buy in of a Clawback, I think, is where I can get the detail. Have the ups and downs right here.

[Alyssa Black (Chair)]: Who are who's who's clawing back what?

[Stephanie (DVHA finance official)]: That's this is the it's been for, twenty years now. This is the part d financing mechanism under Medicare. Presumed savings in Medicaid because of the Part D, that is a clawback from the states to the federal government for the assumed savings. We don't control the math on that. The federal government tells us every year whether we're going up or down on the clawback in terms of what And it's the underlying driver of that is pharmacy costs and utilization. The long acting piece is about $1,000,000 and the buy in piece is about $2,000,000

[Leslie Goldman (Member)]: That was sort of where I was going with this. I'm trying to understand what the clawback is and what the buy in. It might be helpful to separate them, at least so we understand the 33,000,000 is a big number, Just to get our heads around that, or my head anyway.

[Stephanie (DVHA finance official)]: I don't know that we've sent them to you and we should have, but the DEVA ups and downs for the for the budget adjustment are all granular line by line. And so we'll get those to you.

[Leslie Goldman (Member)]: Yeah, don't think we've

[Stephanie Barrett (Joint Fiscal Office)]: seen them yet.

[Stephanie (DVHA finance official)]: Yeah. They should be familiar when you see them, but thank you. I'm sorry about that.

[Alyssa Black (Chair)]: No worries.

[Stephanie (DVHA finance official)]: Next. Next is a downward adjustment in our budget for changes to correct the coding change to the ABA applied behavioral analysis benefit, and you will see that annualized in our '27 budget ask.

[Alyssa Black (Chair)]: I was gonna ask Diva to come in just to talk about this a little bit. But do you wanna give us could you possibly give us sort of a brief overview on

[Deshaun Perez (Commissioner, Department of Vermont Health Access)]: On on this?

[Alyssa Black (Chair)]: Because this is something that we, as the legislature, have have heard a great deal about.

[Deshaun Perez (Commissioner, Department of Vermont Health Access)]: Yeah. I can give you a high level, and then it may be good to kinda bring us in for a for a detailed conversation if that's So what we're doing is what we're seeing on the federal level is a increased scrutiny around the ABA benefit and how that is done.

[Alyssa Black (Chair)]: What is ABA?

[Deshaun Perez (Commissioner, Department of Vermont Health Access)]: ABA is the applied behavior analysis. And it's generally a benefit we serve for the Autism. Thanks, Stephanie. For individuals, children with autism, on the autism spectrum. And so what we are doing here is there has been guidance. And in order to kind of come up with compliant or be more proactive, what we're seeing done in federal oversight is we're no longer allowing the concurrent billing. So providers can't bill two codes at the same time. And so that and that is based on the guidance that we're receiving from the AMA. I kind of talk

[Daisy Berbeco (Ranking Member)]: AMA is.

[Deshaun Perez (Commissioner, Department of Vermont Health Access)]: AMA, sorry. It is the American Medical Association. And so part of that CBT, the current procedure code. And so part of that, it prohibits two clinicians supporting on the same unit with that patient. And so DIVA is disallowing that benefit, the billing of 97,155 and 97,153 for the same member at the same time with alignment with that guidance. Now, those two codes may be billed for the same member on the same day when it's clinically appropriate or the code criteria is met. So that is one of the things that's kind of the concurrent billing piece that we have there. The thing that we're looking at is the telehealth updates based on clinical standards as well.

[Alyssa Black (Chair)]: How many providers in the state of Vermont are we paying? How many do you have enrolled? Because $600,000 for six months

[Deshaun Perez (Commissioner, Department of Vermont Health Access)]: I need

[Alyssa Black (Chair)]: would be $1,200,000 change. $1,200,000 to one profession seems like an awful lot of money impact.

[Deshaun Perez (Commissioner, Department of Vermont Health Access)]: I have to get back to you. I know I just looked at this today and I can't remember the number, but I can provide you the number of providers who are serving this benefit.

[Alyssa Black (Chair)]: I guess I'm just trying to get a sense of how much financial impact this will have per provider.

[Deshaun Perez (Commissioner, Department of Vermont Health Access)]: Yeah, we've also looked at that. So the concurrent piece is about a 12% reduction in provider rate or provider revenue. So we can give you if you find it, we can either answer that question or we can come back and talk more about this.

[Alyssa Black (Chair)]: Yeah. We'll we'll have you come back.

[Stephanie (DVHA finance official)]: Alex, can you switch back to the other slide again? We weren't quite finished with the programmatic changes.

[Alyssa Black (Chair)]: Topper has a question, though, real quickly.

[Francis "Topper" McFaun (Vice Chair)]: My question is this: Are you increasing money for ABA or decreasing it?

[Stephanie (DVHA finance official)]: It's red and it's negative, so we are decreasing it. This is a lower expenditure out for this benefit that we are anticipating with these coding changes. It's predominantly driven by the coding changes. There's, as the commissioner mentioned, some other telehealth.

[Alyssa Black (Chair)]: All right, next.

[Stephanie (DVHA finance official)]: Next adjustment is Stephanie, I'm sorry.

[Alyssa Black (Chair)]: Stephanie, I'm really sorry. Daisy has a question.

[Stephanie (DVHA finance official)]: Just quickly, when you come

[Daisy Berbeco (Ranking Member)]: back to talk about ABA and whatever else, in addition to looking at the provider fiscal impact, can you also let us know the patient service level impact? So how many patients are receiving these services throughout the state?

[Leslie Goldman (Member)]: One's- Leslie. You mentioned telehealth, so when you come back, could you sort of separate out what the telehealth piece is? Yep, we can do that.

[Alyssa Black (Chair)]: Yep, thank you. I'll do a much deeper dive into this. Okay, moving on to

[Stephanie (DVHA finance official)]: FQHCs. This one isn't up to the providers. This is the Medicare Economic index rate increase that is applied to the FQHC and Rural Health Clinic base. It happens mid year, so this is a half year increase, you'll see the annualized amount of it in the next know, the '27 budget ask. The next item is the family planning rate. The legislature increased our budget by $850,000 last year when you built the '26 budget to implement an increase to family planning, but that it was not implementable the way it was provided because of the the directive that was in the annotation and the actual way that the family planning payments work. And so what we're showing here, because we did not implement that, we're showing it down in the budget.

[Alyssa Black (Chair)]: And

[Stephanie (DVHA finance official)]: then the other, this is a cost neutral funding adjustment for cost neutral in terms of the program, not cost neutral to the general fund. This is also the Planned Parenthood restriction in HR1. This is the programmatic cost of it. We're providing the payment to Planned Parenthood, but it's going to be paid for the twenty six year entirely out of general fund dollars. And so that 1,130,000.00 of general fund dollars is the value of federal match that the state is picking up because of the restriction in HR1.

[Alyssa Black (Chair)]: And

[Stephanie (DVHA finance official)]: then we just have a note here that every year DIVA maintains alignment with the Medicaid fee schedules through annual net and neutral factor adjustments in our rate schedules. The program budget is the largest adjustment, but these are the pieces of it. We will get you the ups and downs detail. I'm sorry that didn't get sent to you so that you can see it in a little bit more granular level.

[Alyssa Black (Chair)]: Leslie, did you have a question?

[Leslie Goldman (Member)]: I do. I'm just trying to understand what you mean by family planning rate not implementable, which is almost a million dollars. Like, who's not getting that money? Is it coming from elsewhere? What's the story behind that?

[Stephanie (DVHA finance official)]: So it was not an administration recommend in the budget last year. It was an amount of money that was an add on to the budget that the legislature provided to DIVA to increase the planning rate, and I will get you the details of it, but it wasn't implementable. We sent in for the intent document the reasons that it wasn't implementable as drafted. And so it never went out, but it's sitting in our budget, and we can't send it out under the system that we have. We can't implement it as you directed us to implement it under the system that we have in the way that we pay for the family planning. And so what we're showing here is the taking it out of our budget since we are not able to send it out. It's not a deduct from a current baseline like the ABA is. It's an increase that you recommended that we can't implement. And we will provide you with the details of that. It was back in June when we provided that. It's escaping me, but we'll provide you with the details of why that was not able to be implemented.

[Alyssa Black (Chair)]: When you say as written, who It's a

[Stephanie (DVHA finance official)]: line item that was added for

[Alyssa Black (Chair)]: a specific

[Stephanie (DVHA finance official)]: increase across certain codes. That's where the rub was. It wasn't a piece of session law. It was an annotation to go with the $850,000

[Stephanie Barrett (Joint Fiscal Office)]: Yeah, please. This happened in appropriations committee. I think it was in the house appropriations side, but it was done probably last minute, not quite vetted. And I think what we're hearing is that the way we want it done is unimplementable under our current systems. I think that's what I'm hearing. But that's what it was, it never came to this committee. That's why. Okay.

[Alyssa Black (Chair)]: So I want to be clear though, these were funds that were not recommended in the Governor's budget. The legislature recommended them appropriated money, but the administration didn't feel like they could implement it, so now they're just saying we're not gonna implement it? Or or have you come back to us with are are you planning on coming back to us with language that somehow makes it implementable so that the funds can be used for what the legislature intended them?

[Stephanie (DVHA finance official)]: We are not. What you have in front of you is us saying, as it was appropriated to us, we can't implement it. And so we are recommending that it come back out of our budget. We could work with you to say, if you don't wanna take it out of our budget and you want to find it, if there's an alternate, if you still want the money to go out, we could work with you to say, This is the way it would go out. It wouldn't match what the original intent of the appropriations committee was.

[Alyssa Black (Chair)]: All right, let's move on to Topper, I'm sorry.

[Francis "Topper" McFaun (Vice Chair)]: When you're sending this information to us, the adjustment to correct coding for ABA, what I'm reading there, I understand, correct me if I'm wrong, you're gonna correct the code, but you're also gonna reduce the benefit by doing that. Is that correct?

[Deshaun Perez (Commissioner, Department of Vermont Health Access)]: So, no. So we're not reducing the benefit. We're just saying that you no longer build the two codes at the same time. And because of that, we're gonna see a budget reduction because the way that it's billing, if there that's the additional cost of billing at the same time. But we can come back and talk more about it. I can only give you a high level Okay. Yeah.

[Francis "Topper" McFaun (Vice Chair)]: Well, yeah, that's what I'd like to put the details on that. Thank you very much.

[Alyssa Black (Chair)]: All right, I think we can move on from this slide.

[Stephanie (DVHA finance official)]: Okay. Now we're going into the one time world. And so our budget for the BAA has a $2,720,000 asking it for a cloud migration of the Health Connect. This is necessary to stay in security compliance. Federal funding demands it. And so this work has to be done by the December. And so it's ongoing now. And so it's primarily license driven work. So that's one time new funding ask. And then the second ask in here is reconciliation of the Brattleboro retreat. This number may change in the next few days. We thought this number was set. It's based on actual utilization of bed days. The retreat had a new system in place that they implemented in the summer. And just last night, we were finding out that the data wasn't matching up and it might be less bed days. So this number might be going down shortly for the reconciliation. We're under this alternative payment method with the retreat. It's an annual contract for a certain number of bed days for a certain rate, but our utilization is above that number of bed days. And so for the past three years, we've

[Alyssa Black (Chair)]: had a reconciliation

[Stephanie (DVHA finance official)]: where we owe the retreat more money. But the good news is that we might be a chunk lower than this once we understand where the disconnect on some of the

[Leslie Goldman (Member)]: dates

[Stephanie (DVHA finance official)]: are mismatched between what the retreat is seeing and what our systems tracker has in it.

[Alyssa Black (Chair)]: Do we pay them a perspective payment on what we think?

[Stephanie (DVHA finance official)]: So we we actually have a contract that says we're gonna buy this many bed days in this month, and we pay them that amount at the beginning But of every for the year, our utilization for the past three years has been above that base amount that we have stated in the contract. And the contract then allows for the reconciliation of the overage of bed days that we use or if prior to three years ago, we underutilized bed days because the retreat couldn't meet the capacity that we needed, but now they can and more so. And so it is a question for the future to get that contract aligned more on the baseline for potential use of bed days. And the contract is on the calendar year basis. So that's why you see the reconciliation in the BAA year to year.

[Alyssa Black (Chair)]: Okay, thank you.

[Stephanie (DVHA finance official)]: And then the last slide we have here is just an update on one time funding that you provided to us last year. So provider stabilization, was a $10,000,000 one time appropriation. We currently have about $3,300,000 left in that. A report was required and was submitted to the legislature back in December. But we do have several outstanding applications from larger facilities that came in in early mid and early January, requests that are in those current outstanding applications far exceed the 3.3 that's remaining. And we're working through those. But if you, you know, once you have a chance to review the report that was submitted, if there's questions in that regard, can follow-up.

[Alyssa Black (Chair)]: Will there be in the budget? Will there be a request to put more funds into this provider stabilization? Do we anticipate that this is an ongoing thing where you should always have some funds for this purpose? Because it seems like every single year we're facing.

[Stephanie (DVHA finance official)]: So I think that remains to be seen, but there's also the receipt by the state of the Rural Health Transformation Fund and what aspects and how provider stabilization potentially fits into that or not, I think needs to be thought through and if that thinking is going on right now.

[Alyssa Black (Chair)]: Okay. Thank you. Next.

[Stephanie (DVHA finance official)]: And then the last item is you provided $10,800,000 of transition funding from the global commitment. It's turning out to be $5,100,000 for Sash and 5,700,000.0 for the Medicare Blueprint one time bridge payments. And those payments are keyed up in our system and we'll the Sash is underway. And the 5.7 Medicare Blueprint payments are keyed up in our system and will be out to those practices and community health teams the first week in February. And then in addition to that funding, pure general fund funding of $835,000 for the comprehensive payment reform and $3,100,000 for the primary care transition funding additional money, Those will be going out in two payments, hopefully at the January, early February, and then also in June or July. So that's the status of that significant one time funding that you provided last year.

[Alyssa Black (Chair)]: Okay. Any questions? That's it.

[Deshaun Perez (Commissioner, Department of Vermont Health Access)]: Thank you. That's it.

[Stephanie Barrett (Joint Fiscal Office)]: That's need all to What

[Alyssa Black (Chair)]: is the total from DIVA?

[Stephanie (DVHA finance official)]: The total budget adjustment is 4.9 on the general fund and 29.7 on the global commitment fund. So in total, it's 39.2. And it also 4.9 on the federal funds. So that does not include the reconciliation for the retreat or the cloud migration one time, but our base in total is 39.2 across all the sources of funds.

[Alyssa Black (Chair)]: Okay, so 40,000,000 total, but that includes federal funds as well?

[Stephanie (DVHA finance official)]: That includes federal funds. Yeah, that includes the roughly 60 What funds just general funds? The general fund portion of that is 4.958.

[Alyssa Black (Chair)]: But it also includes global commitment funds, so there's a portion of global commitment funds that started their life as

[Stephanie (DVHA finance official)]: Yes, you're absolutely right. The 29,000,000 of global commitment funds has a general fund matching that is up in the agency's budget. So that there is yeah. The difference is not purely federal. There is a, you're absolutely correct on that. Okay. Just- So for DEVA alone, we're telling, you know, I didn't print out the agency's ups and downs, but we could tell you the total across the entire agency, Tracy can tell you the total across the entire agency on the Medicaid pressures.

[Alyssa Black (Chair)]: So roundabout 20,000,000 started its life as a general fund.

[Stephanie Barrett (Joint Fiscal Office)]: So it's a mix, right? There's 50 admin, there's ninetyten on new adult, there's seventythirty young kids, it's sixtyforty on the regular, so it's a mix. On average, it's sixtyforty ish.

[Deshaun Perez (Commissioner, Department of Vermont Health Access)]: Yeah. But we can't

[Stephanie (DVHA finance official)]: So our 13 on the on the DIVA program budget page of the slide deck, the the portion that is for the the baseline consensus update, the portion of that that is general fund is $14,300,000.

[Stephanie Barrett (Joint Fiscal Office)]: Okay.

[Stephanie (DVHA finance official)]: And so the the slide deck does have the split between gross and and general fund for the for the pieces. I was just giving you the total off the bottom line of our ups and downs. Okay. Yes.

[Alyssa Black (Chair)]: All right. Yes, Brian.

[Brian Cina (Member)]: I just wanted to thank you for answering the barrage of questions around real estate earlier, and I want to acknowledge that it might have felt like we were shooting the messenger and that wasn't the intent and that I'm sorry that you're having to deal with that issue of being forced to return to an office and being the person to convey to us the expense. So I just want to acknowledge that that might have been difficult to be peppered with all those questions and that the intent wasn't meant towards any of you or to question your work, so I want to just say that.

[Alyssa Black (Chair)]: Thank you for saying that. I completely concur that I know that you're in a difficult position with the questions that we're asking. It's just your rent money, basically.

[Brian Cina (Member)]: And you're not even getting to decide it's the tenant where you're living, so I just want to take my lunch through this.

[Alyssa Black (Chair)]: All right, any other questions on anything? Thank you so much for coming in. Thanks for coming in last minute. Really appreciate it. Again, thank you.

[Deshaun Perez (Commissioner, Department of Vermont Health Access)]: Thank you.

[Alyssa Black (Chair)]: We can go