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[Alyssa Black (Chair)]: Good morning everyone. It is Friday, January 23, House Healthcare, and we're starting our morning with a walkthrough of H-two 70, which was our confidentiality for few sports council. We don't ever change the name of a bill, do we?
[Katie McLean (Office of Legislative Counsel)]: Yeah, we do sometimes. There was a discussion yesterday about wanting to change the name of a peer support specialist. I don't know if a decision was made on that, but we could definitely change the name of the bill. Okay.
[Alyssa Black (Chair)]: I'm just reading our agenda, and it still has peer support counseling. Oh, right. Yeah.
[Leslie Goldman (Member)]: It's still in the bill too. Okay. In section one. Alright. Section one. Peer support counseling.
[Brian Cina (Member)]: Is that the bill on the agenda, right?
[Leslie Goldman (Member)]: Yeah. 2.1. Okay.
[Brian Cina (Member)]: There is something.
[Alyssa Black (Chair)]: We might have a 2.2 is what we're saying.
[Brian Cina (Member)]: Yeah. Okay. There was another thing too. Okay.
[Katie McLean (Office of Legislative Counsel)]: So Katie McLean, office of legislative council, you have a draft on your board, and I'm hearing that there are requests for changes. So peer support session is what you landed on. So I will change that right now. I'm in word. Peer support sessions for emergency service providers. Does that work for folks?
[Brian Cina (Member)]: The idea is that we're taking out counseling because it's a charged term.
[Katie McLean (Office of Legislative Counsel)]: Or you could do programs.
[Brian Cina (Member)]: Informal peer communications about what they're going through. It only covers if there's an instituted program in place. I think that was the
[Daisy Berbeco (Ranking Member)]: Peer support for emergency service providers.
[Brian Cina (Member)]: That's a good idea. I like that.
[Katie McLean (Office of Legislative Counsel)]: Emergency service providers. Okay. And then when you change the title of the bill, we do that at the end of the bill. Is that what you want the name of your bill to be? An act relating to peer support for emergency Yeah. Assessed providers? Yeah. When we get to the end, I will add that before you vote on
[Alyssa Black (Chair)]: it. My note. Your confidentiality for peer support.
[Brian Cina (Member)]: That's that's actually sounds good.
[Katie McLean (Office of Legislative Counsel)]: Okay. So I've highlighted some changes in this draft. You're going to see that there's small amounts of reorganization, like consolidating two similar concepts in one place. And then we kept referencing exceptions in subsection d, but e really had exceptions too. So I brought them both into the same subsections. So small things like that. So we have our definitions of emergency service provider. This list almost looks the same since the last time you looked at it, except there was an email last night from the health department asking to get rid of the medical logical person that they had originally requested because they feel that it is covered under the medical examiner and assistant medical examiner. So they said that there's no need for that. So that has been removed. We have the same definition of employer peer support communication, peer support program and peer support session.
[Brian Cina (Member)]: Chris
[Alyssa Black (Chair)]: Horr sent a letter.
[Brian Cina (Member)]: I'm saying the name of the witness because I think it's important people know where it came from. It's on the record for last Friday, that's where it was posted. Which that was the Vermont Police Association, I believe is their title, was requesting that we remove the established or accessed by which says peer support program means a program established or accessed by the employer. They were saying that they wanted us to take out established or access that piece. I can't find the exact language.
[Daisy Berbeco (Ranking Member)]: I've got it up.
[Brian Cina (Member)]: Can you more clear than I am?
[Daisy Berbeco (Ranking Member)]: The police association is suggesting we remove established or accessed by the employer of emergency service providers. They said, quote, The removal of this language would allow for a broader range of peer support counseling services to be utilized, including regional, nonprofit, and independent programs.
[Brian Cina (Member)]: So I think what that would look like is we would strike out established group providers, and it would say peer support program means a program to provide support services to emergence. Does that make sense? We take out that. It's removing something that broadens the coverage, which is what we were just talking about. So they're asking for that specific chain. I just want to make sure I advocated for that because I was in communication with them.
[Daisy Berbeco (Ranking Member)]: That makes sense to
[Brian Cina (Member)]: me. So
[Katie McLean (Office of Legislative Counsel)]: this is the language that you're proposing to delete? Yes. Oh, sorry, this bug is-
[Brian Cina (Member)]: And we would do the same, I think we would, I don't think we have to do it in the next one because the next one doesn't mention the employers if I'll correct. We can look at it next, I'm sorry to jump on that on myself. Striking that out is to suggest the change if the committee that goes along with that suggests the change coming from one of our witnesses in response to this, the letter is on the record. Thank you.
[Leslie Goldman (Member)]: Would it be then, peer support program means a program providing support services?
[Katie McLean (Office of Legislative Counsel)]: It could say it either way, a program to provide or providing. I
[Alyssa Black (Chair)]: agree because it does seem a little duplicative.
[Brian Cina (Member)]: What were you
[Alex McCracken (Department of Vermont Health Access)]: going to do? I'm
[Alyssa Black (Chair)]: sorry. They established their access by Okay. I'm going to leave it up to the committee whether or not they feel everybody in agreement with that. I'm agreeing. I
[Brian Cina (Member)]: don't see anyone opposing.
[Alyssa Black (Chair)]: Okay, I'm going to delete this. There we go.
[Katie McLean (Office of Legislative Counsel)]: Then we have our peer support session language. And then we have a lot of yellow here in the peer support specialist language. So if you remember yesterday, we looked at the definition and then we looked further in the bill and there was more language that kind of felt definitional. Like, this is how we are discussing who a peer support specialist is. So yesterday, we talked about how I was gonna try to blend those two pieces together. And this is the result of it. I have run this by Mark this morning, and he was comfortable with this.
[Brian Cina (Member)]: Mark from the firefighters? Yeah. Presented
[Katie McLean (Office of Legislative Counsel)]: yes. Thank you. Peer support specialist means an individual who has been designated by an employer to serve as a member of an employer based peer support program or designated by a peer support program to act as a peer support resource. Four, has received training in providing peer support to emergency service providers who have been involved in potentially traumatizing events by reason of their employment or volunteer service.
[Karen Lueders (Member)]: Does order need to be Sorry, after some small one. Go
[Alyssa Black (Chair)]: ahead, Allen.
[Allen "Penny" Demar (Member)]: What's going to pertain to training?
[Leslie Goldman (Member)]: Type of training?
[Katie McLean (Office of Legislative Counsel)]: Silo training?
[Allen "Penny" Demar (Member)]: As we see training and providing peer support.
[Katie McLean (Office of Legislative Counsel)]: That's leaving it up to whoever is offering, so you're not being specific. So we're
[Allen "Penny" Demar (Member)]: not looking for certain criteria? We're not. No, but nobody is. So I could be a peer supportist.
[Alyssa Black (Chair)]: No. The employer or the organization that has people working in capacity for emergency service providers, they would be designating a peer support specialist and what training that peer support specialist needs.
[Allen "Penny" Demar (Member)]: So, each organization, actually.
[Katie McLean (Office of Legislative Counsel)]: Yes, and this is an or. So you could qualify just on the basis of being designated by your employer to serve as a member of an employer based peer support program.
[Allen "Penny" Demar (Member)]: Or, I don't know about
[Katie McLean (Office of Legislative Counsel)]: You the could be a peer support specialist because you've received training in providing peer support to emergency service providers. So that's just one potential avenue to be a peer support specialist. And then the last Let's let her
[Alyssa Black (Chair)]: get through the last and then we'll take ask questions.
[Katie McLean (Office of Legislative Counsel)]: And then the last or is otherwise a member of an organized and recognized from a peer support program. We didn't get any information about this and recognized who was doing the recognizing. So you could leave it. You could just say a member of an organized peer support program and remove the recognized. It's up to the committee.
[Alyssa Black (Chair)]: I am recommending we strike recognized. I think because there are so many different professions of the differing organizations, associations, different that I think we need to remain agnostic on and not weighed into like the training or otherwise, I think that we should leave it to the organisations. So, I'm recommending we get rid of recognised.
[Karen Lueders (Member)]: So I've talked with folks, I'm waiting to
[Alyssa Black (Chair)]: help you get through, but I have them put on a bunch of stuff to talk to folks about. Okay, alright. Well, let's, first I got topper. Are we done? No. I'm I'm waiting for it just need to get through the other oar. So, we've got multiple questions around this one little piece. Chopra, you were first. Mine was simple. You mentioned that we didn't need the term, the word or, between one and two.
[Katie McLean (Office of Legislative Counsel)]: That's correct, because you have a list of three, so you put it between the last two items.
[Alyssa Black (Chair)]: Brian, and then Daisy?
[Brian Cina (Member)]: I just wanted to say that I appreciate what you said about wanting to keep it as broad as possible. I think that's what I'm hearing from the stakeholders, not only in testimony, but in the halls that they want us to protect confidentiality in the broadest possible sense. So in terms of peers supporting each other, and I think not overly regulating how they support each other is important here, and that's what I heard the chair suggest. I just want to back that sentiment and anything we do that does that, I will support. But I do want to hear what DMH says and stuff too.
[Daisy Berbeco (Ranking Member)]: I didn't speak with DMH. I spoke with some folks that are in the peer have been the certified peer recovery specialists and mental health specialists, and been part of that before it was certified and then part of certified. And so I want to talk about the definition of peer support specialist. Sorry, not the definition, the title peer support specialist, so that it's not conflated with peer support specialists that do those services as a profession. And I know it's in a different statute. Can I remind
[Alyssa Black (Chair)]: you that Katie actually inserted that there's another part in here where it says should not be conflated
[Daisy Berbeco (Ranking Member)]: with Yeah? Okay. Okay. Sorry. Can we consider calling the emergency responder support peer?
[Katie McLean (Office of Legislative Counsel)]: So can I take a step back and explain what we're talking about? Feel like there might be some confusion. So we do have this language that we've been sort of referencing, which is in a different title. We're saying that there is a certification, a certified peer support provider. And we're saying that this person is not the certified peer support provider. However, based on the fact that they are certified, there could be a peer support provider who is not certified and it's still their profession. And I think that is what you're getting at, that we're not worried about completing the certified peer support provider, but you have a worry that the term peer support specialist gets at the non certified folks who do this as their profession.
[Daisy Berbeco (Ranking Member)]: They are also trained. And so the folks that do this that are peer support specialists in mental health and recovery, they go through training, and they want to protect the professionalism of what they do. And I don't know that saying this shall not be conflated is enough. It's just something to consider. We don't have to do it. But it's my recommendation of changing that name to specify that these are emergency service peer specialists clearly shows that these folks are regulated differently. They're not in the same class of peer support specialists as these folks who do this as a living, for a living?
[Alyssa Black (Chair)]: I'm not inclined to change what the professions that we're talking about here. And if I'm gathering, if I'm interpreting what you're saying, that one doesn't necessarily one is not necessarily inside the other and the other isn't necessarily I think we're talking about two completely different cohorts and one cohort can be a part of this, but the other isn't necessarily part of that. And I think that the language that legislative council has put in here to ensure that we know who we're talking about here is sufficient. Does anyone else have any thoughts on this?
[Katie McLean (Office of Legislative Counsel)]: I think it's that.
[Karen Lueders (Member)]: You
[Alyssa Black (Chair)]: know, I just feel like we've already changed completely the name. Because remember, originally they were peer support counselors or counseling, and I think we landed on peer support specialists. And I think Katie's language has clarified who we're actually talking about.
[Daisy Berbeco (Ranking Member)]: Well, yeah, I disagree respectfully because there's a whole group of folks that are peer support specialists as a profession, And they are trained, and they very much offer supportive counseling to folks. And I just want to be clear that this group of folks has a very different role in doing their peer support. So I do not think that's a scare at all. Are
[Alyssa Black (Chair)]: you suggesting that we include Are you suggesting that this group, that our peer support specialists that do this for a living in many, many venues, are you suggesting that we expand this bill to include?
[Daisy Berbeco (Ranking Member)]: I'm just saying, instead of saying peer support specialists, which right now indicates to me that I mean, that title is used for folks that are peer support specialists in mental health and recovery coaches. It's used for those folks that aren't certified. I'm suggesting you say these are emergency response peer support specialists, because the folks that do this for emergency response are designated that by their employer. And the employer sets the guidelines for what they do. And we are here giving them some regulatory guidelines that peer support specialists in mental health and recovery do not follow? I am afraid that if we do that, then,
[Alyssa Black (Chair)]: I mean, if we look right above here for peer support session, it's almost like saying that they're only there for peer support specialists or emergency services and who have been involved in a traumatizing event, and then we're cutting out all the other things that we talked about, which is the part in here of cumulative or chronic emotional stress by a result of their employment, which may not necessarily be the result of emergency service, but rather just the stress of the employment. We talked about the prevalence of alcoholism And if we then keep changing the definition of peer support specialist, we're probably then it becomes, oh, well is that part of it? I am not in favor of changing. Deb, did you want to? Is there a reason why we can't use consultant Instead of specialist?
[Debra Powers (Member)]: No, because they're not consulting. Right.
[Brian Cina (Member)]: It's a specific Yeah, consulting feels a little more formal.
[Alyssa Black (Chair)]: Yeah, licensed.
[Brian Cina (Member)]: That's why I wouldn't
[Alyssa Black (Chair)]: use it.
[Karen Lueders (Member)]: Go ahead. So Daisy, I don't know if your concern is addressed by the change of title, because the title makes it clear, the group to which this, the change of title we just came up with, makes it clear to which peer assistance is being designated with this one. But does the title help, say, take
[Alyssa Black (Chair)]: away the confusion? I mean,
[Karen Lueders (Member)]: there's also don't confuse it with this, but does the title help?
[Katie McLean (Office of Legislative Counsel)]: I think she looks like she wants to land. I feel like I completely hear and understand what your point is, and I'm not sure everybody is understanding the same. So I'm going to try again to explain because it does make a lot of sense to me. So we have professional individuals who are peer support providers. They have gone through the training and this is their full time profession. They working with all types of populations. Within this group of individual Let me hold that. So we have this group. Sort of not within this group are the folks we're talking about today. And these are folks, this is not necessarily their full time profession. They have not necessarily gone through all the training that this group has gone through. They could just be designated by their employer to do this work without really having a lot of training necessarily. So sort of the scope of what the service they're providing is different. Okay, back to this group who is a professional group. This group has the option to be certified if they want. They don't have to be, but they have the option to be. So this language in B that you're looking at is saying that these folks that are specific to this bill are not the certified population. But we've already said that some of this group isn't certified. And I think that's the point that Representative Berbeco is trying to make is that we never clarify how these folks are treated. And I think the idea is that the term peer support specialist may get confused with the folks, the non certified folks that have all of this training, but are very different from the folks that this bill talks about. Did I muddy the waters or did I? How
[Brian Cina (Member)]: does
[Katie McLean (Office of Legislative Counsel)]: your language in B right there not clarify It clarifies it with regard to half of this population that chooses to get certified, that everyone who doesn't get certified doesn't have the title certified peer support provider. And those folks go by, I don't know, peer support specialists, it sounds like. And so that's where the confusion comes in, is that folks who do this as a profession but who are not certified could possibly be confused for the folks in this bill that this is trying to identify and separate out.
[Daisy Berbeco (Ranking Member)]: I just want to note, I've been working with peer support specialists for twenty years, and they are incredibly well trained and bring a lot more than just lived experience to the job they do. And they have fought very, very hard to be treated like professionals. And I want to protect that peer support specialist is a profession.
[Alyssa Black (Chair)]: Katie, do you have a suggestion of language that would clarify that what we are doing in this section of statute only pertains to the people that we're talking about in the long list of people we're talking about.
[Katie McLean (Office of Legislative Counsel)]: The tricky part is that I'm sorry I'm using my hands, but I feel like
[Daisy Berbeco (Ranking Member)]: That's my favorite issue. So
[Katie McLean (Office of Legislative Counsel)]: the certified folks are in statute. They have something we can cite to. The uncertified folks, we don't have a statutory term or a statute that we can point to the same way we can for the certified folks. So that's the tricky part. If I had a name recognized in statute for them, then
[Leslie Goldman (Member)]: I could just add them to this list and be. Non certified specialists.
[Alyssa Black (Chair)]: I just have one clarifying question.
[Katie McLean (Office of Legislative Counsel)]: So is peer support specialists in legislation anywhere? Is that a name anywhere? I'd have to do a search. That's all. Thank you. We talked.
[Alyssa Black (Chair)]: Karen, and then I'm not sure if I saw anybody else. So I don't know
[Karen Lueders (Member)]: if this I'm Muddies or Muddies. It seems like both groups have either you can be certified or not, but this group is more highly, absolutely professional and highly trained. And
[Katie McLean (Office of Legislative Counsel)]: on this case, they don't have to be certified, but they
[Karen Lueders (Member)]: can be. So both groups kind of have both options, but they're doing very different things now.
[Katie McLean (Office of Legislative Counsel)]: Oh no, I'm sorry. Only the professionalized that does this, they have the option to be certified. The folks that we're talking about in the bill don't have the option to be certified. So they, I mean, in theory, it could be a certified person who decides to fill this role. But this is a role that doesn't necessarily require any training. Remember, we went through our list and or was one item on the list.
[Karen Lueders (Member)]: Some of that. Can I follow-up with you?
[Alyssa Black (Chair)]: Yes. Although, would we be doing any damage if we put emergency service peer support specialist and defined that and changed it throughout the bill?
[Katie McLean (Office of Legislative Counsel)]: I think that probably would clarify things. Okay.
[Alyssa Black (Chair)]: All right, then let's do that.
[Alex McCracken (Department of Vermont Health Access)]: I hope
[Brian Cina (Member)]: that the Senate does a spoon.
[Katie McLean (Office of Legislative Counsel)]: So emergency service peer support
[Alyssa Black (Chair)]: specialist. Yes.
[Katie McLean (Office of Legislative Counsel)]: Okay. I will not do that right now throughout the bill. Okay. But let me write it down and I will do it.
[Daisy Berbeco (Ranking Member)]: Katie, thank you so much.
[Brian Cina (Member)]: Thank you for dealing with all this.
[Daisy Berbeco (Ranking Member)]: It's very important.
[Alyssa Black (Chair)]: Thank you for the hand.
[Katie McLean (Office of Legislative Counsel)]: I know, I'm sorry.
[Alyssa Black (Chair)]: Yeah, Leslie has a question. Go ahead Leslie.
[Leslie Goldman (Member)]: I was just wondering in B, you're going to change it to emergency services peer support specialist.
[Katie McLean (Office of Legislative Counsel)]: We're going to change it right here. The definition, we're going to call that the title of these people who are doing the work in your bill, emergency service peer support specialist. And everywhere it appears in the bill,
[Leslie Goldman (Member)]: we are going to change their title. Okay. So slide down to B where that, so that'll that'll change right there.
[Katie McLean (Office of Legislative Counsel)]: Nope. That will stay the same. Okay.
[Leslie Goldman (Member)]: Yep. Could we add certified or not certified? Or is the problem that the not certified is not in statutes?
[Katie McLean (Office of Legislative Counsel)]: 26. I mean, it's your ability. You could do whatever you want.
[Daisy Berbeco (Ranking Member)]: We solved the problem. I feel like it's okay.
[Alyssa Black (Chair)]: We solved it. Okay.
[Katie McLean (Office of Legislative Counsel)]: Okay. I'm going to keep going. So I've moved Is that okay? Yes. Okay. No,
[Alyssa Black (Chair)]: that's true.
[Katie McLean (Office of Legislative Counsel)]: Subsection B. So this is mostly the same language you've seen. Because we had the same lead in language twice, except as provided in subsection D, I felt repetitive. So I turned it into a list. And that is why we now have an A and B. They had both been phrases that started with accept as provided in subsection B. So instead of having that repetitive language, I broke it into a list. Also, this language led by a peer support specialist, I've integrated into the paragraph. In subsection D, there was a sentence that said the confidentiality only attaches if the peer support is led by a peer support specialist. I became concerned because we kept saying except as provided in D, and that didn't feel like it belonged as an exception. So by moving it out into the paragraphs, it does the same job, but it can't be interpreted as an exception, I guess is what I'm saying. Does that make sense? Or did I confuse folks on that? So it's a little bit wordier. Any peer support communication made in a peer support session of a peer support program led by a peer support specialist shall not be disclosed by any individual participating in the peer support session. What we're removing is a standalone sentence that says confidentiality only attaches if it's led by a peer support specialist. So you're doing the same work in this paragraph without having it embedded in the exceptions subsection. Same thing in Any peer support communication relating to a peer support session led by a peer support specialist between the peer support specialist and another staff member of the peer support program or between staff members of the peer support program shall not be disclosed by any individual participating in the peer support communication. No changes in this two, it's just been renumbered. It had been three. C. We're doing the same work here in this first sentence by pulling that phrase that has to be led by a peer support specialist into this section. Also, we had two sentences back to back that said limitations on disclosure imposed by this subsection. And it was wordy and I think a little bit confusing. So instead, I removed the first of those two sentences and just added it as part of this phrase. So except as provided in subsection D, that's where our exceptions are, any peer support communication made by a participant or peer support specialist, and any peer support session led by a peer support specialist shall not be admissible in a judicial, administrative or arbitration proceeding. Those statements are not permissible, including during any discovery conducted as part of adjudicatory proceeding. So that had been its own sentence, and now we're just saying, Here's another example of when you can't use it. And then we have the second sentence staying
[Alyssa Black (Chair)]: the same.
[Allen "Penny" Demar (Member)]: So we're saying that if there's a lawsuit of any sort, this could not be admissible?
[Alyssa Black (Chair)]: Yeah. Can we do that?
[Katie McLean (Office of Legislative Counsel)]: I mean, you can put it in statute, but then look at the next sentence. So the conversations that peers had during that session are protected. But what's not protected? So limitations on disclosure imposed by this subsection shall not include knowledge acquired by an emergency service provider from observations made during the course of employment or volunteer service or information acquired by the emergency service provider during the course of employment or volunteer service that is otherwise subject to discovery or introduction into evidence. So what does that mean? You are noticing that a coworker has become agitated, is agitated quickly. This is just a general observation you have. It's not tied to statements that were made or notes or reports that were made as part of a session. But if you were asked to testify, you could say, Yes, I have observed through my normal course of work that this person is suddenly very agitated or is quick to anger, whatever. That's an observation you could make. And if that is something that is otherwise subject to discovery and introduction into evidence, then yes, that is something that could be testified to. Does that
[Daisy Berbeco (Ranking Member)]: make sense? Thank you.
[Alyssa Black (Chair)]: Yes. Al and then Brian.
[Karen Lueders (Member)]: So why does that have to be added to that if it's not part of a peer discussion?
[Alyssa Black (Chair)]: You go ahead and say?
[Katie McLean (Office of Legislative Counsel)]: Yeah. I think the reason it's here is because you base this on language in the correctional bill, this is there. I think that's probably the easiest answer. But it makes a distinction, like this is where the line is. You can't talk about this, you can't talk about this. But my guess is that's why we have it here in the first place. So
[Brian Cina (Member)]: what I was getting from this is what you just said, and I want to make sure I'm getting it correctly, that if you turn to your peer for support, that's protected, but there's guardrails around or whatever you call it, the glass you break for an emergency. So if it crosses the line on those things in another part of this bill, then you are able to tell, but otherwise it's contained. I feel like what this is saying is if a person's acting out at work and you're concerned about them, you can tell someone and not feel like you're breaking your confidentiality if it's not part of them communicating with you about it. It allows a person to turn to someone for help, and if a person's not getting help and they're acting out, you could reach out to them and you could say, What's going on? I noticed this. And if they confide in you, then you can support them, you don't have to report it. But if they're like, I'm fine, and they're being dangerous, you're allowed to tell someone and get help before something bad happens.
[Katie McLean (Office of Legislative Counsel)]: Can I just jump in really quick?
[Daisy Berbeco (Ranking Member)]: Yes, please, because I'm
[Brian Cina (Member)]: trying to understand the mechanics of it.
[Katie McLean (Office of Legislative Counsel)]: This particular paragraph is about judicial procedures. So this isn't about just telling somebody that you're noticing something. This is about what information can a court receive and what information can a court not receive?
[Brian Cina (Member)]: So a court could say, can I just role play for a minute? They could be like, Leslie, in the course of work with Brian, what have you observed? And you're allowed to say, I noticed Brian being irritable and coming in late and asking weird questions and being sick a lot, But if I said to you that I was having flashbacks, you don't have to tell them I'm having flashbacks.
[Katie McLean (Office of Legislative Counsel)]: If you said something in a peer support session led by a peer support specialist, then that communication is protected.
[Brian Cina (Member)]: But not confiding in your peer for support outside of a program?
[Katie McLean (Office of Legislative Counsel)]: This bill doesn't touch on that. That's sort of outside the scope of the bill. This is only providing confidentiality protections for communications happening during the session or communications.
[Brian Cina (Member)]: The bill is a function of the bill. I
[Alyssa Black (Chair)]: hope the bill. This is confidentiality around
[Katie McLean (Office of Legislative Counsel)]: emergency service providers seeking support through a peer support session with a peer support specialist. But what you're thinking of is subsection D, which is the exceptions. And in the exceptions, it says, okay, you heard something confidential during one of these sessions, but it's one of these items on the list, in which case it is appropriate to report to the correct person.
[Brian Cina (Member)]: Okay. It just feels like the bill is so limited.
[Daisy Berbeco (Ranking Member)]: This is what they asked for.
[Alyssa Black (Chair)]: Right now they have no
[Brian Cina (Member)]: I get it, I'm not saying no to it, that's what they asked for, but what I've been hearing from people is that they want maybe something more than what they asked for. This is a start though, because right now there isn't any confidentiality technically, so we have to start somewhere. But unfortunately, it sounds like if people confide in their coworkers, they can't trust it's confidential unless it happens in a structured session.
[Alyssa Black (Chair)]: That's true in the world. I would think that's true in the world.
[Brian Cina (Member)]: I'm not telling anybody anything.
[Alyssa Black (Chair)]: If you want it to remain confidential.
[Brian Cina (Member)]: Yeah, no, I think that's, unfortunately, it's sad. It's just a barrier to getting help.
[Katie McLean (Office of Legislative Counsel)]: Okay, I'm going move on to subsection This is where our exceptions are. Confidentiality protections described in B and C shall not apply to the following information as it pertains to an individual designated to receive such information in the normal course of the individual's responsibilities. And we have a list of what type of information could be disclosed. A threat of suicide or homicide made by a participant of a support session or any information conveyed in a peer support session relating to a threat of suicide or homicide. Any information relating to the abuse of a child or vulnerable adult or other information required to be reported by law. After a conversation with the chair, this subsection c used to say any admission of criminal conduct. And I am suggesting language that I think gets at the conversation you had yesterday, which is any admission of conduct likely to pose a risk to public safety. And then we're not talking about the criminality of it. We're talking about preventing a public safety risk. And then any admission of a plan to commit a crime. So the crime hasn't already happened, but somebody is talking about a plan to commit a crime. That can be disclosed for the purpose of potentially stopping the crime before it happens. Everybody.
[Alyssa Black (Chair)]: Thank you for that language, Kate. Yeah.
[Katie McLean (Office of Legislative Counsel)]: Okay. And then I this used to be a standalone subsection. I moved it up into D because we kept saying except with regards to D. And then this was sort of outside of D and I felt like it needed to be pulled in. So nothing in this section is self prohibit what you already have looked at. Any communications between peer support specialists regarding a peer support session or between a peer support specialist and another staff member of a peer support program. We've already seen that. What's new is language based on your conversation yesterday. That nothing in this section shall prohibit a participant of a peer support session from disclosing personal experiences or emotions discussed during the peer support session to the extent such a disclosure is consistent with the participant's obligations under HIPAA. So a person can talk about their own experience that they may have shared during the session, their own emotions that they may have described during the session, if they want to communicate about themselves to the extent they are able to under HIPAA. So if you're talking about a call you responded to, you can't disclose the patient information related, but you could talk about your experience and emotions relating to that call that was traumatic.
[Alyssa Black (Chair)]: Go ahead. Are
[Daisy Berbeco (Ranking Member)]: the entities that fall under this, are they HIPAA? Some of them are.
[Katie McLean (Office of Legislative Counsel)]: You added the mental health hoax, they all have HIPAA obligations.
[Alyssa Black (Chair)]: My question is related to Leslie's.
[Leslie Goldman (Member)]: I'm just looking for the participant. There are two participants, right? The individual receiving service support and the individual giving support. Does that participant refer to both? Say that again, I'm sorry. I'm thinking about participant in this dialogue of peer support, and one is someone who's giving support and one who's receiving support. And does participant refer to both those people?
[Katie McLean (Office of Legislative Counsel)]: I read it to mean the person who not the person who's leading the activity, but the session, but the person who is coming and participating in the session.
[Leslie Goldman (Member)]: I think that makes sense, but I'm not sure that's clear to me, but maybe I'm overthinking it because
[Alyssa Black (Chair)]: I'm thinking of it through the lens of HIPAA. So you were a HIPAA. You would have 20 appointments in a day and you would go home and over dinner, probably a glass of wine after 20 patients. And you would sit there with your family, your spouse and say, gosh, I had such a bad day. I had two patients I had to send to the ER. I mean, is fine under HIPAA. So the same rules would apply to any participant in the peer support session, which I'm reading to include the peer support provider. Okay. That pertains to them and
[Katie McLean (Office of Legislative Counsel)]: I don't know if that's clear then. You could say we could say an emergency service provider participating in a peer support session and a peer support specialist, which name we've now changed, and go from there. Let's list both of them to be clear that we're talking about both.
[Leslie Goldman (Member)]: The provider and the receiver. Yes. Let me out who's there.
[Katie McLean (Office of Legislative Counsel)]: Let me flag that for myself.
[Alyssa Black (Chair)]: I mean, I'm just kind of reading it. If I was one of these peer support designated specialists and I went home sitting around and I'd be like, gosh, it was a really bad day. We had a really traumatic fall and, you know, wow, it was a lot.
[Leslie Goldman (Member)]: Could it be a provider of peer support from disclosing personal experiences? Is that what we're talking about? It is,
[Katie McLean (Office of Legislative Counsel)]: but we have a term defined, so we should use the term that we defined. So I will come back and I will list both because I think participant, at least to me, only reads as the person who is this EMS provider. So I will come back
[Alyssa Black (Chair)]: with that change. Karen? So I just wanted to understand this. If you are
[Karen Lueders (Member)]: availing yourself of a big year of support and you're involved in the various traumatic events, and you're the person that's offered with us as well, in talking about the specific, maybe not thinking HIPAA at the moment, talking about the specific thing you experienced and trying to process that, does that mean in that context, I don't know, you're both under the same umbrella subject to HIPAA, and you're talking to each other about a specific event because you both were involved. I'm just trying to
[Katie McLean (Office of Legislative Counsel)]: I think the change that's being suggested would capture everybody in the room.
[Karen Lueders (Member)]: And would everybody that's in the category that we've listed be subject to? And if not, would they be subject to it, or would they be told about it? Just trying to add a simple This
[Katie McLean (Office of Legislative Counsel)]: is just saying the extent it's consistent with the participant's obligations. So if it's a participant that doesn't have HIPAA obligations, then HIPAA doesn't attach. But if it is, I'm trying to think, alcohol and drug abuse counselor who's now on our list of mental health professionals. They have HIPAA obligations. So if they're participating and they want to later share at the dinner table about their experience. They could talk about their own experience to the extent they're not disclosing protected health information of a patient. Does that make sense? Okay. We have made it to the last section of the bill. So this had been two paragraphs, but because it was sort of saying the same thing twice with regards to two different populations, sort of in two different ways, I pulled it into one paragraph. So an employer, peer support specialist or peer support program shall not be subject to civil liability for injuries or damages arising from the provision of peer support services or for any disclosure made in violation of this section by an emergency service provider who participates in a peer support session unless the conduct of the employer, peer support specialist or peer support program constitutes gross negligence, recklessness, or intentional misconduct. So it's doing all the work of two paragraphs and one now. Updated effective date. And then the next draft, you'll see a line right here that has the updated title, which I will figure out. We'll work in confidentiality of
[Alyssa Black (Chair)]: these sessions. Do you have the next thirty minutes? Are you wanting a new draft now? Can change to Jen. Sure. And then maybe you can work on that draft and then we'll come back and I'm prepared unless anyone has any other questions. I'm prepared to take a vote on this. Okay, let's do that.
[Katie McLean (Office of Legislative Counsel)]: Okay, I'll go find a quiet place. Yeah,
[Alyssa Black (Chair)]: you probably need
[Brian Cina (Member)]: to. Where are my AirPods?
[Grace Johnson (AHS Medicaid Policy Analyst)]: Of course. Jamie, do want
[Alyssa Black (Chair)]: to go off of? Yeah. Okay. So starting with line 14 where
[Karen Lueders (Member)]: it says peer support program constitutes gross negligence.
[Jennifer Carbee (Office of Legislative Counsel)]: Oh, sorry. It's okay. No, no, We
[Karen Lueders (Member)]: don't have to define that. That's already specific. That's language that we use. Okay.
[Katie McLean (Office of Legislative Counsel)]: If you want a definition, can give one to you.
[Jennifer Carbee (Office of Legislative Counsel)]: No, no, no, no. No, no. That's
[Alyssa Black (Chair)]: have markup and possible vote on this, but I think due to our discussion Alex? Hi. Are you prepared to testify today? Yes, think we Okay. Are you wanting me to? Yeah, no, you can come up. I was just based on some of the discussion yesterday, I think that possibly there are some other things that might be included or might have changes. So I'm thinking we need a little bit more time for those conversations to happen. So I'm not holding a vote on this one today, just to let everyone know. Which one? Eleven. 611. I just thought you were going to vote on the meeting. I know, was holding the meeting. We didn't actually make any changes when we walked through it. Did we? Jen Carvey, Office of Legislative Counsel for
[Jennifer Carbee (Office of Legislative Counsel)]: the record. No. You we just did the walk through yesterday. You had some questions, I think, and having gone back now and looked at out test written testimony, from Tuesday, I think and I think some of the information I was trying to look up and answer for you, I think we mostly addressed questions. Did
[Alyssa Black (Chair)]: you mark up where we had questions?
[Jennifer Carbee (Office of Legislative Counsel)]: I think you were just wanting to understand the why. I don't know that there were any, well I think there were people were wanting to understand why DIVA was asking for the in section one for the Department of Homeland Health access to be carved out of the prescription drug, plus transparency reporting. And I think we sort of fumbled our way through it, but you can probably hear more clearly from Great. And Exchange Advisory Committee. This is a federal requirement around adding members who are also members of the beneficiary advisory committee.
[Alyssa Black (Chair)]: How many is too many?
[Katie McLean (Office of Legislative Counsel)]: Right. There was the Yes, that's right. That was on
[Alyssa Black (Chair)]: the council utilization review board.
[Jennifer Carbee (Office of Legislative Counsel)]: Also on the Medicaid and Exchange Advisory Committee, and I don't know the on language up if you want on page seven, and maybe you want to ask, and she's here, about striking out the language saying the commissioner may appoint members to serve more than one term. I wasn't sure exactly why that was. So if you want to clarify, I don't know if that's a federal requirement or not, but if you want clarification on what we're thinking about. Seven, nine thirteen, talks about serving appointing the existing law has the commissioner of appoint members of the advisory committee to serve staggered three year terms. Total advisory is at least 22 members, and to now under the bill would need to move member individuals who are also members of the beneficiary advisory committee as required by federal law. Existing law allows the commissioner to remove members of the committee who failed to attend three consecutive meetings and appoint replacements, and then it would strike that the commissioner may reappoint members to serve more than one group. Thank you. Section three, I think Diva had indicated that this is just sort of a conforming change to reflect the unmerging of the individual and small group markets. Section four is the Clinical Utilization Review Board, and this is where there was a question about whether there should be a a maximum, if there's a minimum on number of members, and also the extent to which members may receive existing members tend to receive per diem compensation and reimbursement of expenses. And so I think there was some concern about expanding the size and whether there would be
[Alyssa Black (Chair)]: a cost to that. Leslie, did you have a
[Leslie Goldman (Member)]: I haven't come across the word reflective health plan and I don't know what that means.
[Jennifer Carbee (Office of Legislative Counsel)]: Reflective health plan is if you sort of look at the existing language there, this was added at the time that the state started doing silver loading and the recognition that silver plans that had all of these additional that had all the premium loaded onto it would not be beneficial for people who are buying off the exchange or or, you know, buying, like, employer sponsored plans couldn't get financial assistance. So the language here is just what we called them. They are very similar to qualified health plans, but with enough of a difference that they are not actually qualified health plans. So the existing language here in 33 VSA eighteen thirteen says, in the event that federal cost sharing reduction payments to insurers are suspended or discontinued, registered carriers so that health insurers who offer qualified health plans may offer and then the question is to individuals or when we had the merged group to both, individuals and employees of small employers, non qualified reflective health benefit plans, that don't include the funding to offset the loss of the federal cost share and reduction payments. And that way, the plans had to be very similar to, but contain at least one variation so that the premiums could be different. Otherwise, they couldn't have a different premium for the same identical plan. Well,
[Karen Lueders (Member)]: I understand the idea,
[Leslie Goldman (Member)]: but what does reflective mean? Just like what
[Jennifer Carbee (Office of Legislative Counsel)]: we we gave we gave it.
[Alyssa Black (Chair)]: They were looked at, like, all the plan designs. I don't know. They're, like, the standard, and then there's the reflectives.
[Brian Cina (Member)]: There's a reason they called it that I don't recall. They reflected Like
[Alyssa Black (Chair)]: they reflect youth Exactly. Was some
[Jennifer Carbee (Office of Legislative Counsel)]: almost everything from the original plan, but with some variation.
[Alyssa Black (Chair)]: Yeah. Okay. Thank you. It's just a
[Katie McLean (Office of Legislative Counsel)]: term we create. Why is this allowed? I thought that there was minimum
[Alyssa Black (Chair)]: Because we allowed it.
[Jennifer Carbee (Office of Legislative Counsel)]: Because the variation was not to remove an essential health benefit that's required under our benchmark plan. It was just varying, say, the cost share for, I think that at one time it was varying the cost sharing requirement for a non emergency ambulance ride or something like that. It was a very small difference in the plan design.
[Alyssa Black (Chair)]: Okay. I didn't know about this. And all we're doing is we're just taking out the employees anymore because we merged the market. Unmerged. Keep getting there. I know. Right. Seems
[Jennifer Carbee (Office of Legislative Counsel)]: counterintuitive. So section four was the clinical utilization review board piece that is now aware of your questions. Section five is the prepaid burial arrangements. And then sections six and seven are moving out the date on the state plan amendment, the deadline for seeking a state plan amendment for Medicaid coverage and doula services. And I think there were some general questions from committee members about why push that data.
[Alyssa Black (Chair)]: Alex, do want to come on up? Thanks for refreshing up on all of our questions.
[Alex McCracken (Department of Vermont Health Access)]: Good to see everyone in person. I'm glad to not be having a fever today. I
[Alyssa Black (Chair)]: am, for the record, my name
[Alex McCracken (Department of Vermont Health Access)]: is Alex McCracken. I use sheher pronouns and I'm the Director of Communications and Legislative Affairs for the Vermont Health Access. So I heard a number of questions on the first two sections of the bill. I'll run through what I remember hearing here and please stop me if there's anything I missed. So on section one, the Drug Transparency Report repeal. The AGO's report here, and I can provide a link to the most recent report to the committee, specifically references that Diva's data is not helpful. It's too complicated to really parse into the report that they're trying to create. And that's specifically because of the way that the rebates work for Medicaid pharmacy. So we would hope that you would see the benefit in removing that language because it's not fulfilling a purpose that the AGL wants it to, and it's creating a pretty significant staff burden for our pharmacy folks. So that's the kind of reason behind the AGL language repeal. And there is a benefit to the carriers continuing to provide that data because they can use it, but for us specifically, there really is no benefit.
[Alyssa Black (Chair)]: I'm assuming you keep track of prescription drug prices anyways under the state Medicaid. Yes. Okay. Would be not good if you're not. Leslie, go ahead.
[Leslie Goldman (Member)]: It looks like the last AGO report was in 'twenty four. I just clicked on your link here, and I'm just wondering how often we really want or care to have that information if we give it up from you and the AGO doesn't do it, what are we losing? And maybe they are doing it, I
[Alyssa Black (Chair)]: guess no better. But it's still required to do it. Yeah,
[Leslie Goldman (Member)]: I don't know how often,
[Alyssa Black (Chair)]: because that was clear. There is a report for 2025.
[Leslie Goldman (Member)]: Yeah, okay, the one that just linked them
[Alyssa Black (Chair)]: was 2020 If you look at the link that document that Katie and Jen gave us that had all the reports on it, it's on there. Thank you. It's an
[Alex McCracken (Department of Vermont Health Access)]: annual reporting requirement and that wouldn't change. We would just be removed from that.
[Alyssa Black (Chair)]: I get it. And so they don't find your information helpful, they find it hurtful in a way. It's confusing. It's open. Okay. Anyone have any questions about that? Thanks for phoning us in. We were all like, Okay. Thank you.
[Alex McCracken (Department of Vermont Health Access)]: Section two, which I have everything in the right order this time, is the MEAC. So I think the question here, I recorded a couple of questions from yesterday. First was whether they get a per diem. I I believe that they do. All advisory committees that work for the state get a modest per diem. It's not very much. It's like $20 or something. It's very low. And I can get the exact number for you, but it's it's not significant. The removal of the commissioner may reappoint members to serve more than one term. That removal is to align with federal requirements that were put in place following the Beneficiary Advisory Committee. So that is to ensure that our state statute is aligned with the federal language. And the other question, I believe someone asked yesterday how often they meet. They're required to meet quarterly, but they do meet monthly. So they meet with a lot of frequency throughout the year, with a couple exceptions in the summer or over holidays. They're very active and we appreciate their work. Were there any other questions on the MEF?
[Alyssa Black (Chair)]: I don't think so.
[Alex McCracken (Department of Vermont Health Access)]: Okay. Reflective health benefit plans. I don't believe there are any outstanding questions on this. If there are, I would encourage us to loop back with Addison because she's going be the one who actually knows what she's talking about there instead of myself. I have
[Alyssa Black (Chair)]: to say, if anyone has any questions about this, then you're going to have to sit and listen to Mike Fisher talk about silver loading for an hour. Just be
[Daisy Berbeco (Ranking Member)]: warned. That's how it's an annual tradition.
[Alyssa Black (Chair)]: No questions. Questions. Moving on.
[Alex McCracken (Department of Vermont Health Access)]: Section four is the So I think the question here is related to whether it's prudent to put in a maximum membership requirement. I brought this to the curb on Tuesday when I met with them to present for the legislature. They felt that that was not necessary language to include. They're not intending to create additional positions within the board. They just wanna make sure they have the flexibility for those staggered terms to keep their board at 10. So there's no intention from the curb to balloon that number up to 500 or whatever. And I don't even know if they could find that many people to be here.
[Alyssa Black (Chair)]: You don't have 100 people waiting in line to get a $20 stipend I wish we did. For attending once a month For public service. Except for in the summer when they're on vacation.
[Alex McCracken (Department of Vermont Health Access)]: Okay. That that was this language is is from the curb, recommended by the curb, we presented that change to them, and they decided to opt against it. So we keep that language there as it's our recommendation. But of course, it's up to the committee's jurisdiction. Is there
[Alyssa Black (Chair)]: any particular reason for the number 10, the minimum? Not that I know of, I
[Alex McCracken (Department of Vermont Health Access)]: think it's just a nice round number, a large enough body to represent a diverse geographic and provider type representation, while not being completely unyielded.
[Alyssa Black (Chair)]: And 10 was what was originally here? Somewhere along the line, somebody decided? Whoever took that committee testimony originally, 10 was what they decided. You were probably here. I might have been.
[Jennifer Carbee (Office of Legislative Counsel)]: I don't know you say anything.
[Alex McCracken (Department of Vermont Health Access)]: Okay, so I think that's all on the curb. Any other questions there?
[Alyssa Black (Chair)]: Don't think so.
[Alex McCracken (Department of Vermont Health Access)]: Okay, moving right along. Section five is the burial fund limits. Were there questions on this? I don't think I recorded any questions pertaining to this section. Are there other limits
[Alyssa Black (Chair)]: for other types of things other than just funeral and burial expenses? I mean, this is essentially so that if somebody incurs unpaid something to medicate, you can then get it from the estate except for up to $15,000 now, right? Am I reading this right?
[Alex McCracken (Department of Vermont Health Access)]: Sorry, can you repeat the question?
[Katie McLean (Office of Legislative Counsel)]: It's for you.
[Brian Cina (Member)]: Okay.
[Alyssa Black (Chair)]: This, because we've never really taken testimony on something like this before, to be honest with you. It doesn't come up very often. This allows people to put up to $15,000 to preserve those monies. And is it towards eligibility? Is it towards Like a spend down?
[Alex McCracken (Department of Vermont Health Access)]: I don't feel like I'm equipped to speak on detail on the burial fund section. I'm happy to bring in some folks from policy to discuss that in more detail with you.
[Alyssa Black (Chair)]: Yeah. I don't think we need to. We might be able to speak to it because if you're this okay? No. No. No. Because you are not testifying. Thank you for your question. But I think I understand, anyways. Yeah, if we want further clarification, I think we'll go too.
[Alex McCracken (Department of Vermont Health Access)]: I appreciate that, thank you. And then moving on to the final section, which I know is the point of the most conversation within this committee, is the request to delay the implementation of Medicaid coverage for digital services to 2028. On this point, I have some remarks that I can share to kind of respond to some of the testimony you heard yesterday, as well as to give some kind of background to why we're recommending this decision. I also have joining me via Zoom, my colleague, Trace Johnson from the Medicaid Policy Unit, who may be able to speak more directly to some of the nuances of the policy and get in the weeds where I cannot. She also has the authority to reach through the screen with a giant curved stick and pull me off stage venture too far in the wrong direction. So I am going to kind of dive in here and give some background. Firstly, I want to start with clarifying the 11:15 waiver process and the state plan process. Those are two separate and distinct payment authorities that in Vermont largely cover completely different portions of the Medicaid program. Even though Vermont has our Global Commitment to Health waiver, we do still have to seek state plan authority for services Diva wants to reimburse for. And that waiver renegotiation process, which has to happen in 2027, as you heard yesterday, is completely separate from DIVAS seeking state plan authority for doula services, and the timelines and processes are not tied together for the purposes of this conversation. So just to level set there, we are happy to bring in Ashley Berliner, who you all know and love, who is our expert on 11:15, if you have additional questions about how those two issues diverge and more details about the process.
[Alyssa Black (Chair)]: Are they negotiated with the same entity in federal government, CMS?
[Alex McCracken (Department of Vermont Health Access)]: They are both negotiated with CMS. I don't know if within CMS there's obviously a lot of differentiation between
[Alyssa Black (Chair)]: So when you're negotiating the eleven fifteen waiver, CMS says we don't even want to see your state plan amendment. We don't care what's in the state plan amendment. It doesn't even pertain to the negotiation around the eleven fifteen waiver.
[Daisy Berbeco (Ranking Member)]: Grace, do you have something on that?
[Grace Johnson (AHS Medicaid Policy Analyst)]: Yeah, sorry. For the record, Grace Johnson. I work as a policy analyst in the Medicaid Policy Unit at the Agency of Human Services. Just to clarify, they both are negotiated with CMS, both our state plan amendments and our eleven fifteen Global Commitment Waiver. They do go through different teams, so it's not the same folks at CMS who review both. And when we are negotiating our eleven fifteen Global Commitment to Health Waiver, they don't largely talk about, relate to, look at the state plan. Although there are very few instances where something that is in our waiver may also be in our state plan, largely the negotiation processes are completely separate.
[Alex McCracken (Department of Vermont Health Access)]: Okay. And again, if you want more detail on that, we are happy to bring in Ashley some time to talk with you about specifics on the eleven fifteen waiver. We'd also want to clarify that there was some testimony yesterday that implied that Diva would need a year after seeking authority for a state plan amendment to implement doula services. We don't believe that's accurate. We can't provide a specific timeline because of the turnaround with CMS being a flexible process, which relies on their response as well as what we provide. But we do not think it would be a year before implementation once we applied for the State Plan Amendment. We feel that it would be a different timeline than that. I want to reinforce that Diva's primary reason for seeking an extension is to allow us more time to work with OPR, VDH, and the doula community to find a way to implement doula coverage that captures, if possible, how doula services are provided today. There are a handful of challenges that Diva faces in implementing a doula benefit, we need time to really address those issues, especially because they all overlap. Historically, Medicaid programs have not covered non clinical services. States are now beginning to cover non clinical services, but CMS still requires a clinical touch point, which you see in the requirement that preventative services must be recommended or prior authorized by a physician or another licensed practitioner working within their scope of practice, or that a doula must have a clinical license. So, there are these various clinical touch points that must exist for licensure. Examples of this are peer support services or IBCLCs, which Grace is much more equipped to speak to than I am. This clinical structure or requirement doesn't fit into the way the doula services are currently provided in Vermont. It doesn't get at the doula's intent of expanding those services. We know that this may be different in the future. We don't know that it will be different in the future, but we are trying to maneuver that with the doula community. This means that Diva has to get creative about how to make these two structures fit together and still meet CMS requirements. We are working and have been working with OPR, BDH, and the dual community to get together and wrap our minds around this process and the options available to us and see what compromise we can make to get this benefit working. But those conversations are really just beginning at this point.
[Alyssa Black (Chair)]: Can I interrupt a little bit? Of
[Brian Cina (Member)]: course, yes.
[Alyssa Black (Chair)]: There was the doula sunrise report in January '25. Because in maybe representative Houghton can remind me, sometime in '23 or '24 where we ordered the Sunrise Report and asked OPR and DIVA to work together to make recommendations on how we would be able to provide doula services. That was at least two years ago. The report came out with the recommendation, both input from OPR and DIVA, that this is covered. And it should be covered. I'm not quite sure why you're asking for time to work with OPR to devise how something like this would be covered and what services would be covered and work with the doula community when for two years you have had that time, and not only have you had that time, you came up with a report that recommended that we do this. I'm surprised, I guess.
[Alex McCracken (Department of Vermont Health Access)]: I appreciate that comment.
[Karen Lueders (Member)]: And
[Alex McCracken (Department of Vermont Health Access)]: we share the frustration around this issue. And it is not our intention to stand in the way of this, and we're very supportive of this coverage. To be honest, I think and we have we we said this last year in testimony, we have reservations around the conclusions in the Sunrise Report. The voluntary certification process may not be sufficient for what CMS needs from us. At the end of the day, it is very difficult for us to approach CMS with something we're quite sure that they will not agree to.
[Alyssa Black (Chair)]: This is covered by Medicaid in well over half the states. It was recommended by CMS in their maternal mortality that states should be covering doula services? I think No state has ever been denied coverage of doulas in their state plan amendments?
[Alex McCracken (Department of Vermont Health Access)]: No state does Medicaid like Vermont does. That's part of it. We are the payer in Vermont Medicaid. Diva is the payer. We are not using an MCO like every other state, and so we carry liability there. We have to make sure that those requirements fit within the CMS clinical requirements. We do have an avenue for coverage, and Grace may be able to speak more on that. We're trying to find the ways that we can get this through CMS approval, and that's why we're continuing to meet with OPR and BDH and the doula community to move this forward. We want to move this forward. I want to be very clear about that.
[Alyssa Black (Chair)]: It's feeling a lot like you don't. A year ago, we took extensive testimony on this a year ago, and Diva was behind this policy. The only thing that they made, that they showed concerns of was that the amendment to the state plan amendment to which this body amended the bill to provide them with more time, and we did that. This bill passed out of this committee unanimously. I can't remember, but I'm pretty sure it was unanimous on the floor through the Senate. The governor signed this bill. And it's feeling to me as though I'm not quite sure why all of a sudden, Diva is coming in saying, we don't want to do this. I
[Alex McCracken (Department of Vermont Health Access)]: appreciate that, Madam Chair. I will say that this is consistent with the testimony we did give a year ago. We were open about our concerns with the Sunrise report. We were open about our concerns with certification for doulas being insufficient for CMS approval. We were open about our concerns about funding it in favor of or in lieu of other programs that may desperately need that. We are here to say today that there is a clinical side of this as well, that the doulas We have an avenue for coverage and I'm going to pass it off to Grace who knows more than me about this, but there is an avenue for coverage that exists, but it is not sufficient to represent how doulas currently operate in Vermont because of that clinical touchpoint requirement. That's where we're running into an issue and it's a sticky issue that affects a number of different coverage areas that we need to wrap our minds around. A tough problem. We need to figure it out and I don't have a great answer for you today, it's one that we are working on and one that we are engaged with. It has been several years, and we have been working on it for several years, Madam Chair. Sorry, may I ask that Grace can chime in on what I just said? Because I think she has more context.
[Alyssa Black (Chair)]: And then Daisy has a question, Brian has a question, and Lori has a question.
[Grace Johnson (AHS Medicaid Policy Analyst)]: Yeah, I'll just add a little bit of color to what Alex has said, which is that there are avenues for coverage, like you mentioned, in other states for doula services. And largely, in the state plan amendments that we've reviewed, they are consistent with what we believe, which is that CMS requires a clinical touchpoint for doula services. In other states, this looks like a prior authorization or a referral by a clinical physician for doula services. That is not in alignment with how doula services currently operate in Vermont. It would be a change to how doula services currently are provided to individuals. And what we are having these conversations with doula providers and what we're trying to get at is how to take the current structure of doula services in Vermont, which are largely not clinical, and align them with the minimum requirements that we need with CMS in a way that continues to preserve doula services in Vermont and allows us to get CMS approval. Other states have other avenues to approve those doula services like that PA or that clinical referral. There are also other states who require that doulas hold a clinical license like a licensed mental health counselor and then become certified as a doula. Both of those are options that are on the table for Vermont, but they don't keep the spirit of what doula providers would like to see with Medicaid reimbursement, And that's part of what we're trying to solution for here.
[Daisy Berbeco (Ranking Member)]: Daisy? Thank you for the explanation. I think Alyssa asked a question that I also had. I'm wondering, in the process of waiver negotiation or SPA amendment, Does tucking this in there, just briefly, would it at all jeopardize reproductive and gender affirming care services that we offer?
[Alex McCracken (Department of Vermont Health Access)]: Meaning, would the process to pursue a state plan amendment impact those services or protections within our existing state plan?
[Daisy Berbeco (Ranking Member)]: Do you have any concern about the risk of those services?
[Alex McCracken (Department of Vermont Health Access)]: I don't know if I can speak to that. That's going to be an Ashley question. There are different areas of the state plan that may be impacted by different requests, and I don't think I can speak to that unless, Grace, you feel like you have more expertise on that.
[Grace Johnson (AHS Medicaid Policy Analyst)]: I think we should probably provide something in writing. I think the future of gender affirming care, if you saw the recent CMS rules, is sort of up in the air right now. When we open the state plan to do a state plan amendment or a SPA, where we put those services in the state plan, whatever pages sort of get touched by the addition of a new service are up for CMS review. You can't sort of just put something in and they don't see any of the language that touches that. And so, if we were to put these services somewhere that touches gender affirming care, that would be of concern to us. We could look and see if that would be a concern if we were to put this in right now and provide that follow-up in writing, but generally just to note that the future of gender affirming care is a topic of conversation at the federal level right now.
[Daisy Berbeco (Ranking Member)]: Just to be clear, I'm not requesting anything in writing, but thank
[Alex McCracken (Department of Vermont Health Access)]: you anyway. Thank you. And it's also a topic of concern for the agency and one that we are certainly keeping close to mind. Brian?
[Brian Cina (Member)]: Earlier you provided three reasons or barriers, I don't know what I would call them, but three explanations. And the third one went by really quick. It was something about funding for this as opposed to other priorities or components or something. I don't want to misrepresent your language. Of course. Can you repeat it and expound on it a little? Just explain what would be the alternative funding versus this? Of course, thank
[Alex McCracken (Department of Vermont Health Access)]: you for that question. I was referring to my own testimony from last year related to the doula bill, which became Act J. P, where I alluded to, we were looking at a very difficult fiscal picture and a lot of unknowns when it comes to fiscal side of Medicaid. So the recommendation from the department was to not look to expand to additional services, given that we were unsure if we could protect all of our existing services. So the the priority is placed on protecting what we have and ensuring that we can weather whatever federal storm is upon us rather than trying to expand at this current moment. So that was the testimony from last year that I was referencing.
[Brian Cina (Member)]: So what I'm hearing is it's not that the administration is saying there's other priorities. It's concerned that if we cover too many things, we're going to use up the funding.
[Alyssa Black (Chair)]: Brian, can I, I'm gonna let you
[Katie McLean (Office of Legislative Counsel)]: go back, but I'm sorry, I have
[Lori Houghton (Member)]: a meeting that I cannot be late for? It's a house joint rules meeting. My question is, can we get something in writing from you all that shows the actions that you've been taking on this since we passed this to see I I agree with the chair. We've been trying to do this for a while. And so I need to be clear that what the work has been happening and where we stand. And that a clear understanding of why you don't think it's realistic
[Katie McLean (Office of Legislative Counsel)]: to do it now would be really helpful to put in writing. Well, we can get that. Okay, thank you. I really apologize.
[Alyssa Black (Chair)]: No, of course. Thank you. Brian is
[Daisy Berbeco (Ranking Member)]: back to
[Alyssa Black (Chair)]: Sorry, Brian. Yeah, sorry. So
[Brian Cina (Member)]: I had to tune out Lori's questions because I would get totally derailed and they know what's happening. What I'm hearing you clarify is it's not that the administration is saying there's other priorities, but that by expanding the scope of covered services, it would deplete a fund or deplete resources from it would spread us too thin, maybe? The testimony I had from last year boiled down to, we know there's a
[Alex McCracken (Department of Vermont Health Access)]: lot of pressure coming on Medicaid in the next year or two, let's wait and see what we can maintain and protect before we look to expand services.
[Alyssa Black (Chair)]: And I just want to would just like to say that that testimony was given last year, and I understand that, but this body and the governor who signed this bill decided that this policy was worth allocating the resources to. And I'm by by Diva coming in and saying, well, is financial pressures in other places, it feels like this SPA amendment is being used as an excuse for a policy that we decided was worth allocating resources to. And honest to me. It doesn't seem as though you're executing the programs that that the legislature has decided that should be in place.
[Alex McCracken (Department of Vermont Health Access)]: Thank you. Madam Chair, may I respond to that? Yes. I do sense your frustration, and I am sorry to hear that that is the impression that the committee is receiving. I can simply say that the fiscal element was not part of my testimony today. It was part of my testimony last year, and the state plan amendment concern was the first and foremost issue I raised in my testimony last year as well, which is the issue I brought before you today. So that is consistent. The other elements I will leave to the money committees to discuss or to sign in appropriations. This currently doesn't have an appropriation as far as I am aware, and that is through last year's budget and through the governor's recommended. But the part that we're really concerned about right now is the other elements of it that make it unworkable. You can give us the funding and we will do it, but we have to be able to do it.
[Alyssa Black (Chair)]: Brian, and then Lueders.
[Brian Cina (Member)]: Yeah, just to finish up that I appreciate you clarifying that it was last year's testimony, not this year's, but because it's part of the big picture, I just wanted to say that I hope that it's being taken into consideration, that when we're looking at the system and overall spending and making do with less resources, that certain investments may yield a bigger return than others, and that doulas may yield better outcomes that save the system money. So just making sure that that's being said, and just asking that you all do your best to figure out a way to navigate these complex bureaucratic hurdles that you're dealing with.
[Alex McCracken (Department of Vermont Health Access)]: Thank you, representative. I just want to say again, we are supportive of doula coverage. We want to see this put into place, and our goal right now is to find a way to implement that in a way that reflects with the way the doula services are actually provided on the ground today.
[Alyssa Black (Chair)]: Thank you. Thank you, Talies. I appreciate it.
[Brian Cina (Member)]: Katie,
[Alyssa Black (Chair)]: are you available at 01:00? Can can we can we vote on two seventy at 01:00? Surely I would like all of our committee members present. So I'm sorry. Lori can't be here.
[Brian Cina (Member)]: He's in that joint booths. Yeah.
[Alyssa Black (Chair)]: So we'll be back at one stop. Sure. And we'll do it really quick.
[Brian Cina (Member)]: The bell shall toll
[Alyssa Black (Chair)]: upon you.
[Katie McLean (Office of Legislative Counsel)]: Thank you.