Vermont Legislature SmartTranscripts:

[Alyssa Black (Chair)]: Good morning, This House Healthcare, February 5, and this morning we are going over the budget.

[Leslie Goldman (Member)]: We're going to

[Alyssa Black (Chair)]: start with central office, AHS, and then move into DEBA. And we have with us Secretary Samuelson. Take

[Jenny Samuelson (Secretary, Agency of Human Services)]: it away. Good morning. For the record, I'm Jenny Samuelson. I'm the Secretary for the Agency of Human Services. We're here with our executive leadership team, including our Chief Financial Officer and the commissioners from each of our departments.

[Tracy O’Connell (Chief Financial Officer, Agency of Human Services)]: Yes, and for the record, I'm Tracy O'Connell. I'm the Chief Financial Officer for the Agency of Human Services. And Chair, do you prefer that we take questions throughout or wait until the end?

[Alyssa Black (Chair)]: I would say let's take questions throughout, but we'll try to keep them contained. Right.

[Tracy O’Connell (Chief Financial Officer, Agency of Human Services)]: I appreciate everyone's willingness to have us in. I know that you've had a couple of the departments from our agency in already. Felt like it was really important this year to ground everyone in the process that the agency went through to create our budget. As a reminder, the Agency of Human Services includes both the Secretary's Office and six departments, the Department for Responsible Health Access, Department of Health, Department for Mental Health, Department for Children and Families, Department for Disabilities, Aging and Independent Living, and the Department for Corrections. Overall, our budget, as proposed, is $3,750,000,000 The agency is the largest agency in state government with a little over 4,000 employees. This identifies where those employees sit within the agency in our current vacancy rates. For our budget this year, we are looking at as proposed, an increase of $86,000,000 or 6.1% increase in general fund based budget. That's an increase of 5.3% general fund for direct services to keep our current services going. But you'll hear throughout the process what we did was identify, what is it that we need to keep the lights on first? And that's this first bucket. The second bucket are a small number of initiatives that support our broader priorities, and those investments are $11,200,000 Okay, our executive leadership team. So the agency's executive leadership team includes myself, the deputy secretary, and the commissioners in each of our six departments. This is important because the executive leadership team was foundational this year in creating our budget and doing it through a new process. So in the past, the way that the budget has been done at the agency is that typically we get a target amount of funding that's available to the agency. The agency then gives a target to each one of the departments. And then those proposed budgets in the past have come up to the secretary's office, and the secretary's office was often the one that would arbitrate the decisions between the departments. What we saw are, at times, one department cutting a service in their department that has significant impact on another department without actually coordinating between departments. If we are really working as one agency and optimizing the fact that these six departments in one really should be acting as one program, we reset this year and really established that for each of our executive team members, not only were they commissioners of their department, but they were the executive leadership team for the agency. And what that means is really looking at what are our priorities, how are we allocating resources for that, what are our policies and protocols across our agency versus department by department. So this year for our budget process, we looked first at the governor's priorities. These won't surprise anyone for any economy, making Vermont more affordable, and protecting the most vulnerable. That executive leadership team then took a step back and said, what are our priorities as an agency for this next year? And really, these also won't surprise you. It's housing with a particular focus on homelessness, substance use, and mental health across the full spectrum, including prevention, treatment, recovery, and stability, and in particular, really looking to create a co occurring system of care that works better for the clients that we serve, health care affordability, sustainability, and quality, and a strong and resilient workforce. What you will see is our budget is aligned to these priorities and continuing the operations of the agency as a whole. In addition to setting those priorities, the executive leadership team did something that we haven't done in a really long time. We took a look at the programs that were federally required. We also took a look at the effectiveness of each one of the programs based on data. How many people were they serving? Were they getting the outcomes that we are intending? What was the cost of the program? What would be the impact of any programmatic changes? Really, to determine, are there programs that have existed over time that are no longer serving the purpose or are duplicating other services? We started with the foundation of our Medicaid program because that's the majority of the budget at the agency. But we also went out department by department and asked them to evaluate their programs. We also evaluated the alignment of the AHS budget as proposed to the priorities and the effectiveness of programs in order to make the decisions.

[Brian Cina (Member)]: Before you go ahead, I just wanted to ask a question about the process. The first thing it looks like was the governor's priorities. Were they considered in that order? Was the first priority growing the economy, and the second one, making Vermont more affordable, and the third one, protecting our most vulnerable, meaning was growing the economy more important than protecting the most vulnerable?

[Tracy O’Connell (Chief Financial Officer, Agency of Human Services)]: We didn't hear them, and we Thank did

[Alyssa Black (Chair)]: you.

[Tracy O’Connell (Chief Financial Officer, Agency of Human Services)]: Okay, so as we looked at it, we took an inventory of the current budget process. We started with our target as we usually would. We took an inventory of our current services and projected cost increases in order to keep the lights on at the Agency of Human Services. Initially, that is an overall budget increase of $170,000,000 The target for the agency and I think folks have been transparent about this across state government was a 3% increase. That 3% increase netted out for the agency a $42,000,000 potential increase. You can see that there's a lack of alignment of about 74, almost $75,000,000 between those two targets. The departments each came forward, going back and looking at that evaluation together with potential programs where they could see savings and reductions, and also potential government efficiencies within our own agency, where we could see savings and reduction. We focused on identifying revenue offsets, where could we bring in more revenue. We looked at administrative and programmatic efficiencies. And we also looked at the evaluation that I talked about, and specifically, which were non essential, non mandatory programs that weren't statewide, programs where there was duplication. Oftentimes, there's been creation of programs that over time conflict. For example, with the emergence of mobile crisis, We've seen that have duplication from other types of services, and those that were less effective in not getting the outcomes. So as the Secretary said, our initial bogey, if you will, that we had to cover was $117,000,000 When we sharpened our pencils, it got down to $115,800,000 in this budget. The two biggest areas are in the revenue loss category and caseload and utilization. And then you can see the other areas. So we'll provide an overview over the next few slides on the areas that we were seeing some pressures. So the first big category is the backfill of lost revenue. So this is where we are receiving less federal funding or less special funds in the state, and therefore, we need to backfill with general funds. The first one is the base FMAP change. That's the federal medical assistance percentage that Medicaid matches the whole Medicaid program. And so it went down 0.73%. And so that equated to $13,000,000 in general fund that we needed to backfill the lost federal revenue. And that FMAP changes every year, and then it has to do on the nationwide basis. And so every state, some are set at the standard 50%. But right now, we are at 50. So I think the key important point about the FMAS is that this is not anything that has changed at the federal level. They use the same calculation that they use every year. It is a normal thing for us to see slight swings up, which we've experienced over the last couple of years, and we are actually at a very high FMAP compared to where we have been. And sometimes we see slight changes down. So this is not anything that has changed anywhere at the federal level, but is a normal part of

[Alyssa Black (Chair)]: the Medicaid program. Is this $13,000,000 is it just our typical FMAP or it is $58.42, something

[Tracy O’Connell (Chief Financial Officer, Agency of Human Services)]: like that. It's not that

[Alyssa Black (Chair)]: 13,000,000 isn't influenced by loss of new adults or

[Tracy O’Connell (Chief Financial Officer, Agency of Human Services)]: No, in fact, is to our favor in this budget cycle. And so that's a question we often get. And I just want to make it really clear. This is a normal part of our Medicaid program. Years ago, FMAP rate sat around fifty four percent. We are at over fifty eight percent. So we're not shocked and surprised to see that start to moderate out. Can you remind me what the enhanced FMAP was with COVID back? Do you remember?

[Alyssa Black (Chair)]: Know it's burned in your brain.

[Tracy O’Connell (Chief Financial Officer, Agency of Human Services)]: Yes. It's not burned in your brain. It should be burned into my brain. If not, I can follow-up on that. Had a number, but I'm not wrong.

[Alyssa Black (Chair)]: Yeah, yeah, I just didn't know if, with the increase and what that rate was at the time, where it netted out, is it around fifty eight, or was it higher than that?

[Tracy O’Connell (Chief Financial Officer, Agency of Human Services)]: It's gone up by a chart. We have a chart with the bump. And it's gone up over the last two years to our favor. The next area is with SNAP admin with HR1, the federal matching rate for those costs was fiftyfifty, and now it'll be twenty fiveseventy five. So the federal government will only be matching 25% and the state will have to kick in 75%. Over this budget cycle, that's a backfill of $4,500,000 And that will go up next year because it's only a portion of the year that's for the federal fiscal year. And

[Lori Houghton (Member)]: then Sorry, and this is for the administration of it. I know there was also a piece about error rate. Vermont is in a great position on error rate. The error rate is at 6%.

[Tracy O’Connell (Chief Financial Officer, Agency of Human Services)]: And beyond that, there's a penalty to states. We are well below that. So this is just for the administration of it. This is just for the administration. And then with the child care special fund where the economist projected a revenue downgrade due to the collection of the payroll tax, the receipts just haven't been reaching the level that was appropriated. And so we're seeing that we have to backfill $8,700,000 of the special fund that General Fund. Then in the next area of caseload and utilization, it's about $27,800,000 General Fund. And a lot of this is what you saw in budget adjustment. So it's the Medicaid consensus, case within utilization, fallback and buy in, developmental services, and the Choices for Care program, both nursing home bed days and HCBS. Next area is salary and fringe for the entire agency is $21,300,000 We did include a request for about a half $1,000,000 general fund to support 12 new pay you staff at Diva to support the Medicaid work requirements and the biannual redetermination work that needs to occur starting next year.

[Alyssa Black (Chair)]: And those are 12 positions dedicated solely to?

[Tracy O’Connell (Chief Financial Officer, Agency of Human Services)]: There are 12 positions dedicated to eligibility enrollment for the Medicaid program. Again, it's the new adult, so it's not the entire population of Medicaid that's going to have to redetermine every six months. This is what we believe that we will need to increase in terms of our eligibility enrollment staff to accommodate that. Can you remind me how many people currently are in redetermination and enrollment?

[Deshaun Rhodes (Commissioner, Department of Vermont Health Access)]: For the new

[Alyssa Black (Chair)]: adult population, 8,000.

[Tracy O’Connell (Chief Financial Officer, Agency of Human Services)]: I'm sorry, how many staff?

[Deshaun Rhodes (Commissioner, Department of Vermont Health Access)]: Many staff?

[Alyssa Black (Chair)]: Yes, how many staff? It's about

[Deshaun Rhodes (Commissioner, Department of Vermont Health Access)]: a new period over 100 FTEs.

[Leslie Goldman (Member)]: So it'll be 112, is that what you're For how many And the size of the population this group is addressing?

[Deshaun Rhodes (Commissioner, Department of Vermont Health Access)]: So don't We can have Addison Sirmalow, the deputy of Metro, will come in when we testify after this.

[Alyssa Black (Chair)]: Yeah, that's just a rough question too. I think they'll go over it in DEVA's budget.

[Tracy O’Connell (Chief Financial Officer, Agency of Human Services)]: DEVA's budget, we will find many of those things. DEVA will be in right after us, and so this gives an opportunity to go get that. Then we had $6,500,000 for operating expenditures, most of that the internal service funds, which is BGS, HR, ABS, the insurances, 192,000 for the Pilgrim Park. What is that? Pilgrim Park is the lease.

[Brian Cina (Member)]: Oh, lease. You said piece, I'm

[Alyssa Black (Chair)]: sorry. I

[Brian Cina (Member)]: get it now.

[Tracy O’Connell (Chief Financial Officer, Agency of Human Services)]: And about a million dollars for operating expenditures at DS. $5,100,000 increase for ADS and ADS is a portion of that. And so you'll actually see a of a corresponding decrease to an ADS portion, the ADS service level agreement. So ADS has changed their model. So a lot of some of the services that were in the service level agreement have now migrated into their core enterprise service that charge to us. So there is a somewhat of a decrease further in the presentation.

[Brian Cina (Member)]: Does that include access to ChatVT?

[Tracy O’Connell (Chief Financial Officer, Agency of Human Services)]: That is a service we receive. Good. We are seeing about 17,000,000 increase in contracts. A lot of this was already in budget adjustment. So the Diva, Gainwell, MMIS vendor, the Maximus Call Center and our Medicaid Data Warehouse, transportation in DMH and TF, forensic valuations at DMH and also the travel nurses, dollars 1,000,000 for the Windham youth crisis stabilization, the well path increase related to the average daily population that DOC is experiencing, and the transition. Oh, this is a new thing that it was not a budget adjustment, but we're backfilling $247,000 for a transitional housing program through the Burlington Housing Authority. Awesome. Yes. We're also annualizing some multi year programs that got started in the '26 budget, but they were only for maybe a partial year. So, for example, the Medicare Savings Plan that went live this past month, January 2026. And so this will annualize it for a full year. We're also annualizing alternatives to emergency departments with DMH and some shelter investments that we had started with one time funds that we are seeking to build the operating costs into the base for DCF. And there are some provider rate increases. One is the Northeastern Family Institute about 252,000. In Diva, there's the federally required increase for QHCs and RHCs that's tied to the Medicare Economic Index. The PNMI inflationary increase at DMH and DCF, that is according to state rule. And with the DMH, the CCBHCs, they will be expanding to five new designated agencies starting in '27. And then for Dale Nursing Home Inflation, which happens every year. And is a required rating? Required. That's the theme here, the rate increases are required rating cases.

[Brian Cina (Member)]: The NFI increase, is that for the hospital diversion programs? Is it for the group homes? Is it for the whole agency? The hospital diversion. Thank you.

[Tracy O’Connell (Chief Financial Officer, Agency of Human Services)]: Tucker.

[Debra Powers (Member)]: Can you go back to the page before that, from the corrections department, well path? 5.6, no means.

[Tracy O’Connell (Chief Financial Officer, Agency of Human Services)]: Yes.

[Debra Powers (Member)]: Are they ICE detainees? So

[Tracy O’Connell (Chief Financial Officer, Agency of Human Services)]: what we've seen is an increase in our daily census in the Department of Corrections. Many of them are, the majority increase in that are in the number of detainees generally in Vermont. So individuals who are picked up and then detained before they have an opportunity to go to court. It does not have to do with the ICE detainees. It is a general increase in the number of people coming into our system, and particularly

[Alyssa Black (Chair)]: detainees. Is that due to court backlogs?

[Tracy O’Connell (Chief Financial Officer, Agency of Human Services)]: I think we can get into that in more detail in another place to space because it will create many more questions. That is both an increase in the amount of people who are coming into the system and are waiting, but more than anything, it's an increase in the number of people who are being picked up. I see probably what you're seeing here. I should say. So a lot of the time people are picked up and then they go out on bail while they're waiting for their support. These are individuals who are being picked up Waiting. And waiting trial. Brian

[Alyssa Black (Chair)]: has a question, but it's something I've never thought about. So, I mean, we do have ICE detainees in some of our correctional facilities.

[Tracy O’Connell (Chief Financial Officer, Agency of Human Services)]: We saw a a significant increase in their contract this year to cover the cost for those to take.

[Alyssa Black (Chair)]: Okay, was gonna say, does the state have

[Tracy O’Connell (Chief Financial Officer, Agency of Human Services)]: to pick up through WellPath? Are served WellPath, we, and again, we can get corrections to come in and provide more information. Most of our commissioners are here representing our executive leadership team. But in this case, last year, we saw a significant increase in the rate that is paid for under the Marshals contract for the cost per person for individuals who are detained here in Vermont.

[Alyssa Black (Chair)]: And the state is being reimbursed.

[Tracy O’Connell (Chief Financial Officer, Agency of Human Services)]: The state is being reimbursed because the amount that the federal government pays the state increased significantly. Go ahead, Brian. I'm sorry.

[Brian Cina (Member)]: I'm also curious, and if we can't get into it today, because it looks like you have a lot to cover, I'm curious about the impact of homelessness on the increase in incarceration, because something we saw on the ground is when it got cold, some people intentionally committed crimes, and others, the governor kind of sent in the cops with the mayor and rounded them up. And so a lot of people are in jail right now would have otherwise been homeless. So I'm curious how much that's driving the expenses, because a lot of them have health conditions.

[Tracy O’Connell (Chief Financial Officer, Agency of Human Services)]: I don't want to create conjecture here. This is actually just an increase in the total number of people who were incarcerated. Anybody who was picked up in Burlington through the accountability court had five or more dockets that were pending. So this was a way to address the court backlog. We have not seen it create a significant increase in the number of people who are incarcerated. So I just want to clarify the record on that. In Burlington, what we essentially did was individuals who had five or more pending dockets, which is a lot, they prioritized in the court system to address, Chair, what you had brought up. It wasn't a roundup. It was moving the court system more effectively and faster.

[Debra Powers (Member)]: Thank you.

[Alyssa Black (Chair)]: Sorry, Daisy has a question also.

[Tracy O’Connell (Chief Financial Officer, Agency of Human Services)]: On the last slide, under provider rates, am I interpreting this correctly that at all of those line items under this $6,000,000 bucket, provider rates are increasing by $6,000,000 rates, yes, that is correct. That drives general population. So actually, it's even more on the gross side. Okay, because I'm confused why with the addition of five CCBHCs, there's only a 2,000,000 up. Yeah, it's on the gross level. It's more like 6,000,000, I believe. Yes. And Can you relate that $2,000,000 to a cap on salaries? Is this related to that? Is that why we're only paying SNAP? That CCBHC's a limited amount because of the amount that we have in the general fund to match the federal. And I think CMH can come in and provide more of a drill down, but I For wonder if could the record.

[Emily Hawes (Commissioner, Department of Mental Health)]: The record, Emily Houghton, commissioner for the Department of Mental Health. Thank you, Jenny, for reminding me to introduce myself. So with the CCBHC dollar sensitive insurer, what's in the current case rate that's allocated to those agencies as well as the cost template, which is not complete yet. They're still working on those rates

[Tracy O’Connell (Chief Financial Officer, Agency of Human Services)]: for July.

[Emily Hawes (Commissioner, Department of Mental Health)]: So there's not a cap from our perspective, but there is a approach using national labor information that provides a range of what most folks are making within a CCBHC setting.

[Tracy O’Connell (Chief Financial Officer, Agency of Human Services)]: Okay, and then I'm looking at, thank you, Commissioner. I'm just really struck by across all of those lines, the $6,000,000 lump sum and provider rate increases. And then in our contracts, just for WellPath, at DOC, 5,600,000.0 increase. WellPath is general fund. These are all a combination of and this is the general fund portion of that. These are plus up significantly, almost double. So almost double. Okay, the slide I'm looking at is slide 11. DOC Wellpath's second line up from the bottom. It's general fund. And so it's $5,600,000 If you're comparing the two of them, that's a gross cost. These are the general fund costs. Yes, but both are it looks to me like we're using $6,000,000 of general fund right here for all of those five different line items for provider increases. On slide 11, it looks like we're using general fund $5,600,000 just to increase well cap providers. It's an increase in the total number of individuals who are currently incarcerated. The other component of it is annualizing the substance use and mental health treatment in our correctional facility. I hear you. It's interesting. It's incredibly shocking that across all of those providers, it's almost equal to what we're increasing for health care services that are done by a contractor for incarcerated people. I just see a deep inequity there. But I just wanted to underscore that.

[Alyssa Black (Chair)]: Alicia, did you want to weigh in?

[Emily Hawes (Commissioner, Department of Mental Health)]: I was just going to, I think regardless of who was providing the services within DOC, that would be what it is. Even if it was a designated agency or somebody else, because it's a straight general fund, they can't fill for any of those services. That is the F part is providing those services

[Alyssa Black (Chair)]: within that sentence.

[Emily Hawes (Commissioner, Department of Mental Health)]: But that's a limit that we have within all of the criminal justice system is that you cannot get Medicaid. You cannot bill what typically would be a reimbursable service in size.

[Tracy O’Connell (Chief Financial Officer, Agency of Human Services)]: Yeah, I understand. My point is that we would love to see that money that's going to WellPath go to these providers who are Vermont providers who are treating people potentially in upstream services, and they're doing a great job at it. They just don't have enough money. I hear you. I'm not signed

[Alyssa Black (Chair)]: up in POC custody, where we

[Tracy O’Connell (Chief Financial Officer, Agency of Human Services)]: are now paying well past all general terms. Okay, now we'll give an overview of the areas of savings that we identified in this budget. Here's the breakdown of all the categories, and he'll give a brief overview of each of those categories. And I will say, Tasha, I will follow-up with another document that would be handy for this group. It's actually a two page summary that lists all of our ups and downs. We still do the old ups and downs format, but this is just a more condensed version that's broken down by department and easier to find information. I'm sorry, listen. Could you also update this slide or provide somewhere what that gross up is? Sure. Okay. Thank you. Yeah, that's what I Okay, so in the revenue category, we talked about this earlier, the new adult. So just based on the utilization, we are able to get 90% FMAP on that group. And so that's $3,000,000 general fund saving. With expanding to the additional five CCBHCs, that is also at an enhanced match rate. So that's a savings of $6,600,000 because we will be earning more on the federal side. There's a $1,500,000 revenue adjustment in the substance use treatment program. And then at DMH, they are going to be able to they're projecting to be able to bill more Medicaid because of lengths of stay that are under 60 that are actually Medicaid eligible. And then for DIVA, there will be a prescription drug copay increase that equates to about $461,000 general fund. And that is a requirement coming out of HR. I'm sure that later. Did you see that? It went down and it went up. Oh my gosh. Computer does not like me today. So we have caseload in utilization in a few areas, one being at Rutland Regional Medical Center, the level one beds, 718,000 general fund, and some caseload with DCF in Reach Up and Substitute Care. And then with Dale, the adult day health and rehab services, 419,000, we're seeing less utilization there. We have identified $7,300,000 general fund inefficiencies. All departments sharpened their pencils, looked at prior year expenditures, and right sized budgets for travel equipment supplies and fleets. So that's $811,000 savings. DMH and DOC vacancy savings $6,100,000 We showed you the slide earlier that shows the current vacancy rates. And so we were able, we felt it was within the budget or within the amounts that are vacant that this is achievable. It's not that we are trying to reach target. It's just there's still room for DOC and DMH to be hiring, we felt this was comfortable based on More closely aligned with the recent experience. And then the $314,000 for Dale, other personal services, is really just a technical adjustment. I'm sorry.

[Alyssa Black (Chair)]: The DMH level one at Rutland Regional, did we hear about that one? Okay, I'll go back and look at your slides.

[Tracy O’Connell (Chief Financial Officer, Agency of Human Services)]: I'm sorry, these here are caseload and utilizations. What we did was we took a look and we said, what is our current caseload? What is our current utilization? This matches what we have seen as historic caseload and utilization at RELAND. If for some reason we saw an increase in caseload in any of these areas, we would be back here in BAA making a request. So this just makes an align.

[Alyssa Black (Chair)]: No, I understand. I didn't remember.

[Emily Hawes (Commissioner, Department of Mental Health)]: It was in the list of the reduction conversation that we had, but

[Alyssa Black (Chair)]: It was also enthralling, I just missed that one. Was so frustrating. Debra, did you have

[Debra Powers (Member)]: a question? Yes. Department of Mental Health and Department of Corrections, they're saving $6,000,000 What percentage

[Tracy O’Connell (Chief Financial Officer, Agency of Human Services)]: is corrections and what percentage is the population? We can that back to you in terms of which percentages, but what these are simply reflecting is the current vacancies that we have seen and the historic trends. The good thing is, in both cases, since the pandemic, we have seen a significant reduction in the total number of vacancies. As we came out of the pandemic, the hospital had close to a 60% vacancy rate. They're down in the 30s at this point. But given the current situation in health care, and it's not that those positions are vacant. At least in the hospital, we're able to cover that with travelers. And so that's where you saw the traveler costs increase. So out of that, DMH is about 3,300,000.0 of that and 2,700,000.0 is DOC.

[Alyssa Black (Chair)]: Okay,

[Tracy O’Connell (Chief Financial Officer, Agency of Human Services)]: programmatic efficiencies. So, the school based services program is currently run out of the agency of education. And our agency and education have been working closely to transition that program over to DEVA. And so by transitioning that over, we think we can achieve $450,000 in savings at the Department of Health Access. DIVA is going to institute additional utilization management for durable medical equipment, the applied behavioral analysis coding compliance that was also in budget adjustment. At DMH, we're proposing to reduce the number of beds at BPCH from 25 to 21, and that's based on actual experience. The whole wing has been closed for significance. That's based on caseload.

[Alyssa Black (Chair)]: Can I just, see you talk about, can I, are we going to talk about the utilization management for DME? Yes, I'll save my questions still then, go ahead.

[Debra Powers (Member)]: What does dropping four or five bids from this physician in a hospital psychiatric place, what does that do in terms of Medicaid reimbursement?

[Tracy O’Connell (Chief Financial Officer, Agency of Human Services)]: That's an interesting question. So the reason we have not had those beds open since before the pandemic, so at this point, this reflects the current utilization in the system. So this will not actually change the overall mental health system. What that means is that it will end up just reflecting what the actuality is. If you're referring to the 16 beds, are you referring to the 16 beds IMD? This does not get us down to the 16 beds, so we will continue to have the IMD phase down. And the last item is, and that's because those beds are actively used in our system.

[Debra Powers (Member)]: That wing there where those beds are wasn't because of trying to get people to work there why that was not utilized. Is that correct?

[Tracy O’Connell (Chief Financial Officer, Agency of Human Services)]: So coming out of the pandemic, I would say that at a 60% vacancy rate, it became very challenging for us to staff that wing. At this point, what we've been monitoring very closely is the capacity of the system. How long are people waiting for treatment? And that's leveled off. I'm not saying that some individuals don't wait. There are individuals who have very medically complex situations who often wait in an emergency department. But for those who don't, the wait times have dropped down to a rate in which it matches or is better than what we saw pre pandemic. And so we feel like the system flow and working with the hospitals is working at this point in time. And so this reflects what we think the capacity is needed in the current system.

[Debra Powers (Member)]: We keep hearing that people are waiting in the lines in the hospital.

[Tracy O’Connell (Chief Financial Officer, Agency of Human Services)]: Happy to bring you the data on that, that we demonstrate that the length of time individuals are waiting is not lines of people out the door. So we have data on that. I actually look at it every week in terms of the wait time for voluntary and involuntary, and it's gotten down to a point where it's why don't we bring you the data? It's gotten down to a point where I don't want anyone sitting in a waiting room for three or four days, but that's not what's happening anymore, unless someone is very medically complex. And again, Brattleboro Treat and VPCH cannot serve those who have medical conditions. They're not a hospital. They're psychiatric hospitals. And so spaces like Springfield and the other hospitals that can provide both medical and psychiatric treatment, are the places that individuals can look for. That's why

[Debra Powers (Member)]: we don't need as many goods in the psychiatric hospital up on the hill. Okay.

[Tracy O’Connell (Chief Financial Officer, Agency of Human Services)]: We're not too busy. Okay, so we have a list of program and service reductions and eliminations. In totality, there are about 38. And again, this one page summary that I'll provide after, we'll lay all those out. But here are a few that we would highlight for you. But the total is 9,900,000.0 general fund. The first one is actually in the secretary's office for refugee transitional housing. A couple years ago $900,000 was built into the base to support refugee transitional housing, but due to the decrease in the amount of refugees arriving. This is really underutilization where we are receiving about 75% less refugees in the state, projecting about only 100. So 400,000 will remain in this program, and that will be to use for some transitional housing, but more so on support services with case management, legal services, employment services. That's why we proposed this reduction. Diva Vermont Legal Aid Medicare Assistance Contract, which Diva will speak to more in the next session, and also the ACO per member per month payment since the ACO has now subsided. Just explain what this Oh, the legal aid. So that contract was Vermont Legal Aid to assist in coordination of benefits with Medicare. The amount that we're seeing through Medicare is actually less than what the value of the contract is. And the statute says the contract can be cancelled if it's cost inefficient to maintain that contract. It's intended to support the drawdown of Medicare funds. Which one are we talking about? The second one. The legal aid. So legal aid has a program that helps us recruit funds from Medicare. The statute says that that program actually has to cover its own costs. And at this point, the amount of revenue that's coming from that program is significantly below the amount that the program actually costs.

[Alyssa Black (Chair)]: Last year, I believe you had bridge funding for the ACO. Is that the per member per month we're talking about or is this a different per member?

[Tracy O’Connell (Chief Financial Officer, Agency of Human Services)]: So the ACO went away and they provided a per member per month two practices as a part of their overall program. I would say that the goal here is this one will sunset because it was a program through the ACO that we couldn't reset. Through the Rural Health Transformation funds, will see significant investment in primary care and other providers on the ground that will surpass this $2,100,000

[Alyssa Black (Chair)]: So this is not because there were multiple per member per month programs through the ACO. This is the one for the large payment that went to a couple practices. Can't remember what we call it.

[Tracy O’Connell (Chief Financial Officer, Agency of Human Services)]: Debra can get into this one a little bit more detail in their budget. Again, I want to reinforce from the top, these were very difficult decisions that we didn't take lightly. They were not made by one department or the secretary's office. They were made by the joint decisions of the executive leadership team. They were based on a review of programs that were sunsetting, a review of programs that were not performing, where there was duplication. And so I do want to reinforce that again here. I think it's really important. These were not decisions that we made lightly. Are there any questions about any of these specific? Again, there's a list of 38 programs that we saw that were either eliminated or reduced. Go ahead, Leslie.

[Leslie Goldman (Member)]: Could you switch to the program?

[Tracy O’Connell (Chief Financial Officer, Agency of Human Services)]: So, the AHEC program is a loan repayment program. Folks will note that loan repayment is done by both VSAC and by AHEC, and so this is a program that is sunsetting. It was a very difficult decision, but in terms of looking at the overall outcomes and retention of providers in Vermont and the duplication of the VSAC, we had to make a difficult choice to eliminate those programs. That said, rural health transformation, while it can't care of its prohibition at the federal level for loaner payments, there are significant investments into workforce, particularly things like tuition reimbursement for health professionals. So will there be

[Leslie Goldman (Member)]: a gap? Think we also saw that there was VSAC also, a cut. I'm not seeing it there here. But I think from BDH, there was

[Tracy O’Connell (Chief Financial Officer, Agency of Human Services)]: a VSAC cut. This education for patients through VSAC.

[Leslie Goldman (Member)]: Okay, so those two cuts. And of course, workforce is a priority. And I hear that you're saying that the transformation money should fill that gap, but there's going be a gap. And what about the people that are already in the program getting support? They apply every year.

[Tracy O’Connell (Chief Financial Officer, Agency of Human Services)]: And so this is in the program where individuals are getting a guaranteed set of funds on an annual basis. And we have to make some very difficult decisions. We cannot do a loan repayment program through Rural Health Transformation, but there are significant investments into workforce programs. We can come back with an outline of what the total amount is. They are things like physician payments for current students, again, doing the same things. These were programs that were difficult to make decisions at CAP. We did look at data and retention of providers here in Vermont. And so based on that data, I had to make some very difficult choices.

[Leslie Goldman (Member)]: I understand. You say many times difficult choices, but those difficult choices have implications for individuals that we're trying to support So work to I'm just concerned that we're going to be leaving people in alert. I understand. I heard you say you have to apply every year. However, people start a career and they start their schooling based on some assumptions, which are now being removed. And what is the plan? I don't imagine that your workforce through the transformation money is going to be up and running immediately because that's hard. It actually is. So are

[Alyssa Black (Chair)]: you saying

[Leslie Goldman (Member)]: that that's going to fill this gap? It's not going to do

[Tracy O’Connell (Chief Financial Officer, Agency of Human Services)]: loaner payments. I want to reinforce here again, and we probably should move on and BDH would be happy to come back and speak to this. But this program is not a program where someone goes to school and is guaranteed when they go to school that they're going to get $10,000 a year of loan repayments. It's not for an individual who got loan repayment last year. It's not an expectation that they will get loan repayment again the following year. That's not the way that this program actually works. And so we're not taking funding away from an individual. I do hear you. And we have, again, to make some very difficult decisions, The Rural Health Transformation programs have to be up and running this year. 195,000,000 has to be obligated in this year and have to be out the door for eighteen months. So those programs will be up and running, or Vermont will not get that funding again.

[Leslie Goldman (Member)]: Okay, but this particular cohort that's already in training This particular cohort was not guaranteed any funding. I understand that. I hear you. However, there is this sort of support of the workforce development. Was published, go on, I get it. But I do feel like we were abandoning cohort people. I hear you.

[Tracy O’Connell (Chief Financial Officer, Agency of Human Services)]: I'm very worried about that. I hear you. Lori? So I appreciate that

[Lori Houghton (Member)]: hard decisions were made, and we still have

[Tracy O’Connell (Chief Financial Officer, Agency of Human Services)]: to do our work. Yes, you

[Lori Houghton (Member)]: And the commissioners who have been so far. Presentations have been great. But I feel like there's been a real lack of data behind where I these cuts are being made. And so in the beginning, you mentioned that you you all looked at data. You asked some really good questions. We need to see that data for these programs. And so Chair Black, we work as a team of a couple of us that work on the budget. And we're putting together letters to grasp the commissioners on what we're looking for. But I am just going to say right now, we want to see the data behind these. And then we also want to understand what the statewide strategy is. You said there's duplication. So if we're losing something somewhere, how is it being taken over? And how is that service going to be absorbed into whatever would be to

[Tracy O’Connell (Chief Financial Officer, Agency of Human Services)]: come back and share the data. We don't have the context and the amount of time today to do that. No. No.

[Lori Houghton (Member)]: No. I understand. Yeah. And what we would like to do is actually have it in writing and then come back as needed.

[Tracy O’Connell (Chief Financial Officer, Agency of Human Services)]: We can do that. Okay.

[Debra Powers (Member)]: Thank you.

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

[Brian Cina (Member)]: I'm gonna let go because we really need to get through more stuff.

[Alyssa Black (Chair)]: Gosh.

[Tracy O’Connell (Chief Financial Officer, Agency of Human Services)]: How about I? Okay. And then we would want to highlight the initiatives that we are proposing. We're seeking $31,000,000 between base and one time funds to support sustained investment in emergency housing. So $10,100,000 for family specific domestic violence and medically vulnerable shelter options, a substance use recovery shelter, case management enhancements, rental assistance and staffing, and then to continue a portion of the regular GA program. Then we also are proposing to fund the Opioid Recovery Employment Program through Dale's Hire Ability Division, and that's $875,000 That was previously funded by the opioid settlement money. But that was not recommended, it's my understanding, from the committee. So this is another program that has offered good data on effective outcomes. So we're seeking that in the budget and then expanding the DOC pre trial supervision statewide. We need $200,000 in order to fund a probation and parole officer in every office throughout the state. And then, I'm not sure if we have more time, but the rest of the slides are really just digging into the central office, what provide for services in the central office. If you want us to keep going.

[Alyssa Black (Chair)]: I'm just looking ahead at your slides

[Brian Cina (Member)]: I'm curious about the refugee program. Are you seeing any strain in that area considering that many refugees are being targeted for money right now? We just heard one was detained recently before his ICE appointment or whatever, so I don't know if you're seeing any extra stress there.

[Tracy O’Connell (Chief Financial Officer, Agency of Human Services)]: The refugee program provides supports and services for refugees who are currently here, including things like housing, helping to get folks connected with employment services. What we are actually seeing is a decrease in the funding that's needed for the program because we're not seeing as many people come community. To Again, the Regency Program will be happy to come and speak more, but no, I don't think that I think that overall, the stress level is very high, the financial burdens.

[Brian Cina (Member)]: There's a social cost, the noneconomic cost. Lori?

[Tracy O’Connell (Chief Financial Officer, Agency of Human Services)]: We did one year bridge funding for SAASH for AHEAD. That is not happening at least this next year. So is SAASH funding still in this budget? SAASH funding is not in this general fund budget, but what we are looking at is funding. There's two things that so as a reminder to folks, when CMS, when the all payer model, we exited that, and before AHEAD, where another model comes up, there are Medicare programs like Sash, which serves primarily only Medicare beneficiaries, and the Blueprint portion of the primary care payments that are Medicare portions. Those we are looking at, they are Medicare funded. We're looking at how we can support them in the World Health Transformation.

[Lori Houghton (Member)]: But there is no solid as of right now?

[Tracy O’Connell (Chief Financial Officer, Agency of Human Services)]: Is a plan for them in the rural health transformation. Can we see that language?

[Jill Olson (Medicaid Health Systems Director)]: I'm Jill Olson, Medicaid Health Systems Director. The language is pretty general in the rural health transformation, but as we wrote it, there's whole there's series of sections on the blueprint and the blueprint payments. So I'm not sure it's actually going to eliminate it for you in the way that you're asking because we were intentionally open ended in some of our descriptions. So I think there is more work to do with behavioral square to sort this out, but that is our plan.

[Tracy O’Connell (Chief Financial Officer, Agency of Human Services)]: And again, this is a Medicare

[Alyssa Black (Chair)]: They are the operators actually. I thought we couldn't use any of the rural health transformations in Chittenden County.

[Tracy O’Connell (Chief Financial Officer, Agency of Human Services)]: So, SASH is a statewide program, the administrator of that is Cathedral Square. There's some nuance in the rural health transformation funds. If those funds are supporting services that are delivered in rural communities to rural Vermonters, we can use those funds. So whilst Cathedral Square is a provider in Chittenden County, the majority of Sash was delivered in the rest of the state outside of Chittenden County. Again, a this Medicare program, and until we are in another program, another coming in from Medicare, this will continue to be a challenge. The ultimate long term plan was to, if we end up going to AHEAD, it is funded under the AHEAD model. Where are we on AHEAD? And then Lori

[Lori Houghton (Member)]: Can I just stick with Oh, Sash real yeah? When Obviously, big concern that July 1 comes and there is no plan.

[Tracy O’Connell (Chief Financial Officer, Agency of Human Services)]: There is a plan. Would this well,

[Lori Houghton (Member)]: if we don't have SASH in the budget, when would the SASH end?

[Alyssa Black (Chair)]: They have calendar year funding for each funding through this calendar year, so the problem starts on January 1.

[Lori Houghton (Member)]: Of twenty seven. Seven. Okay, that's helpful. Thank you.

[Alyssa Black (Chair)]: Karen, and then how is everything going with AHEAD?

[Tracy O’Connell (Chief Financial Officer, Agency of Human Services)]: The simple answer to that is with the new administration, we need to start negotiations on the AHEAD model with some updates that they have in the model. We've just started that, so we can provide that more information in the coming months. I just wanted to notice the snap shift from 50% to Is that permanent? Yes. Then there was no transition for that? It was something that came out of HR1 and a major change, So it was as soon as HR1 was implemented. Effective October 1, the federal fiscal year.

[Lori Houghton (Member)]: I'm sorry, one last And this, I know we're putting a lot on you, so this doesn't have to be an immediate thing. But it would be really helpful to have one page that shows truly where the lack of federal funds from HR1 or any other actions, not like the FMAP one, but how it's affecting AHS. And I don't need a lot of detail about the program and the amount that we're losing. That happen without too much

[Tracy O’Connell (Chief Financial Officer, Agency of Human Services)]: We can make that happen. I think things like Satch, though, will not be on there. That's right.

[Lori Houghton (Member)]: It's not anything to do Yes, but like the SNAP and Yeah.

[Alyssa Black (Chair)]: Thank you.

[Tracy O’Connell (Chief Financial Officer, Agency of Human Services)]: I think the secretary of AOA actually has that for everybody. Oh, then we could just ask that. Correct. Okay. And present that to the joint just so it's a check. Any other, do you want to keep going? Don't think so. Okay. Thank you, I appreciate your time today.

[Alyssa Black (Chair)]: Thank you.

[Tracy O’Connell (Chief Financial Officer, Agency of Human Services)]: Thank you.

[Alyssa Black (Chair)]: All right, let's move on to Diva.

[Brian Cina (Member)]: Before we move on, can I just say I looked ahead and I want to acknowledge that you didn't cover some accomplishments? I see that you mentioned some accomplishments. I want to acknowledge that I'm seeing that.

[Tracy O’Connell (Chief Financial Officer, Agency of Human Services)]: Thank you.

[Brian Cina (Member)]: I mean, we were critical, you know, for instance.

[Tracy O’Connell (Chief Financial Officer, Agency of Human Services)]: If we're actually very much in the back and forth on the budget, I just wanna be really careful. We've had to make some really difficult decisions, but I think the budget review process is important.

[Alyssa Black (Chair)]: Just begun.

[Tracy O’Connell (Chief Financial Officer, Agency of Human Services)]: Commissioner, maybe you can speak to that as we make the transition. Us doing this and to this location can make a huge difference in terms of us all being on the same page and being able to cover things across the agency. Is that the first

[Brian Cina (Member)]: time you did that?

[Emily Hawes (Commissioner, Department of Mental Health)]: Yes, absolutely.

[Tracy O’Connell (Chief Financial Officer, Agency of Human Services)]: I don't

[Alyssa Black (Chair)]: have an indication, but who do we have on Zoom with us today?

[Deshaun Rhodes (Commissioner, Department of Vermont Health Access)]: We should have Addison and Rachel Stillwell.

[Alyssa Black (Chair)]: I'm sorry, I didn't have Addy. Up. Rachel's Is

[Tracy O’Connell (Chief Financial Officer, Agency of Human Services)]: Alicia not with us? Oh, there's Alicia right there. We're still live, everyone, just to let you know.

[Alyssa Black (Chair)]: There's one of my nose in the hall. It's gonna be loud.

[Emily Hawes (Commissioner, Department of Mental Health)]: Welcome. So

[Tracy O’Connell (Chief Financial Officer, Agency of Human Services)]: let's start in. Although I lost half of my

[Alyssa Black (Chair)]: committee. I'm doing it. Okay. You can go ahead and start whenever you're ready.

[Deshaun Rhodes (Commissioner, Department of Vermont Health Access)]: All right. Good morning. I am Deshaun Rhodes. I am the Department of Vermont Health Access Commissioner.

[Alicia Cooper (Director of Managed Care Operations, DVHA)]: Morning, everyone. Alicia Cooper, Director of Managed Care Operations for the Department of Vermont Health Access. Good morning, Addison, Deputy Commissioner at DIBA.

[Alyssa Black (Chair)]: I'm sorry, Allison, we're having

[Tracy O’Connell (Chief Financial Officer, Agency of Human Services)]: a very hard time hearing you. Is this any better? Yes.

[Alyssa Black (Chair)]: A little bit better, yes.

[Allison Novak (Financial Director, DVHA Business Office)]: Closer to my microphone. Allison Novak, Financial Director in the Business Office.

[Alyssa Black (Chair)]: Thank you.

[Tracy O’Connell (Chief Financial Officer, Agency of Human Services)]: Hi, everyone. I'm Rachel Stillwell. I'm a Financial Director in the Diva Business Office.

[Alyssa Black (Chair)]: Thank you.

[Deshaun Rhodes (Commissioner, Department of Vermont Health Access)]: We're missing Alex McCracken. I see where she is. There is extra security today.

[Tracy O’Connell (Chief Financial Officer, Agency of Human Services)]: Oh, that's true.

[Leslie Goldman (Member)]: Once in

[Alyssa Black (Chair)]: a while, I see her over there. Have Do we want to start or does she have slides?

[Deshaun Rhodes (Commissioner, Department of Vermont Health Access)]: She has slides.

[Alyssa Black (Chair)]: Oh, she has slides.

[Deshaun Rhodes (Commissioner, Department of Vermont Health Access)]: She has slides.

[Alyssa Black (Chair)]: Should we take a break? I think we should. Let's take a break.

[Deshaun Rhodes (Commissioner, Department of Vermont Health Access)]: Okay.