Vermont Legislature SmartTranscripts:

[Rep. Leslie Goldman (Member)]: Good

[Rep. Alyssa Black (Chair)]: morning everybody. It is Wednesday, February 11. We're continuing on budget recommendations. And this morning, we're starting off with Vermont Medical Society. So Jessa and Doctor. Morris, do you wanna

[Dr. Anne Morris (Associate Dean for Primary Care and AHEC, UVM Larner College of Medicine)]: Why don't we take it? Yes.

[Jessa Barnard (Executive Director, Vermont Medical Society)]: I think Doctor. Morris may look like she's on the schedule twice, but she's really second on AHEC. So She okay. Got it. Yes. So There were some schedule moving pieces this morning. Yes. Exactly. Great. That's that work. But we are coordinated, but coordinated, but separate. So good morning. And she was right here in the purple jacket.

[Rep. Alyssa Black (Chair)]: Yeah, was seeing if you were coordinated.

[Jessa Barnard (Executive Director, Vermont Medical Society)]: Oh, no, not literally. Should, we could have done that. We did not color coordinated. Good morning. Thank you so much for having us this morning. Jessa Barnard, the executive director of the Vermont Medical Society, and also sharing this testimony on behalf of the Vermont Academy of Family Physicians and American Academy of Pediatrics Vermont Chapter, so Vermont primary care clinicians. I won't be exclusively talking about primary care impacts, but largely, this is really about both some downs in the budget that we have real concerns with and some additional needs to stabilize primary care. And I wanna acknowledge right up front, because I know you've heard a lot about the RHT grant already, but there are reasons we're still here asking about budget items because RHT funding, as I'm sure you have heard many times over, can't go to base rates and can't go to provider based payments, and also can't supplant budget items. So we have a real concern with if these are cut in the budget, to us, looks quite Our understanding is we can't then just say, Oh, but RHT can cover it, because that looks like we're replacing budget funds with RHT funding. And some of the items just wouldn't even be eligible for RHT, like we'll talk a bit about loan repayment. So we're here both to talk about some base funding for primary care and some workforce items. And as I mentioned, I'm tag teaming a bit with Doctor. Ann Morris from AHEC. She'll really be getting into the details of the workforce items, but I just wanna say how important they are to the primary care clinicians of Vermont, we absolutely support rescinding the cuts to the AHEC program. So I don't have slides. I have a one page Well, actually two page, I guess, front and back handout that should be posted with some arrows in both directions. We hope this visual helps. You can let us know if is helpful or not. We were trying to kind of keep it simplified and high level. The first two items are about cuts in the governor's recommended budget that we strongly oppose. So he, as I mentioned, there are cuts to primary care workforce programs, and Anne will go into more detail. It includes loan repayment, early pipeline programming, and physician placement services. And I think we've all had the experience of struggling to get a primary care clinician, find a new one if yours retires. We know many primary care clinicians are nearing retirement age. I think I'm a bit preaching to the choir, but I will just say our organizations strongly oppose eliminating the state funding for these programs. It eliminate really almost all of the funding for these services. And again, we don't think RHP can be a replacement for them, especially the loan repayment. We have heard very loud and clear from AHS that CMS has said no, loan repayment is not an acceptable use of RHT funding. So we oppose those cuts. There is also in the budget, and I think you've heard this from Diva, Vermont has had, as many of you know, sort of an aggregator of payments, One Care Vermont, our statewide ACO, that sunset at the 2025. There are some programs they're still hoping to administer for 2026, but the all payer model and our ACO that took payments from different payers and paid them out to primary care and hospitals and others is ending, is over. And so Diva had contributed to that as well. All payers paid in, Medicaid, Medicare, some of the commercial payers. The hospitals were also assessed dues. And then there were several primary care programs that then went to help support offering primary care services and stabilizing our primary care practices. Diva in their budget sort of books this as savings, but ending 5,000,000 in gross payments to primary care programs that was being paid practices. That was going as a $4.75 per patient per month, per attributed patient per month payment to primary care practices. We understand DIVA's reasoning or rationale is that with the end of the ACO, they don't have a mechanism to get those funds out the door. Our ask is to direct those to still be going to primary care practices, even if it's not through the ACO, that Diva directly pays primary care all the time. They in fact have a separate, and I'll talk about this a little more, sort of a higher, what they call conversion factor, a way they pay primary care practices already more than specialty care practices, so that we would ask that that funding, rather than just book that as savings, we should keep those payments in the primary care fee schedule. I have a

[Rep. Alyssa Black (Chair)]: question about this. Yes. Because I'm confused. And this may be a question for Diva that I didn't ask the other day because I wasn't thinking about it. So 4.75 were two per member per month. There was the blueprint per member per month, which are like goes to NCQA blueprint practices. That was always flowing through. Well, first it used to flow through blueprint, then it was flowing through the ACO. And there was also a Medicaid management per member per month that has been in existence for as long as I can remember. And that used to flow straight through Diva. Correct. And then I it started flowing through the ACO.

[Jessa Barnard (Executive Director, Vermont Medical Society)]: They merged those two payments into one

[Rep. Leslie Goldman (Member)]: through

[Rep. Alyssa Black (Chair)]: GACO. Correct. So is this the elimination of the blueprint per member per month, or is it the elimination of the Medicaid management fee?

[Jessa Barnard (Executive Director, Vermont Medical Society)]: That's a great question. My understanding, and it would be good to clarify with Diva, my understanding is this is not the Blueprint per member per month payment. I have never heard Diva say they don't plan to continue their participation in the Blueprint programs and their Blueprint per member per month, that this was their primary care management job taking care of your patients fee, but it's a good point. At one point, had $1.67 that they used to pay directly to practices separately that then got wrapped into the ACO payment. So it's kind of it's the ACO payment and that management fee, I think, would be this channel flowing that was going through the ACO. Part of it used to come directly from the blueprint. The blueprint still has the MPMs. So

[Rep. Alyssa Black (Chair)]: I'm concerned because they're saying, well, now that the ACO is gone, we can't administer it, but it used to always come through Diva. It would come every single month on a remittance advice.

[Jessa Barnard (Executive Director, Vermont Medical Society)]: Correct. And I think they're going to have to go back to paying their blueprint PMPM themselves too. I think they're working on that. My understanding is they're working on that mechanism because the ACO was administering that for them and can't do that anymore either. So my understanding is Diva will be doing some PMPM payments to primary care.

[Rep. Alyssa Black (Chair)]: Just- I'll get clarification on that.

[Jessa Barnard (Executive Director, Vermont Medical Society)]: Per member per month. So for whichever payer, each Medicaid patient that goes to that practice, they are making that payment per month. They sort of add it up into one payment. This practice has 200 Medicaid patients, so we multiply four seventy five by 200 and pay that practice with their month. And as we were talking to the chair about it, One Care, the ACO helped to flow those funds at one point, but before that, it was Medicaid directly paying some of them. And my understanding is they will be going back to doing that. Thank you. Thanks for the questions. So these are both proposed, I will just call them cuts, in the governor's recommended budget that we oppose, both the workforce and what has become really a base payment to primary care. If you're ready, I will move on to another item. So this is not addressed really one way or the other in the governor's recommended budget. The first one being the sort of traditional way, the fee for service way that Medicaid pays for professional services. And I know that your committee has gotten a little bit into the distinction of kind of how different types of providers are paid, and that there's sometimes facility fees, sometimes different types of fee schedules. So what I'm talking about is the fee schedule from Medicaid that goes to individual clinician services. So your physicians, PAs, APRNs, and wherever they are providing services to Medicaid patients. That fee schedule, DIVA, typically bases on Medicare's fee schedule. So every year, January 1, Medicare publishes a new fee schedule that has both a lot of detail in terms of how certain services are assigned, call it a work value, like how much effort goes into providing that service. And then they multiply that by what's called a conversion factor, like a dollar amount multiplier. So Medicare publishes that, and Diva typically follows those changes to the codes to keep the fee schedule updated. It's a lot of work to go. I mean, there are thousands of codes. It's every type of your office visits, your molar removals, your all sorts of things go into that thousands of lines of codes. So Diva updates which codes they include and how they value them along with Medicare, but then they use their own state based, I'll call it their conversion factor, their number that turns that into a dollar amount that the practices get paid. So this year, what they have proposed, and in fact, what went into effect January 1 already, is they updated all their codes like that, but then they adjusted their conversion factors to be budget neutral, because that was their guidance. This committee has done a lot of work around this issue in the past and requested that DEVA provide additional analysis of what other options would look like than just a budget neutral fee schedule. One of them is what it would look like to add a inflationary index to how practices get paid. Practice expenses go up, how much it costs to pay your staff, to keep your lights on, your health insurance for your own employees. It's very expensive to run a provide medical services. So, Diva did provide us the analysis of what it would look like to match what is a federally public, Medicare published annual, what they call economic index. That's the federal government's estimation of what it costs more to run a practice this year than last year. That is 2.67% for 2026. And that is what we are requesting that the professional fee schedule receive. That comes out to 3.3, that middle box in the middle of the page, that's 3,310,000.00 gross. Of that, only 788,000 actually goes to primary care, way it breaks out, 529,000 to specialty care, and actually almost 2,000,000 to psychiatric codes, mental health codes. If you are interested in more detail, some of you may be, some of you may not, on the back sheet page or the second page is the breakdown that which goes to primary care or specialty, and then even more detail of ups and downs within the types of services, because of these two factors at play, not just the dollar amount, but how they value codes. So there are sort of from Medicare that Diva also imports. So there are winners and losers, I will say within that, but that is the ultimate sort of, if you added the inflationary adjustment to help practices stay open, keep their doors open, pay their own staff, that is the total amount that would come out to. I will say if DIVA stuck with what they've proposed, which is a budget neutral, they call it budget, it's actually a teeny decrease. Sometimes we've measured where Vermont's fee schedule is relative to Medicare. The budget neutral is actually a reduction relative to Medicare, because this year for the first time in actually quite a long time, Congress is requiring Medicare give a slight increase to their professional fee schedule. So we would go from, for primary care services, for example, 114 percent to 110% of Medicare. And for specialty services from about 80 would be about 80 to 80 86 to 85%, I believe, with the budget neutral approach. With the inflationary approach, we stay more even to Medicare, where Medicare, like the percent of Medicare would stay about the same, because this is about the inflationary factor that Medicare is also adding in this year. So for 2026, Medicare's conversion factor went up. Actually went up. Congress required I know, and usually we're in this committee, the chair is asking that question. We're often saying, Don't do what Medicare does, because Medicare actually decreases year over year for complex federal formula reasons. This year, Congress actually is requiring about a 2.5% increase to Medicare. And yet Medicaid It's not matching that either. Is keeping the exact same conversion factor. They're on same conversion. Yeah. Well, I think it's actually there are some slight changes because of all the all the RVU adjustments, but then they adjust their conversion factor to be budget neutral is what they're proposed for '26.

[Unidentified Committee Member]: Okay.

[Jessa Barnard (Executive Director, Vermont Medical Society)]: Or, well, calendar year '26, FY '27, fiscal year '27.

[Rep. Alyssa Black (Chair)]: Did we do some work a couple years ago on trying to untie Medicaid to Medicare by essentially taking out the conversion factor piece, stop tying the conversion factor

[Jessa Barnard (Executive Director, Vermont Medical Society)]: to Medicare. Correct. And they are not tying their conversion factor to Medicare, but I think they were Obviously they have to follow their budget guidance. And I think their budget guidance was most of their fee schedule. I think with very few exceptions, almost all of their fee schedules are proposed to be budget neutral for this year. Except ones that I believe there are a few where it's federally mandated for like, for example, the FQHCs, I think they are required to include a inflationary adjustment for my look, I can't answer this authoritatively, but I've been watching as they've come out with their fee schedules, the vast majority look budget neutral for this year, including this one. So yes, they are not pegging it to Medicare, they are sort of doing their own. And I will say you did do some work asking them to look at various scenarios. They did send those over to me and I'd be happy to share them. This was only MEI, the inflationary index was only one. They sort of looked at various models and provided us that information. So, I appreciate that they are sharing the analysis. Their ultimate recommend, what is in the budget is a budget neutral approach. Oh,

[Rep. Leslie Goldman (Member)]: sorry. Just a clarification. Yes. I'm looking at your chart. Yes. Thank you. It's a lot of information and stuff. Don't know acronyms. I don't know what. Sure. Yeah. Yeah. Thank you. Want to spend time on that, but.

[Rep. Daisy Berbeco (Ranking Member)]: Oh, I'm sorry, go ahead. Go ahead. So, yeah, so

[Jessa Barnard (Executive Director, Vermont Medical Society)]: this is the second page of my testimony. It's a chart from Diva. So again, much appreciation to Diva for providing this, because it's the only way I understand what the ups and downs are each year. So this is if you added a 2.67 inflationary factor, the EPCP is the enhanced primary care payments. So they have a different conversion factor for primary care codes than specialty codes. The line, so that shows the way it would break out if it was a 2.67% overall increase, point is 74% increase to those primary care codes. If you remember, it's primary care, there's sort of a dual taxonomy. You have to be a primary care provider providing certain services. So if you fit in that bucket, you get this different pay fee schedule or different value of your fee schedule. So that would be a 4.74% increase. Non EPCP, that's basically specialty care services, would be a 0.71% increase. Then actually for the first time this year, they've broken out psych and mental health services separately, just because of the way Medicare has been revaluing codes. We've noticed over the past couple of years that any increases to primary care, it was less sort of how we define primary care, actually looked to go quite a bit to those codes. So it was just to take a look at kind of how that breaks out, why they're listing that separately. It's the same And then below that is breaking it out in more detail. Again, the primary care on the top line, specialty care second line, and then within specialty care, how that kind of breaks out. I will say even with an inflationary increase, it is actually a decrease to OB, and that is concerning to many of us, and again, that's because of how Medicare, because of the two part formula, how they revalue the value of codes and then how they pay for them. So that's not a conversion factor problem, that is the Medicare is trying to kind of give more work points to office based services than kind of procedural based services, which in concept is a good thing. It's meaning things like primary care and services that take a lot of time talking to patients, they're kind of over time recognizing surgical procedural services, or maybe getting more relative to talking to patient type services. But OB is one area we have concerns about how that impacts in particular.

[Rep. Alyssa Black (Chair)]: Is that is it 26 or is it for 27? Aren't there some big changes coming with OB, the event event basically getting rid of the bundled global OB services? I feel like I heard that something.

[Jessa Barnard (Executive Director, Vermont Medical Society)]: I'd have to dig into, I don't know that that was for Medicare 26 fee schedule. And I will say we have clarified, OBs providing, if they, OBs can fit in that primary care fee schedule, but remember, it also has to be like primary care services. So things like labor and delivery do not fall in that bucket. That's actually been something, if this committee is interested, we have suggested is that sort of all OB services, least that labor and delivery should actually be considered a primary care service, in which case it would get the enhanced payments. And that would really help our birthing units. If we have a birthing center, it would help everybody who does those services stay in operation.

[Rep. Alyssa Black (Chair)]: 01/01/2027, it's changing. Oh, thank you. Appreciate that. Next year. That should actually be a good thing. Yes, that could help with Yeah.

[Jessa Barnard (Executive Director, Vermont Medical Society)]: Because OB services, they bundle together all of the prenatal visits and the delivery and the couple of postpartum visits into one payment, and it hasn't been adjusted very much over time. In fact, it's been going down, so it's been really hard to one of the reasons it's been very hard to sustain working units regardless of where they've been located. Okay, I am conscious of time here. I think one more kind of detailed one, the others are pretty they're much easier to describe. We've done a lot of work with the legislature, this committee, and others to talk about kind of the impacts of the ending of One Care Vermont, the ACO I've mentioned. Regardless of your opinion of the ACO, one thing they were successful at is directing more payments to primary care, sort of being that aggregator, using not just payments from the payers, but actually hospital dues on top of that to pay primary care in different ways more than they were getting paid before. You and the full legislature did really helpful work last session to help fill what we've been calling a gap in funding between the end of the ACO, and if we join the AHEAD model in 2028, the start of the AHEAD model, which would bring, we hope optimistically, some more funding to primary care. So you, the legislature directed some funds to fill that 2026 gap. There was actually a pretty big settlement with the UVM Health Network and Green Mountain Care Board, which directed substantially more funding to fill that 2026 gap. So we feel actually pretty comfortable that sort of the loss of funds to primary care are covered until the end of calendar year 2026. So the timeframe we're really looking at is January 27 through June 27, so half of the fiscal year. There is no plan for how do we sustain primary care practices until 2028, again, when we potentially join the AHEAD model.

[Rep. Alyssa Black (Chair)]: Have practices started seeing those payments from the UVM settlement?

[Jessa Barnard (Executive Director, Vermont Medical Society)]: I believe, that's a great question, I should confirm they were planning to make a payment towards the January, and I should confirm if that's gone out. One Care was making them in monthly payments in all of this settlement. One Care is actually one of their sort of things they agreed to do, even though they're closing, is to make two more payments to help get this settlement out the door to practices. And I there as far as I last spoke to them, their plan was a January payment and a June payment to divide all, like a year of payments into two to help practices make up the loss of those funds. I just want to go on record as saying that UBM settlement was not bridge funding. It was never intended to be bridge funding. It was intended to be UVM,

[Rep. Alyssa Black (Chair)]: excess revenue, going to places that were needed. But I don't like the idea that it was supposed to be ACO bridge funding. So I just want to put that.

[Jessa Barnard (Executive Director, Vermont Medical Society)]: Yeah, I don't think any of us But not. I will defer that decision making to the health network and the Green Mountain Care Board. That was not a legislative. And I will say we do appreciate, I mean, regardless of the intent or use, has been important to fill that need. It will be helpful to sustain practices for the full calendar year. Because the legislative funding that was directed last year in the budget was a partial fill of that gap. And then the 11,000,000 really did finish filling that gap and include other partners who had worked with the ACO, like DAs and SSAs and home health that might not otherwise have received that sort of gap funding. Okay, last two things I will mention quickly. We strongly support So there is a medical student scholarship program, which Doctor. Morris will talk more about. That has a legislative in language sunset of 2027. We strongly support removing that sunset. There is language to do that also in S197, the sort of primary care reform bill that's getting some testimony in the Senate. But I personally would love to see it in multiple places, not knowing exactly what's moving where this session. So if that could go in budget language, that would be very helpful and make sure it's really moving. That scholarship has been really helpful from our understanding. And I'll, again, let Anne give you more of the details, but at least to remove that sunset to allow it to continue moving forward would be great. And then there is a program working with pediatric practices, Dulce, which embeds family support specialists in certain practices that really helps join the family through each of their visits and help screen for social determinants of health, make sure they get the referrals where they need. It's sort of like an almost more intense version of the blueprint, I think of it. And that program does not, from my understanding, have any source identified currently of ongoing funding to keep it working with the six practices they're working with.

[Rep. Alyssa Black (Chair)]: Is that being

[Jessa Barnard (Executive Director, Vermont Medical Society)]: funded through bullet rent? It's getting funded, I believe, maybe through the mental health integration pilot. And I don't think that is planned to continue, is my understanding, is that there's no sort of continued opportunity or availability of funding from the Blueprint or elsewhere. And I am not the expert on Dulce. I can definitely, if folks are interested, connect you or I'm sure that folks involved would be happy to provide more detail and testimony. But we do think that the pediatric practice is working with those family support specialists have really valued the service and think it really is helping their families. And they're often working in conjunction with the family support centers in their communities.

[Rep. Alyssa Black (Chair)]: Copper, did you have a question?

[Unidentified Committee Member]: Yes, thank you, Madam Chitt. How long has the program, the scholarship program that has 22 scholarships to date, how long has that been in effect?

[Jessa Barnard (Executive Director, Vermont Medical Society)]: I will let Doctor. Morris give you the details. I should know that off the top of my head because we were in 2022. I was gonna say, I think there was a five year window before the sunset went into effect, so 2022, with the intent that the legislature, I think, put that in place, wanting sort of data on how it's working. The challenge is that if you think about medical student training, they're a medical student, and then they go to their residency before they could even start paying back their service obligation to Vermont. So the students are just starting to come back to Vermont now. So fully understand the legislature may wanna see sort of effectiveness and how it's working before not having any check back. But it's just with this sunset, it's too early to even really have meaningful data yet, because those students, the first class is just finishing their residency now. So it's sort of a sunset before we can even show you the data on, the full data on how it's working or getting many of them back in Vermont. Thank you all very much. Oh.

[Rep. Alyssa Black (Chair)]: Yeah, go ahead, Leslie.

[Rep. Leslie Goldman (Member)]: I just wanna make sure I understand your chart.

[Jessa Barnard (Executive Director, Vermont Medical Society)]: Front page or back page?

[Rep. Leslie Goldman (Member)]: Front page. Front page, yes. So I see what's not in the governor's recommend. Yes. So that's the 3.31. That's what you're saying here. But your ask, I'm trying to make sure I understand what your ask is, because I'm not getting it. Sorry.

[Jessa Barnard (Executive Director, Vermont Medical Society)]: We have a number of asks, both to not approve or to oppose the or restore the funding that the governor is proposing to cut. Okay. And to fund the items, increase the fee schedule and continuing those. The are all in the middle white boxes. The white boxes are the asks. Okay.

[Rep. Leslie Goldman (Member)]: So you're not and just remind me about the scholarship.

[Jessa Barnard (Executive Director, Vermont Medical Society)]: The scholarship and again, I'm deferring a lot of the detail to Anne, but my understanding is that there is rollover funding because not all of the scholarships have been, you could say, used. There's up to 10 per year and not up to 10 students have applied each year or been awarded the funding each year. So even if we didn't add more funds, but at least allowed the program to continue, it could continue to use those rollover funds for a certain amount more time. Not indefinitely, but

[Rep. Leslie Goldman (Member)]: Because somewhere there are some in here, which I have not seen and missed, that there's a recommended sunset for the incentive scholarship.

[Jessa Barnard (Executive Director, Vermont Medical Society)]: Not because it's in session law. Okay. So you wouldn't necessarily see that in the budget or

[Rep. Leslie Goldman (Member)]: Okay. So that's why it hasn't come up in front of us

[Jessa Barnard (Executive Director, Vermont Medical Society)]: or somewhere along the line. That is why we were bringing it to your attention. Okay. Got it. It was in there when when the funding originally passed or and when the and the authorizing language creating the scholarship passed. Yeah. So it is it is in legislative language that there is a sunset, and we're just asking that language to be repealed.

[Rep. Daisy Berbeco (Ranking Member)]: Okay. Got it. Okay.

[Rep. Alyssa Black (Chair)]: Can I ask you about the CPR payments? Yes. CPR payments, if I recall through one care, they were like the large, larger global payment. They displaced fee for service.

[Jessa Barnard (Executive Director, Vermont Medical Society)]: But there were only a couple practices on those. There were 19 practices, and what we've been asking for the kind of what you could consider bridge funding is on top of fee for service, not necessarily It's like, because aren't they just gonna revert back to We have already 2026, they reverted to fee for service. This is kind of keeping them whole for what they were receiving above fee for service.

[Unidentified Committee Member]: Okay.

[Jessa Barnard (Executive Director, Vermont Medical Society)]: Because they were getting a capitated global payment from the payers, which is also unfortunate that it went away. And hopefully we will have an opportunity later this session to talk to you about S197 and trying to move primary care payments to more capitated payments for everyone.

[Rep. Leslie Goldman (Member)]: So another question. I'm curious to know, is there private equity in any of the primary care practices that we're thinking about?

[Jessa Barnard (Executive Director, Vermont Medical Society)]: That may be a question for the blueprints. Off the top of my head, I am not aware that the primary care practices I know of that work with, for example, MSOs are in the I'm not aware that they are in the blueprint. They tend to be more direct primary care or concierge practices. And to be in the blueprint, you have to meet patient centered medical home criteria. And I don't know, my sense is those practices either can't or don't choose not to meet those criteria.

[Rep. Leslie Goldman (Member)]: The blueprint practice. Yeah. So I'm thinking about blueprint practices, and you're saying likely not them. And how about other practices out of the blueprint world?

[Jessa Barnard (Executive Director, Vermont Medical Society)]: So the bridge funding, for example, that we're talking about is going to, I'm just trying to think, do my analysis here. So that's going to practices participating, who had participated in One Care. The Diva professional fee schedule, there are direct primary care practices who accept insurance. So concierge typically does not, direct primary care does, and then also charges a subscription fee on top of that. So if they see Medicaid patients and accept the Medicaid fee schedule, you could have a direct primary care practice who also works with an MSO who helps provide administrative services, billing supports, that kind of thing.

[Rep. Leslie Goldman (Member)]: But you're not aware of of I mean, that's what I'm curious about. Is it happening? Or I I could see what you're saying. I am not aware. It might be happening.

[Jessa Barnard (Executive Director, Vermont Medical Society)]: It might. I am not aware. I am not aware. I don't have direct knowledge that it is or is not. Don't think we, other than the direct primary care practices working with MSOs, I am not aware personally of any primary care practices in Vermont owned by private equity.

[Dr. Anne Morris (Associate Dean for Primary Care and AHEC, UVM Larner College of Medicine)]: Thank you, Joseph. Yeah, thank you very much. Thanks for your time.

[Rep. Alyssa Black (Chair)]: Doctor. Morris, if want to come on up.

[Dr. Anne Morris (Associate Dean for Primary Care and AHEC, UVM Larner College of Medicine)]: My feet touched the ground.

[Rep. Alyssa Black (Chair)]: Is it great when that happens?

[Dr. Anne Morris (Associate Dean for Primary Care and AHEC, UVM Larner College of Medicine)]: Good morning, Chairwoman Black committee members and guests. Thank you for allowing me here to speak today on behalf of the Vermont AHEC Network. I'm Anne Morris. I'm the Associate Dean for Primary Care and AHEC at the Walker College of Medicine. And before I go on, I also want to introduce, I have some students that are with me today. This was not on purpose. We had actually planned on being here as part of a two week AHEC scholars elective called community engagement. And part of that is looking into medical advocacy and how as primary care providers, that part of our responsibility as professionals. And so we had planned on being here today. So that's why we're here. It just so happens I'm also going to testify. Three of these are fourth year students who are actually going into primary care. So going into family medicine, we presume going into family medicine, pediatrics, and a step of obstetrics and gynecology. So that's actually really exciting for us. So some of you already may know me from my previous advocacy efforts around reducing administrative burdens for primary care providers, including testimony here on prior authorizations and step therapy. Two weeks ago, while testifying on S197 before the Senate Health and Welfare Committee, I urged the total legislature to invest, really invest in primary care, knowing that to some, it may feel paradoxical to dedicate more money into a system that seems to have exponentially growing costs. But similar to adding oil to your car to make the engine run more smoothly, investing in a primary care system that values preventative services, continuity of care, and the flexibility to provide comprehensive care through interprofessional teams that are built to meet the needs of the individual communities will not only decrease the total cost of care, but will also improve healthcare outcomes for all Vermonters. Now, purpose of my testimony today is not to convince you that primary care is important. I think you all know that already. But rather to acknowledge the complexity of creating a primary care delivery system in its entirety, and ask you not to lose sight, then in addition to building the system to provide care, we in parallel need to have a system that develops, trains, and supports our rural primary care workforce. Attached today, have a couple of infographics that are going to talk about our AHEC programs. We'll specifically talk about something called our educational loan repayment, and then includes testimonials from many of our recipients. So that is, you may have those in front of you. We know that nationally, fewer people are choosing careers in primary care compared to other healthcare specialties. We know that lack of salary parity, high educational debt, and administrative burdens contribute to the reticence to choose primary care specialties. We know that this is compounded in rural locations by having a small pool from which to entice students to enter into healthcare fields. To address the primary care workforce shortage, a variety of methods are used to increase the chances that a healthcare provider will choose to practice in a rural location. These include early exposure to healthcare career exploration through primary education, like middle school, high school, as well as rural training experiences in both medical schools and residency programs. Evidence shows that residency training at teaching health centers, such as the now funded Maple Mountain Consortium, significantly increases the likelihood that physicians will practice in a rural area post residency, very often as in the vast majority of the time within 100 miles of their training site. We also know that scholarships and loan forgiveness, such as the Vermont Educational Loan Repayment Program, and that AHEC scholars student incentive scholarship benefit recruitment and retention in rural areas. I'm just gonna say the AHEC scholarship for that from now on. To help states address this workforce dilemma, HRSA developed Area Health Education Centers, AHEC, to address healthcare professions shortages, especially in rural and underserved areas. AHEC in 44 states strive to provide programs that address healthcare recruitment and retention, health professions training, health profession support, meaning continuing education. In 1996, with encouragement from this Vermont legislature, UVM Lehner College of Medicine created the Office of Primary Care to show its commitment to primary care in Vermont, which led to the establishment of the Vermont AHEC network. Today, this network consists of a program office, which is the administrator of the HRSA grant at UVM, and then two centers, Northern Vermont AHEC and Southern Vermont AHEC. It's funded by HRSA, the state through VDH, and our 14 hospitals. As a network, we strive to provide statewide healthcare professional development programs to ensure that all Vermonters have access to high quality primary care. Our early pipeline programs are how we grow our own healthcare workforce. In the last five years, we've hosted activities in 46 schools and other venues leading to nearly 20,000 student interactions, 76% of which have occurred in rural communities. For comparison or for scale, Illinois's AHEC, which has nine centers, reaches about 2,000 students annually. This includes career exploration workshops in schools, after school career pathway plannings, near peer mentoring programs, which I think is really important to state near peer, between high school or college students and our medical students, and summer immersive and residential healthcare enrichment programs. These programs have led to technical certifications, such as CPR, Stop the Bleed, and the Vermont EMS first responders. In the last few years, we've certified 95 new Vermont EMS first responders. Further, of the 52 alumni from the Governor's Institute of Vermont Health and Medicine Institute who have achieved secondary degrees, twenty eight have graduated from a Vermont College, and thirty six have earned a health related degree. So these are working. In medical school, the AHEC Scholars Program reaches 79% of the LCOM students. The AHEC Scholars Program is a voluntary enhanced curriculum that allows students to increase knowledge, strengthen leadership skills, and gain competencies with the goal of learning about community medicine, social drivers of health, and how to provide whole person care. Thirty nine percent of those enrolled students complete the two year commitment above and beyond their actual curriculum, and graduate with the distinction of being a national AHEC scholar. Further, our data shows that from 2022 to 2025, LCOM students who completed the AHEC scholars program were two times more likely to enter a primary care specialty compared to their peers. Further, at the Vermont AHEC scholars medical student Scholarship Loan Incentive Program, that was created by statute as a $1,400,000 grant to provide up to 10 in state tuition reimbursement awards per year to third and fourth year medical students who are entering primary care and agree to a year of service obligation in a rural Vermont location post residency. So for each year of the award, they have one year of service obligation essentially outside of Chittenden cap. We have currently granted 25 awards. We have seen an average of three to four awards per year. This current cycle, which ends today in terms of the application, has at least six and up to eight applicants. So we're seeing an increase. And I anticipate this interest and commitment to the program will increase as the changes in federal student loan caps and the public service loan forgiveness programs come down the pike. By statute, this program will end in 06/30/2027, and this is what we'd like to ask you to extend. Currently, the fund has approximately $476,000 still in it or 11.9 awards. So if we give six or eight awards, excuse me, We'll still have five to six awards that we could give next year. And hopefully, we will Sorry. Hopefully, we will be able to get the legislature to further fund this award in future so that we can continue to award these in the future. The Vermont Educational Loan Repayment Program, or the ELR program, for healthcare professionals support primary care physicians, dentists, and nurses who to receive loan repayment in return for a one to two year service obligation to a rural primary care practice. So these are outside of medical school, they're now in practice. In twenty eight years of this program, we've distributed $29,500,000 through 3,364 awards. During this time, 37% of state dollars distributed to awardees have actually been matched with worksite dollars. And again, this program works. More than 60% of recipients stay at the work site after completing service obligations. And finally, our physician placement service is a non biased resource to medical students, residents, fellows, and physicians who are seeking employment in Vermont. Over the past five years, this program has contributed to 62 physician placements, 71% of which were in primary care practices, and fifty five percent of which have been in rural counties. Testimonials from Vermont practices and hospitals have been robust in the services and benefits that this saves them. Saves them individually up to between $15,000 and $40,000 per recruitment on an average, or an estimated savings of over $1,000,000 in recruiter fees for Vermont practices. So, our hospitals and our practices are truly benefiting from that. For the brevity and purpose of this budget proposal, I will not review continuing educational services available at no charge to all of our primary care providers. These programs are a two year award and not up for review this year. But we'll comment that continuing education services not only support our primary care workforce needs, but also improve the access to medical care in rural areas by helping to increase the scope of practice and the comprehensiveness of the care provided in the medical home. So it helps to keep the care where people are, which is the cheapest, the most inexpensive way to provide care when thinking about this system. So I would therefore like to ask this committee to first remove the statutory sunset date for the Vermont AHEC scholars medical student incentive scholarship. And then two, to provide level funding to three longitudinal programs through the Vermont Department of Health that have been removed from the governor's FY twenty seven budget. So those are specifically $500,000 for the AHEC support grant, which helps to fund healthcare pipeline development programs. It's been level funded since FY 2006, and is divided equally between all three AHEC centers. And this funding has been despite repeatedly meeting and exceeding our CRRSA and our VDH work metrics and outcomes. Second, 667,000 for the educational loan repayment program, which has provided $29,000,000 in loan repayments to Vermont primary healthcare workforce over the last twenty nine years, and has a proven track record of retaining award recipients long after their one to two year service requirement. And then $50,000 for our MD placement grant, which helps to support the AHEC physician placement services, providing unbiased career support to those seeking practice in Vermont. Again, it's assisted 62 placements in the last five years and estimated saved over a million dollars in recruitment fees. These funds are crucial to support the ongoing work of the Vermont AHEC network in growing and supporting our primary care pipeline. They are unlikely, as you've heard, to be replaced by the Rural Health Transformation dollars, giving restrictions on using RHDP funds to supplant our current programs, as well as the clear exclusion on monies for loan repayments. There is no one size fits all solution for our workforce woes, But lack of providers worsens primary care access, leads to increased utilization of emergency services, and increases the overall cost to our healthcare system. We cannot reform our primary care delivery system without simultaneously investing in our primary care workers. Thank you.

[Rep. Leslie Goldman (Member)]: Any questions? Okay, Tumbare, and then Leslie, and then

[Unidentified Committee Member]: Before I ask this question, I wanna specifically say that I agree with what if they ask, hope that I'm not gonna ask you any questions.

[Rep. Alyssa Black (Chair)]: But

[Unidentified Committee Member]: 40% of the participants don't stay here. Is that what you said? Sixty percent stay here. In

[Dr. Anne Morris (Associate Dean for Primary Care and AHEC, UVM Larner College of Medicine)]: which program, sorry.

[Unidentified Committee Member]: Think it was primary care.

[Dr. Anne Morris (Associate Dean for Primary Care and AHEC, UVM Larner College of Medicine)]: Yeah, in loan repayment. So we know if we look at the five year data in the loan repayment, we know that sixty percent looking at five years out are actually still in their sense.

[Unidentified Committee Member]: After they've made their commitment? Yes. Okay, 60%. Yep. 20% don't. Correct. That's a lot.

[Dr. Anne Morris (Associate Dean for Primary Care and AHEC, UVM Larner College of Medicine)]: Yeah. I think part of it is recognizing that these funds are going to many different providers. So they're going to MDs and DOs, they're going to dentists, they're going to nursing that can include APRNs, nurses, LNAs. Specifically, we see in the nursing sector that it can be hard to keep, that is one of the hardest places to keep providers. And that is because frankly, they can almost make more money in a sign on bonus to move to another job than to stay where they are. And that's something that's out of our control. So the money that they're receiving makes it, the salary bumps that they can receive, makes it hard for them to stay.

[Unidentified Committee Member]: That's a big reason.

[Dr. Anne Morris (Associate Dean for Primary Care and AHEC, UVM Larner College of Medicine)]: Is that, I mean, that's one of the reasons. I think you also are looking at administrative burden for providers. You're looking at having places for Vermonters to their partners to work, their ability to buy houses for young providers that are coming out of medical school with a minimum average of $250,000 in debt. And most people would say it's actually significantly much more than that. When they start, they're essentially paying three mortgages. They're paying their loans, which are upwards of $2,000 a month. They're paying, if they're starting a family, daycare costs, which could be upwards of $2,000 a month. And then they're trying to have either a rent or a home payment that could also be upwards of $2,000 a month. So it's just incredibly difficult for providers to stay and meet the financial needs of their families.

[Unidentified Committee Member]: When you're talking about paying loans, you're talking about the first two years of their education,

[Nolan Langweil (Joint Fiscal Office)]: the money they borrowed for that.

[Dr. Anne Morris (Associate Dean for Primary Care and AHEC, UVM Larner College of Medicine)]: Yes, and it's all four years of their education just for medical school, and then they have a minimum of three years of residency training after That could be extended, in some cases, to four or five years in primary care. And then you also have undergraduate loans, and in some cases, they also have graduate school loans. And sorry to be long winded about this, but they could have 10,000 to $20,000 that they have paid in medical school applications, or in residency applications as they're trying to get there. So there's a lot of equity that we could discuss there in terms of what people are investing in, in order to become healthcare providers. And it really does take a vocation for them.

[Rep. Alyssa Black (Chair)]: Okay, let's get to Brian in a minute. I've got Leslie. I got Lori and then Brian. Not Lori. Not Lori. Don't have question.

[Rep. Leslie Goldman (Member)]: No, Thank you. Thank you for this. We were told, you addressed this a little bit, but I just want to make sure I understand it, that this program is okay to go away because the Rural Transformation Plan is going to take it over. That was hard to imagine because here's a program that's standing and operating and what's it going to take to get that program up and do this work? But now what I'm hearing is that it's not legitimate use of the money anyway. So that's done, right? That IP act, let's just say that. Am I understanding that right?

[Dr. Anne Morris (Associate Dean for Primary Care and AHEC, UVM Larner College of Medicine)]: That is correct. So there are some very small parts that we may be able to submit RFA fors. RFA. RFA, so that we may be able to submit applications for grants to participate in small parts. But this funding goes away and will take away. There is nothing about early pipeline development or health careers exploration. The vast majority of the RHT programs are really looking at post secondary certifications and accreditation programs and things like that. So you mentioned,

[Rep. Leslie Goldman (Member)]: I can't remember, did you say 19 states have this, have they had or

[Dr. Anne Morris (Associate Dean for Primary Care and AHEC, UVM Larner College of Medicine)]: how 44 states and several of our territories.

[Rep. Leslie Goldman (Member)]: And are they all funded by legislative grants?

[Dr. Anne Morris (Associate Dean for Primary Care and AHEC, UVM Larner College of Medicine)]: They all are HRSA grants. And then you have to have matching monies that are coming from the state, that could be state funds, that could be gift funds, that could be a variety of ways. Most states provide state funds.

[Rep. Leslie Goldman (Member)]: In the same model that I think.

[Dr. Anne Morris (Associate Dean for Primary Care and AHEC, UVM Larner College of Medicine)]: Yeah. The benefit of AHEC is that they can be innovative in each state. So I just want

[Rep. Alyssa Black (Chair)]: to be and I know Brian has a question and Daisy, but I want to be clear. If the state removes our money, you lose your HRSA federal grant.

[Dr. Anne Morris (Associate Dean for Primary Care and AHEC, UVM Larner College of Medicine)]: We are at risk of losing that. Correct. Correct.

[Rep. Leslie Goldman (Member)]: And how much is that altogether? I'm sure it's

[Dr. Anne Morris (Associate Dean for Primary Care and AHEC, UVM Larner College of Medicine)]: here somewhere. It's a five year grant fund, which I believe is $4,200,000 from HRSA that comes in annually. And then we match annually from HRSA? 4,000,000 over the five years.

[Rep. Leslie Goldman (Member)]: Oh, so not annually, but but Correct. It's divided by five. Is it

[Rep. Alyssa Black (Chair)]: a one to one match?

[Dr. Anne Morris (Associate Dean for Primary Care and AHEC, UVM Larner College of Medicine)]: Is it yes. Brian, did you have a question?

[Rep. Brian Cina (Member)]: Do. Thank you. Can you hear me okay?

[Rep. Alyssa Black (Chair)]: Yes. Can hear you well.

[Rep. Brian Cina (Member)]: Yeah. I was hoping to get there in person to ask you, but I don't I think you're gonna end minutes before I I get there. So I wanted to ask, you mentioned well, there's two questions. One is you mentioned that the first class, so to speak, or the first cohort, maybe is a better word, of of folks who took advantage are gonna be coming out of their residency soon and that we're just gonna start be start to see the the reward of the investments soon. And I'm curious if you could say a little more. Like, if we were gonna try to measure the success of this program, what what would be the numbers we'd be looking at over the next few years in terms of people returning and where they're going to? And then the second question I have is you talked about the factors influencing people wanting to stay in Vermont or come to Vermont after. And you mentioned housing and their spouses getting a jobs. You didn't mention health care, and I'm wondering how health care access for health care providers plays into this. And what and could some kind of system of universal primary care that guaranteed primary care providers an income while guaranteeing them and their family's primary care? Could some kind of incentive like that also help? Thank you.

[Dr. Anne Morris (Associate Dean for Primary Care and AHEC, UVM Larner College of Medicine)]: Thank you. So in terms of the awards, we have 25 awards that have been awarded. So over the next five years, we essentially have the potential to bring about five providers back through this program annually. We have 11.9 more awards based on the funds that are still existing. So we basically have the opportunity to add from this $1,400,000 grant from the state, 34, 35 total physicians coming into the state. So that I think is good news. We have 59, I misspoke two weeks ago, we have, I believe it's 59 open primary care physicians right now. And so with that number coming in, plus 50% of the UVM family medicine residents staying consistently. So that's another four physicians annually, and Maple Mountain Consortium, as it continues to grow over the course of the next several years, that potentially adds to, we're looking at almost 50 providers coming in. It is starting to move that needle in terms of bringing primary care providers into Vermont. In terms of access for primary care for primary care clinicians, we feel the burden of that just as much as our primary, our constituents do, all of our patients do. I have to wait nine months to get my child, their well child check, just like you do. I had to wait ten months to get my preventative care screenings, just like our patients do. One thing that has happened at UVM Medical Center with the residents and fellows, it became such a difficulty to get new residents and fellows primary care, access to primary care, that they started a program that helps to get those residents and fellows into primary care practices within six to twelve weeks if they've identified themselves as being new clinicians. That is for the residents and fellows to try to help to keep them healthy so they can help to provide the care in the state. That doesn't necessarily include their families and their children, their partners and children.

[Rep. Alyssa Black (Chair)]: Oh, Daisy, and then we need to

[Rep. Daisy Berbeco (Ranking Member)]: Do you have your budget requests written out anywhere? I didn't see it clearly right now. They are in my testimony, I can

[Dr. Anne Morris (Associate Dean for Primary Care and AHEC, UVM Larner College of Medicine)]: submit to you. Yes. Okay. Thank you. And I think they're on the VMS one as well.

[Rep. Daisy Berbeco (Ranking Member)]: I'll connect with you to make sure I have

[Rep. Alyssa Black (Chair)]: the right one. Alright, thank you. You're welcome. Thank you so much. Alright, Roland, although you might have to make a small

[Nolan Langweil (Joint Fiscal Office)]: Yes, so we're gonna have to, Ashley's gonna do most of the talking anyway. I'm just driving. Okay. And at some point, I'm gonna get a text from Jen's gonna come over, I have to shoot across the phone real quick. Okay. But testify in your bill.

[Rep. Alyssa Black (Chair)]: What's our bill?

[Nolan Langweil (Joint Fiscal Office)]: $5.57, like your bill.

[Rep. Alyssa Black (Chair)]: $5.77.

[Nolan Langweil (Joint Fiscal Office)]: $5.77. So it'll be quick, but I just, so we're just, and then toss her if somebody could just drive for like the three minutes or longer there. Wow, I really scared everyone away. We

[Rep. Alyssa Black (Chair)]: love doctors. Doctors. I'm originally here going over budget, but I thought it might be good set to get a little bit of education on what exactly is global commitment. Nolan and Ashley are going to talk to us about it. Once we look at all these columns, we know what we're talking about.

[Nolan Langweil (Joint Fiscal Office)]: When we say Nolan and Ashley, we mean mostly Ashley, and Nolan's just driving and piping in here and there. Really shouldn't even have my name on it.

[Rep. Alyssa Black (Chair)]: I'm really good at these graphics, by the way.

[Nolan Langweil (Joint Fiscal Office)]: I made this one. I made this one on my own. I'm quite proud of it.

[Rep. Leslie Goldman (Member)]: And the EKG. I

[Nolan Langweil (Joint Fiscal Office)]: was very proud of myself. I'm not very artistically inclined. But anyway, for the record, Noel Langwell, Joint Fiscal Office.

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

[Nolan Langweil (Joint Fiscal Office)]: So yes, as we have discussed, we are going to do a quick overview of global commitment. But I am going to let Ashley pretty much do all the talking at this point. She's the expert. Thanks,

[Ashley Berliner (Director of Medicaid Policy, Agency of Human Services)]: Milan. So I know many of you have heard of this before, but I agree that it's such a foundational document in the state of Vermont for how we operate our entire Medicaid program. I really appreciate you asking for us to come in and talk about the eleven fifteen Global Commitment Waiver today. So an eleven fifteen waiver is something that the federal government can issue a state Medicaid program, and it essentially allows states to waive some, though not all Medicaid laws. Section eleven fifteen waivers are intended to encourage state innovation in the Medicaid program, and they are often used for states to be able to pay for things that otherwise wouldn't be able to be paid for under the normal rules and laws of the federal Medicaid program. Eleven fifteen waivers are approved on a five year cycle, five year term, but demonstrations can be continuously renewed, amended throughout. The one core theme throughout all 11 fifteen's in the country is that they must be budget neutral. That is a statutory requirement. So you cannot spend any more with an eleven fifteen waiver than you would have spent without an eleven fifteen waiver. So for states that don't have an eleven fifteen waiver or if our eleven fifteen waiver were to go away, we would be limited to being able to cover exclusively what is authorized in our Medicaid state plan, which is the mandatory and optional services in the Social Security Act and the mandatory and optional populations on the Social Security Act. Medicaid would have to be administered in strict compliance with all of those federal regulations. Next slide. So what does the waiver do for Vermont in particular? We have had the Global Commitment to Health eleven fifteen waiver since 2005. It's evolved significantly over that time, but it continues to allow Vermont Medicaid to operate in two really distinct ways. It gives us Federal Financial Participation, FFP, for populations and services that otherwise would not be allowed under Medicaid law, and it also allows us to have flexibility in the way that we manage our Medicaid program, the way we pay, the way we structure our provider networks. So federal funding and federal flexibility are really the core tenets of why we have around the state of Vermont. In terms of the federal funding, it gives us federal funding for this list of programs and services you see up here. It allows us to provide Marketplace subsidies up to 300% of the federal poverty level on the exchange for people that are above Medicaid income limits. So people above 138% federal poverty up to 300% get an increased marketplace subsidy to buy their commercial insurance.

[Rep. Alyssa Black (Chair)]: Can I interrupt you really quickly and ask a question about that since you is there a limit on how much our subsidy in that population is? Yes. There is?

[Nolan Langweil (Joint Fiscal Office)]: Yes, we can only get up to 300% federal poverty.

[Rep. Alyssa Black (Chair)]: No, no, no, no. How much money can we subsidize for that population from 138 to 300? Is there a limit?

[Ashley Berliner (Director of Medicaid Policy, Agency of Human Services)]: Yes. Yes. If the terms are in our eleven fifteen standard terms and conditions where When we turned this on, were the only state in the country that allowed marketplace subsidies. Now we have some company, Massachusetts notably has a very generous marketplace subsidy program. But there is a limit. There are rules for what subsidies can be provided. There is also dollars in our budget neutrality agreement for how much we can spend on marketplace subsidies generally, like globally.

[Nolan Langweil (Joint Fiscal Office)]: Currently the way it works is we take whatever the folks are getting from their federal subsidy and then we're doing another 1.5. So if we wanted to change that, we would have to go back to CMS and ask for permission and it would go against our TAP and so there's lot of other considerations. Okay,

[Rep. Alyssa Black (Chair)]: thank you. Sorry to interrupt you.

[Ashley Berliner (Director of Medicaid Policy, Agency of Human Services)]: Problem, appreciate the questions. The Community Rehabilitation and Treatment, the CRT expansion benefit, Department of Mental Health is actually in the process of rebranding CRT, so that might be a term that you don't need to get too comfortable with, but it essentially means that we provide a mental health wrap benefit individuals that are above Medicaid income levels who have severe mental illness, SMI. This is a really unique thing to the state of Vermont where people who aren't Medicaid eligible but have acute mental illness or mental health need are entitled through our Medicaid program to receive wraparound services. So the Department of Mental Health administers this program. It's something we're really proud of and it means that regardless of your income in Vermont, you have comprehensive mental health coverage. V Pharm is a pharmacy assistance program for people 64 in the state, so it reduces cost sharing for pharmacies. The moderate needs group is a choices for care program that allows people who are not quite eligible for nursing home level of care to receive some level of services with the intent to keep them out of a nursing home level of care. So we kind of like to think of that as pre long term care Medicaid. IMD payments. There is a federal prohibition on paying for IMDs in statute for individuals between 22 64. We have an eleven fifteen waiver that allows us to pay IMDs, both substance use disorder IMDs and severe mental illness IMDs, mental health focused IMDs, to sixty days. So our waiver explicitly allows us to pay for Valley Vista, Brattleboro Retreat, the Vermont Psychiatric Care Hospital for stays up to sixty days. There is an arbitrary cutoff of sixty days per federal law. We have fought that tooth and nail and have not been successful at getting past that sixty day barrier, but it is something that covers all of our substance use disorder IMD stays and a good amount of the brought over retreat stays as well that are under that sixty day limit. Children's Palliative Care Services is administered out of the Health Department and this provides palliative care services for children who are at end of life. We also have a long list of investments. Nolan has a link to that at the end of presentation, but that is everything from paying for two eleven to providing funding for the health department laboratory to paying for respite care for individuals who have family members that need respite. It's a really kind of broad list of services that we cover that otherwise wouldn't receive Medicaid match.

[Nolan Langweil (Joint Fiscal Office)]: There's also a link to it on the website and on your website for today.

[Ashley Berliner (Director of Medicaid Policy, Agency of Human Services)]: So that's the funding piece of this. And then on the flexibility, this is a little more abstract, but it essentially allows us to operate our Medicaid program as we do today with Diva as the public managed care like entity. So I like to contrast it with what most other states are doing. Most other states in the country, the vast majority use private managed care organizations to carry out the functions of their state Medicaid program. So California, for example, has Kaiser United who are these commercial insurers who are providing coverage to the Medicaid population on the state of California's behalf. That is the vast majority of Medicaid programs in this country. In Vermont, we, instead of contracting with private managed care, contract with Diva as a public managed care entity, and it allows us to take advantage of the same flexibilities that are in federal law around managed care. So federal statute really advantages managed care organizations and provides them flexibility beyond what a state could normally pay providers. It allows them to pay for things a little bit differently, have a little bit of a different provider network. So by using DIVA as a public managed care entity, we can take advantage of all those federal regulatory flexibilities and still can keep it in house and administer that program within our own state system.

[Nolan Langweil (Joint Fiscal Office)]: And by the way, that's part of the, that mechanism is part of the reason why when you look at the ups and downs and it shows up as a global commitment on the map together in one line, you go to AHS and it's broken out there. That's part of that mechanism. AHS is the contractee or contractor. So that's part of why it's in two places.

[Ashley Berliner (Director of Medicaid Policy, Agency of Human Services)]: So specifically it allows us to pay our providers in ways that wouldn't typically be available to us under the state plan, so value based payments. Several of the mechanisms we pay, like the bundled payments that we pay, all of that is really using our managed care flexibility. It allows us to waive rules of statewide ness, which really is what lets us administer our home health agencies, our designated agencies in the way that we do in these geographic areas because we can limit them to where you live. There are also waivers of the upper payment limit, which is a huge benefit to Vermont. Federal law requires that Medicaid programs have to be below the upper payment limit for Medicare in certain categories such as inpatient hospitalization, outpatient hospitalization, and nursing homes. The eleven fifteen waiver waives that upper payment limit so that we can exceed Medicare rates in those categories, and we do quite significantly in the inpatient hospitalization and nursing home categories because of the Brattleboro retreat payments, which are significantly higher than Medicaid, Medicare, and really skew that upper payment limit. And also our state run veteran's home in White River Junction really skews the upper payment limit on the nursing facility side. So if those were to go away, that would be a significant impact to Vermont's ability to pay for either of those facilities. Did we lose Nolan?

[Rep. Alyssa Black (Chair)]: We lost Nolan for just a few minutes.

[Rep. Brian Cina (Member)]: Okay.

[Rep. Alyssa Black (Chair)]: Tasha is ably sitting in his place. We

[Rep. Brian Cina (Member)]: have a stunt couple.

[Rep. Alyssa Black (Chair)]: Now are we are we still the only state that manages our own Medicaid exclusively?

[Ashley Berliner (Director of Medicaid Policy, Agency of Human Services)]: We're the only state that manages the entirety of our program. Arizona also manages a good chunk of their program in a similar way, but we're only state that has the entirety of the Medicaid program under our waiver.

[Rep. Alyssa Black (Chair)]: Have we done analysis over the years of whether it's more efficient, whether our providers are receiving better payments. Have we done an analysis on this as compared to other states that use traditionally a contract with a commercial managed care organization

[Rep. Daisy Berbeco (Ranking Member)]: to I administer their

[Ashley Berliner (Director of Medicaid Policy, Agency of Human Services)]: don't know if I'm going to be able to answer your question exactly. We have done an analysis on whether or not this flexibility is beneficial to us, and one of the key constraints in Vermont is that we don't have the bodies, the lives to pull in private managed care. Apparently, we tried it in the nineties and it did not work. It was not successful because we literally didn't have enough Medicaid lives to support it. In terms of payment to providers, that is wholly within the constraints of our state budget. So we actually would have a lot more flexibility to pay providers than a managed care organization would if it was within our state budget and authorized for DIVA to pay out, that really has no bearing on the administration.

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

[Ashley Berliner (Director of Medicaid Policy, Agency of Human Services)]: Next slide. This is just a visual depiction of that private managed care like concept. So the Agency of Human Services is the single state agency, which is a term of art in Medicaid law, which requires the single state agency to carry out certain functions like determining eligibility for Medicaid, program integrity, functions, and setting policy. And then AHS contracts through an intergovernmental agreement with DIVA, who functions as this managed care entity. DIVA then subcontracts with all of the other departments and AOE to carry out certain provisions of the Medicaid program. So of course that's not DIVA doing absolutely everything under the Medicaid program. DIVA is subcontracting to DMH, to MEDAH, to AOE, DAL, etc. So that's all this is. It's just a visual depiction.

[Rep. Alyssa Black (Chair)]: Daisy has a question.

[Rep. Daisy Berbeco (Ranking Member)]: Ashley, maybe more related to the previous slide. Can you talk a little bit about whether we can just continue to put all our programs into this waiver and get them matched? I know there's a cap. Can you talk a little bit about that? And also, who determines what we propose to add to the waiver? And a little bit about that process.

[Rep. Leslie Goldman (Member)]: And then the other thing is,

[Rep. Daisy Berbeco (Ranking Member)]: once something is part of the waiver, what are the quality control measures like?

[Ashley Berliner (Director of Medicaid Policy, Agency of Human Services)]: Those are great questions. So for the first question, we have that piece about it being budget neutral is really essential. So we have a budget neutrality agreement, which is actuarially certified, and it puts caps in place by population, by waiver only services, and by investment. So we have waiver specific caps for B Farm, for moderate needs, for CRT, for the new adult population, for the kids aged blind disabled population. Every eligibility group has its own budget neutrality cap that is set in advance. So that is something that we really pay attention to and have to make sure we stay within because that's the key kind of fundamental concept of the waiver that allows us to continue. So that's a really big constraint. In terms of can we still add things, when the waiver is closed as it is right now, so we have an operating waiver agreement, it's not in the process of being amended. We have investments that can be added throughout the course of that closed period. Investments are something that have evolved more than anything else in our 11/15 waiver. When they were established initially, it was the wild, wild west. We didn't even have to tell CMS what we were doing. Now we are under a very close microscope. They are looking at absolutely everything. We have a very detailed application process for issuing new investments and the criteria is extremely tight. So the last time we got new investments through was under the Biden administration. We have not received any new investments under the Trump administration. It is not an impossibility. We still have the option to add new investments, but we're under such close scrutiny and we have such broad authority otherwise that it hasn't been something that we've been like really needing. If there was something to arise that felt like it could plainly fit in an investment category and we have very clear authority, then we would have the option to add that. So that's the second question you asked. And then the third question of who decides what goes on the eleven fifteen waiver? That is a really timely question because we're about to, we actually just kicked off our launch for the renewal. Our eleven fifteen waiver currently is set to expire at the 2027, which means that we have to get an application in, in 2027 for CMS to review and approve to extend our eleven fifteen waiver. So we have contractors that we've contracted with. We are contracting with the same vendor that we worked with during our last renewal, which was really successful. We do a lot of engagement with the commissioners to understand what the direction of their departments is. And traditionally in a different year, not this year, nothing is traditional now, we would be doing a lot of stakeholder engagement to really understand like what is it that we need in Vermont that is innovative? What can we do to really continue to grow our eleven fifteen labor program and presence? This year, given all of the circumstances, we are playing defense and we are really focused on maintaining what we have. We have the best waiver in the country. I feel really confident saying that. And so we are not looking to add new things or put anything shiny in there that we don't already have. We really want to preserve the existing services and programs. So that's the framing that we're going into this next renewal and how we're thinking about it. That answer your questions?

[Rep. Daisy Berbeco (Ranking Member)]: Yes. I'm going to try not

[Rep. Leslie Goldman (Member)]: to say that it doesn't look in

[Rep. Daisy Berbeco (Ranking Member)]: the budget like a lot of these are being preserved because I see a lot of the investments are being cut.

[Ashley Berliner (Director of Medicaid Policy, Agency of Human Services)]: Well, let me elaborate on that. So we're like a little bit out of you're really jumping the gun on me here in these slides, but I think we can actually just skip to this part. So the 11/15 waiver, as I said, it expires at the 2027. We are extremely worried about being able to get the thing, even though we're playing defense, we're extremely worried about being able to get these things through. They are really innovative. They are outside of what other states have. Vermont is a unicorn, we're out on an island. And so a lot of what's in our waiver feels like a long shot to get into the next waiver. Investments are at the top of the list of vulnerabilities. It is very unlikely that if we have to negotiate with this administration on our waiver that we will be able to maintain those investments. So that is why the budget looks the way it does, is rather than cut programs that we think we'll be able to preserve in a future state, we're looking at programs that we think are not going to be preservable. We're going to have to cut that, if not this year, next year. That was, that's really the calculus and why the budget looks the way it does. In addition to the fact that a lot of these investments, we stood up in a way, some back in 2005 that, and I don't want to speak to any specific investments not having the list in front of me, but some of these were stood up in a way that didn't have really clear oversight over them, didn't have really good outcome measurements. And so we don't feel like they're necessarily doing what they were intended to do and aren't as effective as we want them to be. And so we feel like in addition to them being unlikely to continue in our new waiver, we're also not really seeing the return on investment in many of those cases. So I think both of those combined show you the picture of why those investments are showing up in the budget the way they are.

[Nolan Langweil (Joint Fiscal Office)]: And when we first started doing global commitment, it was pretty, there was a lot of flexibility in what could be an investment. And sometimes we were just like, let's make it an investment. And then the Fed started cracking down on us and providing more criteria and more specificity. And then in each continuing waiver, and even in the last waiver, now we can't even just create a new one without their permission. So it has evolved, and the amount of money that we can put into investments had decreased in the last waiver. Was like a step down in how much we can do for investments. What I will say is in that negotiation, AHS was able to negotiate something that had been investments to become actual part of BASE. I think Blueprint was an example, and there might be, I think graduate medical education is another example of something. And I imagine in the future negotiations, some of those investments may become part of BASE. At the same time, we might lose investments altogether.

[Ashley Berliner (Director of Medicaid Policy, Agency of Human Services)]: That's absolutely one of our strategies is to think through the high performing investments and rather than have them as investments, which we know CMS has a lot of concerns with because they don't have much oversight, making them explicit waiver authority. So that gives them, there's a lot more guardrails and precedents around that when you move it into waiver authority versus investment. So that's one of the things we're really looking at as well.

[Rep. Alyssa Black (Chair)]: Did you want to go back to the previous slide that you skipped over?

[Ashley Berliner (Director of Medicaid Policy, Agency of Human Services)]: I think it's just, it's a helpful if you go to the, after that one, Nolan. Yeah, I'm not going to read the slide because I already read it in terms of what the money is for, what money we're getting for the 11/15 waiver. This is just a visual depiction of that And it shows, I just think it's a really helpful reference guide for folks, like what does our waiver give us. The top half where it says allowable without waiver are things that even if our waiver went away today, we would still be able to pay for. The bottom half with waiver only are the things that are at risk or the things that would go away if we didn't have an eleven fifteen waiver. So the administration, how we pay and how we administer, it covers the entire slide, but actually what we get dollars for, it's that bottom half of the slide that we're really going to be looking to defend going into our renewal.

[Rep. Alyssa Black (Chair)]: Any questions? Go ahead, Leslie.

[Rep. Leslie Goldman (Member)]: I'm just thinking about defending the investment, think is the word you use, defend. And what kind of data do you use? How do you do that? What is the defense? Is it Yeah. That's my question. Yeah.

[Rep. Daisy Berbeco (Ranking Member)]: That's

[Ashley Berliner (Director of Medicaid Policy, Agency of Human Services)]: great. Nolan, do you want to take the slides down? I think we're probably good on those. So I oversaw the renewal in 2022, and I actually remember specifically being in this committee and saying we have no data on our investments. And I really did not like being in that position going to CMS where we had no data on our investments and yet we were asking for this really unprecedented thing to continue. So in order to remedy that going in into the next renewal, we established two contracts that we didn't have before. One is with the University of Chicago to provide quantitative and qualitative evaluation of about 40 of our investments that we think warrant that. And the other one is with the University of Massachusetts who subcontracts with the University of Vermont to look at our Medicaid program as a whole and therefore our eleven fifteen program as a whole. So we are just in the early stages of everyone having all the data that they need, all the data sources, the sandbox had to be built, all these tech things that I don't understand. We're in the very early stages of them having that access, and now the evaluation experts in those universities can start to play. And so we anticipate later this year before we have to go submit our renewal application, we'll have clear data, both quantitative and qualitative on whether these investments are working or not. Like do we, do we want to defend them or should we be pivoting and investing that state dollar into something else that's more effective? And then on the waiver side, are things like mental health expansion actually making anyone better off? Is pharmacy assistance for the elderly population making anyone better off? Are premium assistance subsidies helping people maintain coverage? Those are some of the questions that we're looking at more broadly. And I don't have answers for you right now. We started this in 2023 after our last waiver, like getting the RFP out, getting the contracts. And we're just now in a place where they have the tools and the systems and the permissions where they can start playing around and producing documentation and results. So I'm hoping we're much better positioned going into the next negotiation.

[Rep. Alyssa Black (Chair)]: I'm sorry. Can I ask you said that you've identified 40, around 40, I think you said Yes? Of this long list of investments. Okay.

[Ashley Berliner (Director of Medicaid Policy, Agency of Human Services)]: Yes. And some of them we didn't put on the list because we know they're just revenue enhancements. Right? Like, we know that the public health lab has to happen. We don't need an evaluation of the public health lab. So that's an example of why that's not on there.

[Rep. Alyssa Black (Chair)]: Go ahead.

[Rep. Leslie Goldman (Member)]: Well, that's interesting to me because why, if you have to have a public health lab, would it be in a vulnerable, potentially vulnerable position as an investment?

[Ashley Berliner (Director of Medicaid Policy, Agency of Human Services)]: Because Medicaid programs don't pay for public health labs. That's a state function. So in Vermont, we've been able to leverage our waiver because we have this very novel and unique investment authority to pay for things that benefit public health that other states don't have. So

[Rep. Daisy Berbeco (Ranking Member)]: it's about

[Rep. Leslie Goldman (Member)]: the uniqueness of the waiver?

[Ashley Berliner (Director of Medicaid Policy, Agency of Human Services)]: It's about the uniqueness of the waiver and the traditional uses of Medicaid, which the Trump administration has been very clear they wanna get back to.

[Rep. Leslie Goldman (Member)]: Right. And and this analysis that you're about to do, where does it go? Is that something that we end up seeing or it how does that get distributed?

[Ashley Berliner (Director of Medicaid Policy, Agency of Human Services)]: So the analysis on the investments, your committee actually has a a report requirement for us. So we'll be getting that to you as it comes, I believe. I can't remember exactly how we structured the language. We're not getting all the investment evaluation at once. So it's like as it comes, we'll be sharing that with you on the cadence that University of Chicago is providing it. And then the stuff that is more broad waiver evaluation, I would love to share with you when we have it. I don't have a really good sense yet on what exactly that's, like what shape it's gonna take. It's not gonna be a report in the same way the investments are. It's more like producing tables to fit into our waiver renewal application. So I think it would make good sense to come back next session before we start negotiating with CMS as we're getting all We'll have all this together and we can talk through the outcomes then.

[Rep. Alyssa Black (Chair)]: Thanks. Thank you. Thank you, Ashley. And Nolan?

[Nolan Langweil (Joint Fiscal Office)]: I can just add In one last the budget language, the Governor's Code language, there is authorization for AHS to start negotiating for the next wave. So just remind that there is a legislative role of giving them the authority to do that. And then the last thing I will say, and I think I would be remiss if I didn't say it, think Representative Black's favorite line that I like to hear.

[Rep. Alyssa Black (Chair)]: It wasn't in the slides, I looked.

[Nolan Langweil (Joint Fiscal Office)]: I know, do you want to say it?

[Rep. Alyssa Black (Chair)]: If you've seen one state's Medicaid, you've seen one state's Medicaid. Yes, and a joke that just keeps giving.

[Nolan Langweil (Joint Fiscal Office)]: Just keeps giving, and

[Rep. Leslie Goldman (Member)]: the reason is

[Nolan Langweil (Joint Fiscal Office)]: every state that has a waiver, they all look different. We are the, I think, I don't know if Ashley said this enough, we're the only state that does most of our Medicaid program through a lump of teamwork. So I will leave it at that. I couldn't even help say it, sorry.

[Rep. Alyssa Black (Chair)]: Thank you, thank you both very much. Thank

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

[Rep. Daisy Berbeco (Ranking Member)]: that was wonderful.

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

[Rep. Alyssa Black (Chair)]: Alright, let's ring up Mr. Fisher and Emma.

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: Good

[Nolan Langweil (Joint Fiscal Office)]: morning.

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: Mike Fisher, health care advocacy.

[Rep. Daisy Berbeco (Ranking Member)]: And as we

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: get ourselves set up, maybe we'll just start with the recognition that we are here

[Unidentified Committee Member]: to do

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: three presentations wrapped up into one. So that's just a little bit confusing. So we sort of organized it to attempt to do exactly that. We're gonna kinda go through first our comments on DIVA's budget recommendation and then give you an update on MSP Medicare Savings Plan launch. And then finally give our budget request, make our budget request. And here was your answer.

[Rep. Alyssa Black (Chair)]: Yeah, Doctor has a question already.

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: HCA, healthcare advocate. What

[Unidentified Committee Member]: do you mean by that?

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: I'll say more about it in the second half when we get to it, but the governor recommended a level funding for the health care advocate, and we are requesting $450,000 in it.

[Unidentified Committee Member]: So it's over above us.

[Rep. Alyssa Black (Chair)]: Alright. Alright. Oh, beautiful.

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: Let me just click through to I did that slide. So just launching right in. We've also recognized the tremendous challenge that DGA will be in under to adequately support Vermonters through the challenges that HR one presented and see DIVA's request for 12 positions and think it is vitally important if we are going to avoid losing a lot of people on Medicaid that Diva Be Well staff. We work closely with Diva every day on individual cases, on patterns that evolve, on outreach, and making sure that they they and their contractor, Maximus, HAYU, the Health Access Eligibility Unit, are well staffed and prepared to support for mothers.

[Rep. Daisy Berbeco (Ranking Member)]: And so we're going to talk a little bit more about that. We are also going to be speaking to two budget items that we oppose, the proposed increase in prescription drug copays for Medicaid beneficiaries and the family planning rate change not being implementable. So to say a little bit more about this one, so starting with the good things, we definitely support the funding of 12 new positions at Diva. HR1 requirements, as they detailed in their presentation to you last week, major changes in terms of immigration status, eligibility impacts, more frequent redeterminations for the expansion population every six months, which is going to massively increase their paperwork and processing and work requirements

[Rep. Brian Cina (Member)]: for

[Emma (Office of the Health Care Advocate)]: the expansion population. So all of those things are coming at us as a state, whether we want it or not. And we think that this is going to definitely increase the workload for the staff. And we think that Vermonters will suffer if Diva is not fully staffed. Understaffing can lead to longer wait times for processing of applications. It can lead to eligibility errors when you're doing too much at once. You've got too much on your plate. And that ultimately can lead to unnecessary gaps in coverage for folks and even terminations when they should be eligible.

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: And and let me mention, it is not in f y twenty seven, but it's part of this overall effort. Another very significant impact from HR one is the loss of automatic reenrollment for the QHP. That comes in the next year, but it is just part of this overall increase

[Emma (Office of the Health Care Advocate)]: in challenge for Vermonters and need for a highly functioning GP. Yeah, major increase in administrative burden. So we fully support this request of theirs.

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: And and let me just say let me just say exactly the right timing in all of that of of when it'd be good to get from Diva the exact timing of all of that and when that is needed so that people are on board and prepared to do the supports in the right time.

[Rep. Alyssa Black (Chair)]: Absolutely. I just I don't think we asked. So the changes regarding more frequent redeterminations and the work requirements begins in January '26.

[Emma (Office of the Health Care Advocate)]: So January '27. Oh, that's right. We're on '26.

[Rep. Alyssa Black (Chair)]: I know. It's all important. '27. Yes. And the changes to the automatic enrollment for the QHP the exchange, that will be in for plan year '28, which will begin in November '27.

[Emma (Office of the Health Care Advocate)]: Okay, lot coming at us. All right.

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: So no surprise. And I did my sort of required thing. I called up Diva and said, heads up, we're gonna be making this argument. They're aware. Maybe listening. We, of course, oppose increasing co pays. And we note that it was described in the presentation here and elsewhere as a requirement of HR one. Would be curious to hear exactly how that's so. We don't understand that to be accurate. We we yes. HR one requires that there be co pays and Vermont already has co pays of $1 to $3 So a decision to increase the co pays is, I guess it's the next slide. It make sense to us for various reasons, even a four or eight dollar co pay might not sound like a lot, but for the income levels we're talking about, it can be prohibitive. We see it being prohibitive. And then also, I think it

[Unidentified Committee Member]: was noted in committee the

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: other day, or maybe the question was asked the other day. Yes. When we collect money from people for Medicaid programs, we share that revenue from lower income people back with the federal government. It would be

[Emma (Office of the Health Care Advocate)]: So in order to save the state $461,000 the state is giving up or forfeiting $639,000 of federal money and transferring that entire $1,100,000 load onto low income Vermonters. And so that's going to show up for low income Vermonters at the pharmacies. People are going to go to get their prescriptions and not be able to get them. People will ration their drugs. People will skip their drugs. But that's $1,100,000 of costs that's being pushed onto low income providers. And just as some context, I did spend a little bit of time yesterday pulling 138% of the federal poverty level, which is the cap for Medicaid for children and adults. In 2026, that's $1,835 a month. I pulled the HUD, Housing Urban Development, 50 percentile rent for 2026 in Chittenden County. They monitor that for the entire country. One bedroom apartment is $17.69 dollars. So $8.

[Rep. Brian Cina (Member)]: One bedroom, you said?

[Rep. Alyssa Black (Chair)]: One bedroom. What is it?

[Emma (Office of the Health Care Advocate)]: $17.69 dollars That's the 50% percentile. So there's more expensive, and there's less, but probably worse conditions. As we all know, housing is scarce in general. But my point is that people who are on Medicaid for children and adults do not have a lot of money. Just start. Dollars 8 is a lot for one prescription. And if you have a lot of health care needs and multiple prescriptions, many people do, like I do personally, that adds up to a lot of money that you can't afford. And skipped health care is, as we know, always more expensive down the line.

[Rep. Alyssa Black (Chair)]: Can I just and I see Leslie? Were there any other proposals within the governor's recommend that would actually cost Vermonters more and give the federal government money other than this? I

[Emma (Office of the Health Care Advocate)]: mean, yeah, we'll talk about We have some slides on the family planning rate increase, the money we're not pulling down from the federal government. I guess the last thing I wanted to say is just that I reviewed Diva released their 2025 annual report. It's about 100 pages long. They released it last week. I went through it in detail earlier this week. I just want to note that this is against the background that Diva's pharmacy costs are actually decreasing. So they note in the report there's a $4,000,000 decline in their net prescription spending by the state for Medicaid enrollees between fiscal year 'twenty four and fiscal year 'twenty five. You'll also see in the budget line items that the V farm projected savings based on you all expanding the Medicare Savings Program, allowing people to access that 100% federally funded low income subsidy program. They are expecting to save the state $1,800,000 over the course of seven months. So drug spending is going down, and they have made a proposal to increase the costs for medicating all these.

[Rep. Alyssa Black (Chair)]: Leslie? So

[Rep. Leslie Goldman (Member)]: I should probably ask, but I don't recall why they asked for this increase anywhere. I don't know if it's living anywhere, but I didn't see it. I don't recall it. So maybe that's a question we can ask. Yeah, I appreciate you talking about the loss of federal funding. When you just did your presentation, think I need help understanding what the cuts will lose us in federal funding and how to think about that.

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: There's one thing that you would expect consistency from the HCA on, wherever we can, we're looking for as much federal participation at, you know, using the current you know, the rules to draw down federal dollars to help Vermonters help Vermonters access the care they need.

[Rep. Leslie Goldman (Member)]: Yeah, I don't know if

[Rep. Alyssa Black (Chair)]: Are you referring to Diva's testimony specifically on this?

[Rep. Leslie Goldman (Member)]: I think I'm thinking about the whole healthcare budget and all the cuts that they've recommended and how it impacts the loss of federal funding. I mean, is just an example of that, yes.

[Rep. Alyssa Black (Chair)]: Yeah, sure, of course.

[Nolan Langweil (Joint Fiscal Office)]: For the record, the whole thing will address this fund is I'll let the administration justify their thinking. But what I will say is that it's part of their structure on how they were trying to achieve saving reductions. I will also, and I've said this before and I'll say it again, that's the thing about Medicaid, a double edged sword. You're always leaving money on the table, but you also always have to commit money to do it. So it's always a double edged sword. So I don't like to say we're leaving federal money on the table, because we have to buy the state dollar to do it. It's hard to get that double edged sword.

[Rep. Leslie Goldman (Member)]: I just like to understand how much it comes, what the one side of the edge, that's what I'm just wondering. I mean, we have to commit state dollars, but what do we lose in not making that commitment in a larger, and this is maybe not the right time because you're doing a presentation, but

[Rep. Alyssa Black (Chair)]: it just struck me that you brought it up. And

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: our job is to stand up for the low and confirmed vouchers that are common. Understood the dynamic, and this is not a place we would support leaving money on the table or not filling down the center

[Rep. Alyssa Black (Chair)]: left. Yeah.

[Emma (Office of the Health Care Advocate)]: All right. So the second major piece of opposition that HCA has to the DEPA proposed budget is the inaction or or finding that the family planning rate increase that was approved by law in the last session is not implementable. So that was an 85 just to jog folks' memories, that was an $85,000 general fund appropriation leveraged up to capture $765,000 from the federal government for an $850,000 gross investment in family planning. So states have been able to access the ninety-ten match, which is incredible, for family planning services for Medicaid since 1972. That's more than fifty years. I won't say anything more about that. That is when the ninetyten match came into existence. We are learning now that it has not been happening. And the inability to implement this code, we now know coding change, as was described to you last week in testimony, is costing family planning providers in Vermont $765,000 in forgone federal money. And what are family planning services? I think Representative Cina, you might have asked this last week. Just a quick review. Those are general reproductive services, artificial counseling and management, contraceptive services, routine primary preventative services such as APP tests. I believe states define those services within a set of guidelines. So Vermont defines those. And we do have a service list. We do have codes. We do have a family planning Medicaid program with codes. And we are very interested in working with them and learning more about where the barriers are to implementing any further coding tweaks that need to be implemented.

[Rep. Brian Cina (Member)]: Does family planning include any or all of the following: supportive counseling or therapy?

[Emma (Office of the Health Care Advocate)]: I do not want to speak to the long list, but I can send you a copy of it.

[Rep. Brian Cina (Member)]: Adiba's. All right, then I won't ask you all the

[Emma (Office of the Health Care Advocate)]: form. I'll tell

[Rep. Brian Cina (Member)]: you what I'm curious about. I'm curious if abortions are in there and I'm curious if gender affirming care is in there only because those are two things that are under attack. So if you send me the list, I'll look. But if you notice it in the list and you wanna flag it for me, Oh, you asked about this, that would help, but I'll look at it.

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: So we'll look at the list, but I think we can say confidently that abortion care is not covered by Medicaid. Thank you

[Nolan Langweil (Joint Fiscal Office)]: for clarifying that.

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: The state pays for abortion care.

[Nolan Langweil (Joint Fiscal Office)]: Out of our own general fund. Yes.

[Emma (Office of the Health Care Advocate)]: Thank you. Yeah. Planning services are gonna be delivered by primary care doctors, primary care practices, and also Planned Parenthood clinics. But this is money that is going to your primary care providers as well. Many people get their pap tests and screenings for cancer and those types of things. At primary care.

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: A little bit this is a principal thing. Yeah. $765,000 is you know, we shouldn't leave money on the table. We shouldn't let not draw down money that's due to us. But a little bit of it is a principal thing. Medicaid should be able to do this. And if they are lacking the resources, if they are lacking the staff to be able to implement this and things like it, it's incumbent on us to make sure that they are staffed well enough to be able to draw down the federal dollars that are due to us.

[Emma (Office of the Health Care Advocate)]: Absolutely. And this is spending Vermont is paying for this. This is not foregone services. Vermont is paying at a worse rate. So this is worse for the general fund. And that's why it's really important to prioritize situations where you are already paying for those services, the government is offering you a better rate, and you're saying right now, no, sorry, like to pay more. So this is really in the best interest.

[Rep. Brian Cina (Member)]: It sounds like these are not controversial services. I think that's what I was getting at. These are standard medical services that people aren't arguing that people need or don't need.

[Emma (Office of the Health Care Advocate)]: Yeah, family friendly services are required under the data.

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: And to be clear, the federal government is offering us a ninetyten metric.

[Emma (Office of the Health Care Advocate)]: That is how important they are, the best metric possible. So, yeah. Looking at

[Rep. Alyssa Black (Chair)]: the list of codes, there is not one controversial code

[Rep. Brian Cina (Member)]: on there. Oh, you found it that quick. Oh, you're a coder.

[Rep. Alyssa Black (Chair)]: Absolutely.

[Rep. Brian Cina (Member)]: We should speak up. We should find it.

[Nolan Langweil (Joint Fiscal Office)]: Yeah, okay. Okay. Yes. For the record of the language, just want to say that I did receive a memo from Diva on why it's complicated and I recommend that maybe the committee have them in to explain it to you.

[Rep. Alyssa Black (Chair)]: That's just

[Rep. Leslie Goldman (Member)]: to ask that. How do we get around this properly?

[Rep. Brian Cina (Member)]: She's got to come

[Nolan Langweil (Joint Fiscal Office)]: in and explain to you.

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: Thank you, Nolan, for saying that. We will also be very interested in understanding why it's not in

[Rep. Leslie Goldman (Member)]: Yeah.

[Emma (Office of the Health Care Advocate)]: Yes. Engaging with that as well.

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: We sure hope it can be. Yes.

[Emma (Office of the Health Care Advocate)]: And so really, our recommendation is that house health care should ask DIVA why is it not implementable, and what can we do to help you implement it? Do you need more staff? Do you need more money for Gainwell to change their coding? Let's do it. Because, again, the state is paying for these services no matter what, and we're paying at a worse rate right now. Right. There are comments on the legal questions. We're all fired up.

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: We're going to shift gears unless there's any

[Rep. Alyssa Black (Chair)]: questions. Let's move on. MSP. Happier territory.

[Emma (Office of the Health Care Advocate)]: Yeah, so the Medicare Savings Program expansion, it's finally here. Legislators, you passed Act 113 of 2024, Act 27 of 2025. Those were the big budget bills. You also heard about the Medicare Savings Program and smaller bills throughout that time, and they all got rolled into the big budget bills. It's happening. Vermont's Medicare Savings Program was expanded on January 1. There's an estimated 14,000 remotters who will be newly eligible for this program. We are passing around our poster flyer that we've made. We hope that you will help us spread the word, because part of getting the benefit to people is getting them to sign up and learning about the benefits. So just as some background, a quick overview of the Medicare Savings Program. It is a Medicaid funded program that helps people with Medicare lower their costs. And people with Medicare are typically over age 65 or they're under age 65 and they have a recognized Social Security disability. They've been receiving SSDI income for two years, at which point Social Security automatically enrolls you in Medicare, whether you want it or not. And in 2025, so just in December, about a month ago, the Medicare Savings Program was capped. The highest income limit was 135% of the federal poverty level. So on January 1, the income limits increased. There are now two levels of MSP. There's QMB and QY1. QMB is capped at 150% of the federal poverty level, and QY1 is capped at 202% of the federal poverty level. A reminder that QI1, which is the last column that you're seeing all over the right, is 100% federally funded, that benefit for Vermonters.

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: I think we should skim through this. Yeah, maybe just go first. I think just to recognize that QMB does pay for Medicare premiums, and importantly, it pays for deductibles, pays for out. So it is Medicaid like coverage. It's just a few tiny differences, a few differences that actually, in the great scheme of things, seem tiny. It can be very important to some people, but it's very much like Medicare.

[Emma (Office of the Health Care Advocate)]: QA And one is different in that it only pays your Part b premium. So it doesn't help with cross sharing of the doctor. It doesn't bring your cost to the doctor's office down to zero. But it does pay your Part b premium $20.26. That's $202.9 a month. So that's almost $2,500 a year that you get to keep in your Social Security check. That is huge for people who are not living on a lot of money at a fixed income. And both QMB and QI-one automatically deem you eligible for the Low Income Subsidy. The Low Income Subsidy is the 100% federally funded drug benefit program. It lowers your Part D drug premium for Medicare sometimes down to $0. It gives you all kinds of other benefits and it drastically lowers your co pays. In Diva's budget, there's a line item that says V farm savings, 1,800,000.0 for seven months. That is because you have shifted most of your V farm population onto LIS additionally. And so LIS will pay first and the state second. So there are massive savings to the general fund because of that.

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: So Diva automatically moves. So Diva's been hard at work at this, as has the HCA. And Diva automatically moved two groups of people over the last couple of months. The first group was 8,600 people in December who trans who who were on an MSP program, but were newly eligible for chimney. And then more recently, another 3,000 people were moved into of the beef farmer thing is what they did. You there's so much bad news out there. Everywhere we turn, there's bad news that people, you know, there's risks of losing coverage. There's risks of and people are losing coverage. People are losing key supports to be able to afford care. This is the incredible bright spot. We have, in next section of our presentation, we're going to be talking about the advocacy team at the HCA. We have these eight advocates who are on the phone every day talking to Vermonters about the puzzle of trying to get the care they need, and there's a lot of hard conversations. There's a lot of bad news. I'm sorry. These are the rules. And so even just selfishly selfishly for the Vermonters who are newly eligible who get support, but also for the people you know, I just wanna reflect to the people who support them. It It's incredibly good news for the set of homeowners who are eligible and really appreciate that this committee was a leader for that.

[Emma (Office of the Health Care Advocate)]: And it was very well timed with the exit of many Medicare Advantage plans from the state. A lot of those folks cannot afford Medigap supplemental plans. Very expensive, many, many hundreds of dollars a month, you're living on a fixed income. So the MSP expansion was huge, just a bright light for so many people,

[Rep. Alyssa Black (Chair)]: and will continue to be. So 14,000 people. Do we know how much Can you remind us again how much the general fund investment was and what is the estimated cost savings for Vermonters?

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: You're jumping ahead a couple of slides.

[Rep. Leslie Goldman (Member)]: Oh, I am.

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: So we noted we were looking for the actual cost, and we noted in this year's Diva presentation to you that the annualizing of the MSP was 2.8. So doubling that,

[Emma (Office of the Health Care Advocate)]: we think it's the annualized, full annualized would be about 5.7.

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: Yeah. And to your point, it has an incredible return on investment. Just to go through these lines, I'll just say, for $5,700,000 of state general fund dollars to be able to add value to this low income senior and disabled population of $67,800,000 is miraculous. I can't think of another place that draws down such support. The first line, the cost sharing savings, I wanna be honest. We think this is very understated. We think it it is much more, but we have a but it's hard to actually get the number. The Part B premium savings, dollars 34,900,000.0 cash in low income people's pockets.

[Rep. Leslie Goldman (Member)]: Love that.

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: And that number is just a straight up $202.90 per month, multiplied by the population we expect to be in there.

[Rep. Leslie Goldman (Member)]: Is that the 8,600 population? I'm just trying

[Emma (Office of the Health Care Advocate)]: to think about population. Oh, how many people? Does that across, yeah. Yeah, there's 14,000 people. So regardless if you get the QMB or the QI-one benefit, you will get your Part B premium paid for.

[Rep. Leslie Goldman (Member)]: So that's 14,000? Yes. 1.6 is 14,000.

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: And then the last one, the 30,000,000 is a federal calculation of the value of the low income subsidy.

[Emma (Office of the Health Care Advocate)]: Which is the drug benefit.

[Nolan Langweil (Joint Fiscal Office)]: The

[Emma (Office of the Health Care Advocate)]: drug That's 100% federally funded. So it's really amazing.

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: So, I mean, you know, we're we're not making a big push this year. We're not coming to you saying, hey, bring Windham from one fifty to one fifty five, one sixty. I I you probably every time I'm before you, I'm gonna say it would make sense to do so. But I think in fairness to Diva this year and in recognition of the challenges, the budget challenges you guys are under, we are not making that push this year. But this is a place, you know, you want to give free access to primary care. Here's how you do it for a key population. You want to, lower prescription drug costs, here's how you do it for key population. And you draw down a miraculous amount of federal monies to help you do.

[Rep. Alyssa Black (Chair)]: Go ahead.

[Rep. Leslie Goldman (Member)]: Me just ask a question. Is any of this at risk?

[Emma (Office of the Health Care Advocate)]: You're not aware of any risk. Diva is submitting the SPA, which is an amendment to the state Medicaid plan. I don't know if they've already submitted it, but you can only submit it in the quarter that the effort becomes effective. Many other states have already done this and have increased the eligibility limits for higher than us. So that's why you made me feel confident. Really quickly, I'll just say we have been super busy doing trainings. The ACA trained our advocate team, those eight advocates Mike mentioned. We've also done trainings with the SHIP counselors. Those are the Medicare counselors that work with Vermonters for free around the state. The agency, the Area Agency on Aging Consortium, We presented to the Medicaid and Exchange Advisory Committee the other week. My colleague Alicia and I did a major training for Diva Assisters for forty or forty five assisters last week. We trained the Workers Center, which does events around the state at libraries to talk to people about health care programs. We're going to a conference hosted by the Champlain Valley Office of Economic Opportunity, and we'll be presenting on MSP as well. We are really hitting the ground running and trying to get the word out, and we hope you'll help us get the word out.

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: Which if you mean that's you asking you for your help. Yes.

[Emma (Office of the Health Care Advocate)]: If anyone didn't get it, let us know because we can send you all the materials.

[Rep. Alyssa Black (Chair)]: My front porch forum.

[Emma (Office of the Health Care Advocate)]: All right. That's awesome. Yeah. People need to learn about it in order to sign

[Rep. Leslie Goldman (Member)]: up and actually experience the benefit of it. I did too, and someone from outside my area thanked me for putting it That was great. Was able to really reach.

[Emma (Office of the Health Care Advocate)]: Awesome. Yeah, Diva's been a fantastic partner. Along the way, we've been working really closely with them for the past year, gearing up for this big change. And we're continuing to work closely with them on notifications and outreach. Any questions? Yeah? Go ahead. The loan income subsidy, it says here that you automatically qualify. You don't automatically enroll. You do, actually. And maybe that was a poor choice of my heart. So when you apply for the Medicare Savings Program, Vermont and you are found eligible for Vermont's Medicare Savings Program, Vermont sends a data signal to the federal government that you are automatically eligible for low income subsidy. Is that new? I don't know if it's new or not. I do think that there were some rules and requirements around that in the last year or two. But definitely, it is happening. Because it was a couple of years ago that we had to actually Hold people or take them off because they had not applied. Well, so for the B Farm program in the past, if you were under a certain income level, yes, the state of Vermont called you and said you were required to apply for low income subsidy. And if you apply through the federal route, there is a lower income cap and there is a resource test. So one of the reasons that expanding the Medicare Savings Program is particularly amazing is that it functions as sort of a backdoor onto the Low Income Subsidy Program. The Medicare Savings Program does not have a resource test. It just looks at your income. And the income limit is higher. So many other states realized this long before we did, but we are getting caught up. And that's why now there will be incredible savings to the vFaun program because everybody who's on the MSP and vFaun is automatically Thank getting moved on to you. That will pay

[Rep. Alyssa Black (Chair)]: our benefit. We changed it to 150 last year. That's why we do 145 to 150.

[Emma (Office of the Health Care Advocate)]: To align with the low income subsidy. Yes. Yeah. It's wild how it's all moving on the back end. It's mostly good news. A

[Rep. Alyssa Black (Chair)]: list list. A list list.

[Emma (Office of the Health Care Advocate)]: Okay. We're going to move on to our last section of this presentation.

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: To state again, Brittapper. Our base funding for the last number of years has been $2,000,406. That $4.00 $6 I've always wondered about. And we are requesting an additional $450,000 It's just the cost of it is the cost of running this team and continuing to do the services we do. There's just two points I really wanna make for, you know, sort of to justify our request. Vermonters need us now more than ever. The last two years of open enrollment with the loss of Part C have been incredibly hard for the responders, hard for our team too, as they maneuver, manage the system. And during those open enrollment periods, we've been busy, as busy as ever. And what's before us with HR one is, again, this just feels like as, you know, an all hands on deck dynamic where we are going to need to be in the community and supporting community organizations and supporting Vermonters in in new and different ways if we are to avoid losing Vermonters coverage. So and then finally, wow, we've had a good run-in the last couple of years. Our return on investment, our deliverables have been frankly, don't hold us up to this in future years because this is miraculous. But we think it's, you know, that the $2,000,000 that you got, that you paid for the HCA results in $120,000,000 of drawdown savings. And, you know, a key piece of that is what we've been talking about MSP. We've been working on MSP expansion for

[Rep. Daisy Berbeco (Ranking Member)]: Several years now.

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: Several years now, developing the case for it and bringing it to and and doing community organizing, doing press work, building a coalition, and really appreciate your partnership on that on that and something we've worked on for maybe four years. And then also significantly the silver loading, represented Berbeco's favorite term, silver alignment. I should say this is the second year where we've been able to organize our marketplace in such a way to draw them an additional $53,000,000 for Vermonters who get premium tax credits. And again, the ACA recognized this a number of years ago and advocated for it. This advocacy was not before the legislature, it was before the Green Mountain Care Board. Effectively, ultimately, we were ignored for a couple years. The board went a half step that we told them wouldn't work and didn't work for a year. And it's now been in place for '25 and now '26. I don't feel confident that that will continue going forward. Just a heads up, NBPP, the notice of benefits and payment parameters rule that just came out, I think may put this at risk for next year. And I think that Diva and others are trying to understand exactly exactly what the new role will be. But for this year, it delivered an incredible amount for Vermonters. And then finally, you know, it's only $3,000,000, which is a small number compared to the other ones, but maybe I'm underselling it. The $3,000,000, the savings that we give and we get, that the helpline gives individual promoters who call us asking for help is maybe as important as any of the other numbers. You know, sometimes it's $10 that someone's saying, I don't know how I'm being charged this and and and I need your help. And the advocate figures out a way or under you know, determines that something wasn't followed, done right, and saves the person some even just a few dollars, or sometimes a lot of money, in bills that they shouldn't be receiving.

[Rep. Daisy Berbeco (Ranking Member)]: Yeah, and I'll say, I think we like the advocates. I've worked as an advocate for many years, I still take some cases. Advocates do not enter a dollar saved amount unless it's absolutely clear. So if you tell somebody that they're going to qualify for the MSP and you're pretty sure they're going to qualify, you probably won't write down the amount unless you know unless they call you back and they're like, I did qualify. So it's vastly undercounted. And advocates also provide a lot of support that has infinite value but doesn't have a monetary value, like helping somebody navigate a Medicaid transportation appeal that allows them to access substance use treatment where they didn't have no way to get to it. There's no dollar figure for that. But it's life saving or altering. So

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: we submitted this report to you. And it's on your web page. And if you have more questions or want to read more details about the types of cases and hear comments from people who received our help, that's available to you. But I also wanted to just, you hear me say this every time, but I'm gonna spend this a minute longer on it today. You see me every day. Probably like, oh my God, he's here again. When we're talking about Medicaid programs, I bring Emma with me. When you have prescription drug questions in front of you, you get Charlie from our team. You see Sam a lot lately on the corporate practice of medicine bill, but his real expertise is the hospital budget process. When you see that we're in the community doing a presentation or when you get a communication that has a nice graphic on it, that's Alicia's work.

[Rep. Daisy Berbeco (Ranking Member)]: I have a poster. Alicia.

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: And then you have, when you call us and say, I have a constituent who needs some help, there's eight advocates there who are supervised by an attorney and have left one person out, and that is when you ask us a numbers question and we have to dig into exactly why something is working the way it does. Eric is our person we turn to. So you see me often, and I only do as good a job as I'm able to do because I have such a strong team.

[Rep. Alyssa Black (Chair)]: I'll try to get for you a dollar figure on the emotional belief that I personally receive every constituent email that I then am able to forward to you to help constituents. You're priceless. Thank you. You. Let's take a break until 11:30 and it can go off at five.