Vermont Legislature SmartTranscripts:

[Rep. Alyssa Black (Chair)]: Welcome, it is Wednesday. I was trying to figure out what day or it's Wednesday. Oh, Thursday? Thursday! February 19. I'll take Wednesday, I'll take it. It's the extra day. First, apologize for the tardiness, and if you recall, it was a week or so ago, somewhere along those lines, that we some great testimony on insurance coverage for prosthetic and orthotic devices, of which the committee really wanted to hear more. So first, we have in Led Council because we've never done a walkthrough of a bill that's been on our wall. And so we're going have a walkthrough of that. And then we have some testimony from Blue Cross.

[Jennifer Carbee, Office of Legislative Counsel]: Great. Thank you. Good afternoon, Jen Carvey from the Office of Legislative Council. The bill up here. This is H432. This is an act relating to health insurance coverage for prosthetic and orthotic devices. One thing I will flag from the beginning is that this bill was introduced in 2025. So some of the dates, if you move forward with this, would need to be pushed out a year. So this bill amends an existing provision in Title VIII in the health insurance chapter on what is currently called, I believe, prosthetic parity, although this may also need to be updated. I think that all of the numbering has changed and maybe some of the language as I look at it since we did S30 last year that we wrote. So a lot of changes need to be made. But this is coverage for prosthetic and orthotic devices and starts out with some definition language. It amends the definition of prosthetic device to add orthotic devices, so prosthetic and orthotic devices. And the current definition is an artificial limb device to replace and whole or impart the arm or a leg. Just would change that to say it means leg, arm, back, and neck braces and artificial legs, arms, and eyes, whether standard or custom made. So this is expanding the scope of what we're talking about when we're talking about prosthetic devices and adding in orthotic devices. Would require under existing law, health insurance plans must cover provide coverage for prosthetic devices in all plans, at least equivalent to that provided by the federal Medicare program. This expands on that a bit by adding again orthotics and specifying some particular sections of federal Medicare statutes and regulations. You find a typo in one of these when I was going through and sort of reviewing what they are, but these are pretty comprehensive Medicare coverage and payment provisions around prosthetics and orthotics. And then it specifies that coverage shall be provided for a number of things. So under current law, coverage may be limited to the prosthetic device that is the most appropriate model that is medically necessary to meet the patient's medical needs. This would change that to say coverage shall be provided for all of the following. First, a prosthetic and then adding or orthotic device that is determined by the covered individual's treating healthcare provider, that part's not necessarily different, to be the most appropriate model of that and then the standard changes from medically necessary to meet the patient's medical needs to adequately meets the covered individual's medical needs. And then it adds a new covered requirement for a prosthetic or orthotic device determined by a covered individual's treating healthcare provider to be the most appropriate model that meets the covered individual's medical needs for purposes of performing physical activities, such as running, biking, swimming, and strength training as applicable, and maximizes the covered individual's full body health and the functions of their lower or upper limbs or both. Also requires coverage for a prosthetic or orthotic device determined by the treating healthcare provider to be the most appropriate model that meets the covered individual's medical needs for purposes of showering or bathing. Specifically requires that all materials and components necessary for the individual's use of the prosthesis and orthoses described in subdivisions one through three. Instruction on using the device or devices, materials, and components described in subdivisions one through four, and the medically necessary repair or replacement of a prosthetic or medical orthotic device material or component, and more detail to come. Directs health insurance plans to consider coverage for prosthetic and orthotic devices to be habilitative or rehabilitative benefits for purposes of federal and state requirements around coverage of essential health benefits. It says for purposes of the coverage around the activity specific and the bathing and showering prosthetic or orthotic devices, a health plan may require the covered individual's treating provider to determine that the additional prosthetic or orthotic device is necessary to enable the person to engage in physical activities. And then it gives examples such as running, biking, swimming, strength training, showering, and bathing as applicable and to maximize their whole body health and the functions of their lower or upper limbs or both. It requires health plans to make their utilization review determinations in a non discriminatory manner and cannot deny coverage for a prosthetic or orthotic device solely on the basis of a covered individual's actual or perceived disability. It also prohibits a health insurance plan from denying coverage for a prosthetic or orthotic device for a physical activity for a covered individual with limb loss or absence if the plan would provide coverage for an individual without a disability who was seeking a medical or surgical intervention to restore or maintain their ability to perform the same physical activity. And it requires health insurance plans to include language describing those rights under Subdivisions three and four in the plan's evidence of coverage and any benefit denial letters. Some changes are just a little bit sort of cleaning up or updating language. So any dispute between, and we're just changing from the terms insured and carrier to covered individual and health insurance plan. So any dispute would continue to be subject to independent external review. This keeps the language that allows a health insurance plan to require prior authorization for prosthetic devices in the same manner extent as prior authorizations required for any other covered benefit, just clarifying under the Plan. Section E requires the Plan to ensure access to medically necessary clinical care and prosthetic and orthotic devices and technology from not fewer than two different prosthetic and orthotic providers who are located in this state and are in the plan's network. And then it talks about what to do if those providers are not available. So in the event that medically necessary covered prosthetic and orthotic devices are not available from an in network provider in this state, then the plan has to provide processes for referring someone to an out of network provider, fully reimbursing the out of network provider at a mutually agreed upon rate, less the covered individual's inpatient in network cost sharing. There is existing language requiring plans to provide coverage for what under current law is medically necessary repair or replacement. This changes that to coverage for replacement of a prosthetic or orthotic device or replacement of any part of it without regard to continuous use or useful lifetime restrictions. If the covered individual's treating healthcare provider determines that the provision of a replacement device or part is necessary because of, and there's a list, a change in the individual's physiological condition, an irreparable change in the condition of the device or part of the device, or the condition of the device or part of it requires repairs and the cost would equal more than 60% of the cost of a replacement device or the part being replaced. It also allows a plan to require confirmation from the treating healthcare provider if the prosthetic or orthotic device or part being replaced is less than three years old. The last two are just updating some language. So the first keeps language saying that the health insurance plan cannot impose any annual or lifetime maximum on coverage. It expands that to prosthetic and orthotic devices for this less than what applies to all terms and services under the plan. Some of this language may not even exist in our current statute because of change federal changes. And then the change in what is now subsection F or becomes subsection F is just changing a may not to a shall not. It doesn't have a substantive difference. I just think it's clearer to say shall not otherwise. Sounds like may or may not. Section two directs a report on insurance claims for prosthetic and orthotic devices. So again, remembering that this was in the 2025 bill. So from last year's bill, it says on or before 07/01/2029, each health insurer that is subject to an annual reporting requirement under a different statute, which is really sort of the bigger insurers, insurers with at least 2,000 covered lives in the state for major medical health insurance or issue plans in the Exchange, I would also report to the Department of Financial Regulation regarding the insurer's experience with this expanded coverage for prosthetic and orthotic devices for plan years, and this had for plan years 2026, 2027 and '28. So you'd want to move those out if you were going forward with bill. The report would be in a form as required by the Commissioner of Financial Regulation and include the number of claims for the goods and services required by the statute in each of the plan years and the total amount of claims paid in the state for those goods and services in each of those plan years. So basically, what did this end up costing? And then by 12/01/2029, the Commissioner of DFR would provide a report with aggregated data for all health insurers by plan year to committees of jurisdiction, including this committee. Section three is the effective date. So again, from last year's bill would take would have taken effect on January 1 and rolled out over the course of the year as on on the date that an insurer offers issues with use of health insurance plan, but in no event later than one year after. And the remaining sections will take effect on passage. And I do always have to flag when we talk about a health insurance benefit mandate that to the extent these are services not currently covered by plans in the exchange, there is the potential for a state cost with the state having to defray any additional premium attributable to this benefit in the qualified health plans. That is the federal requirement. And I don't know if those should be seen as the expansion of an existing mandate or a new mandate.

[Rep. Alyssa Black (Chair)]: Can you say that again? Good. Sorry. It's been

[Rep. Allen “Penny” Demar (Member)]: a long time

[Rep. Alyssa Black (Chair)]: since we've done something like this.

[Jennifer Carbee, Office of Legislative Counsel]: Yes, we have not. Forgot mandates. So there's a what's called a state defraile requirement. And under the Affordable Care Act for any new health insurance benefit mandate that added, that a state adds after 2012, which is something's kind of got frozen in place, the state is required, the state is on the hook to pay any additional premium amounts for qualified health plans that are attributable to that new benefit mandate. So if it costs x amount to add a benefit to a plan, then the state would be on the hook to pick up that amount for individuals, any person covered under the plan, if it is deemed to be a new benefit mandate.

[Rep. Leslie Goldman (Member)]: State pay additional premiums by creating a new mandate.

[Jennifer Carbee, Office of Legislative Counsel]: Is that right? Yes. Yeah. That's attributable to the new mandate. It's state defraile. You can look it up or we can talk more about it or have Annie in to talk about defraile.

[Rep. Alyssa Black (Chair)]: So we're I see And

[Jennifer Carbee, Office of Legislative Counsel]: if there's curiosity about what the cost would be, that is an actuarial question that is not Maybe your insurers can do it, but it's not for me and it's not for JAPO.

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

[Rep. Alyssa Black (Chair)]: want be clear

[Jennifer Carbee, Office of Legislative Counsel]: that Nolan has said any wonderful things, he's not an actuary.

[Rep. Alyssa Black (Chair)]: I'm wondering because it's existing that it's covered. It's covered that they have to cover a device that's medically necessary. So even the fact that we would essentially be changing devices that treat the whole

[Jennifer Carbee, Office of Legislative Counsel]: I am flagging for you the fact that this may be an issue. I cannot give you a definitive answer on whether this triggers state to frail. We haven't talked about a mandate in a long time and people just need to be aware that there is that additional element. Allen?

[Rep. Allen “Penny” Demar (Member)]: Well, that's what people with insurance, if they don't, state to come to differ. What about no insurance?

[Jennifer Carbee, Office of Legislative Counsel]: This doesn't apply. If you have no insurance, you still have to pay out of pocket for whatever sort So service you're

[Rep. Allen “Penny” Demar (Member)]: basically, you're saying this bill is only with people with insurance? Yes, provision. So Medicaid would be not involved in any manner of paying?

[Jennifer Carbee, Office of Legislative Counsel]: So Medicaid is a separate program. It is not affected by this statute, but you can hear from Medicaid about their coverage of prosthetic and orthotic devices if there's interest in that. That is great because it leads me in my next question, if you can expound on that a

[Rep. Alyssa Black (Chair)]: little bit. So we're not affecting Medicaid in this. That's right. We're not telling Medicaid that they have

[Jennifer Carbee, Office of Legislative Counsel]: to cover all of this. So I should be clear. This definition uses the definition that was in the statute, which did include Medicaid. Under the way we have kind of decoupled things in the existing, in the new statute, I'd have to look to see whether Medicaid is pulled in here or not. Typically, the state has decided whether Medicaid is in or out for a particular coverage requirement. So, yes, this lang as written, this language does, stand corrected, include Medicaid in the definition of health insurance plan. We tried to be a little bit clearer going forward about not rolling Medicaid into the definition of health insurance plan because they're regulated and governed differently.

[Rep. Allen “Penny” Demar (Member)]: Wouldn't there be some liability there if you did one and not the other two?

[Jennifer Carbee, Office of Legislative Counsel]: I don't believe so. I mean, there are different programs. We have different benefits in Medicaid and in what's required in preventive insurance.

[Rep. Alyssa Black (Chair)]: Leslie? This may not be

[Rep. Leslie Goldman (Member)]: for you, but I don't know

[Jennifer Carbee, Office of Legislative Counsel]: if there's a definition of whole body health. What does that mean? That's a great question. Believe in some model language. Maybe others who can speak to that.

[Rep. Leslie Goldman (Member)]: In previous testimony, we had talked about people walking on the beach and showering. But showering was included, but not the beach. I'm just thinking about our previous testimony, did that qualify for a second prosthetic? But I'll ask someone else. Can you also help me understand the difference or what it means to

[Jennifer Carbee, Office of Legislative Counsel]: be rehabilitative or rehabilitative? These are terms from the Affordable Care Act. And I don't know if DFR can speak to that or if you need me to look it Great. I might have look it up. So if I could easily give you an answer from something that I And it could be later. Seems. Well, alright. Here we go. Here's something from New York State. So let's see what they find. All right. So rehabilitation services. This is from something that they adapted from a federal regulation and the National Association of Insurance Commissioners' glossary of health insurance and medical terms. Rehabilitation services. Rehabilitation refers to healthcare services that help a person keep, restore or improve skills and functioning for daily living and skills related to communication that have been lost or impaired because a person was sick, injured or disabled. These services include physical therapy, occupational therapy, speech language pathology and psychiatric rehabilitation services in a variety of inpatient and or outpatient settings. Rehabilitation services refer to healthcare services that help a person acquire, keep or improve partially or fully and at different points in life, skills related to communication and activities of daily living. They address the competencies and abilities needed for optimal functioning and interaction with their environments. Examples include therapy for a child who isn't walking or talking at the expected age. Adults, particularly those with intellectual disabilities or disorders such as cerebral palsy, can also benefit from rehabilitative services. They include physical therapy, occupational therapy, speech language pathology, audiology, and other services for people with disabilities in a variety of inpatient and or outpatient settings. I'm not sure how helpful that is, but some of those No, I could see the discussion totally.

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

[Jennifer Carbee, Office of Legislative Counsel]: I believe both Habilitative and Rehabilitative Services were in the list of 10 essential health benefit categories that were in the Affordable Care Act. That's where they sort

[Rep. Alyssa Black (Chair)]: of came into the more common parts, habilitative. It's really a question about language, but I'm not sure you would be the best person to explain that.

[Jennifer Carbee, Office of Legislative Counsel]: I think it out there and then others

[Rep. Alyssa Black (Chair)]: can But put it I do know that we have someone on Zoom with us that had been in here before. I'm wondering what the difference between prosthetic and orthotic is terms of

[Jennifer Carbee, Office of Legislative Counsel]: We'll have to jump on that, but I can look into it. If there is not someone who can get you that answer, I can get you that answer, but I can't. We're adding essentially it was prosthetic and we're adding in orthotics to all of this language. Yes, and expanding the definition you know, of what constitutes prosthetic and orthotic devices beyond just arm and leg. Yes.

[Rep. Alyssa Black (Chair)]: And I'm wondering I'm

[David Heiler, So Everybody Can Move]: happy to answer a little bit if if you want just to to touch on it. I mean, essentially, the difference between a this is David Heiler from the So Everybody Can Move initiative. And David. It is the the difference is basically, a prosthetic is is to, provide a a limb where there is none. An orthotic is something that can help you if if your limb is is severely damaged or disabled.

[Rep. Alyssa Black (Chair)]: Okay. And just to be clear, a prosthetic and a limb is we're basically just talking arms and legs, or are we talking about, like, toes, fingers, and Would

[Jennifer Carbee, Office of Legislative Counsel]: that be considered a limb?

[David Heiler, So Everybody Can Move]: Anything that replaces a missing part would be considered a prosthetic, and anything that sort of, helps to enhance a damaged or injured part would be an orthotic. I mean, people use orthotics on their on their knees to brace their knees. That would be considered an orthotic.

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

[Rep. Allen “Penny” Demar (Member)]: How does that how do you explain with the eyes? Let's give me some scenarios where that would be under this plan.

[David Heiler, So Everybody Can Move]: Are you asking me or is that Whoever. Directed to

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

[David Heiler, So Everybody Can Move]: That's a great question. I'm assuming that if you needed an eye replaced, that would be considered a prosthetic eye, know, so that that would be considered a prosthetic. And, again, you know, I would imagine that in your insurance coverage, that would be, already something that would be covered. I don't know. Can you hear me? Yep. Any additional eye eye parts that would be needed and required, but that would be considered a prosthetic as well.

[Rep. Alyssa Black (Chair)]: Question? No. Oh, sorry. I thought you had a question. Yeah, Wendy. It kind

[Rep. Wendy Critchlow (Member)]: of changes the flavor of the whole thing. Initially, I was like, the prosthetic device was for a replacement of one that was already, that they already had, like an enhanced one. Orthotic, I would assume would be the same thing if somebody has a false eye, which we probably can cover it under insurance for the first time around. They're looking for a second one? I mean, guess I just don't understand what the, how the orthotics fits into this bill. Yeah, I

[Rep. Alyssa Black (Chair)]: think I'm a little confused. I think that's why I there examples of orthotics that you would need different orthotics for different activities?

[David Heiler, So Everybody Can Move]: So my associate from the National Organization has just joined Kyle, if it's all right with you guys, I'm gonna have him I'm gonna defer to him on that one.

[Rep. Alyssa Black (Chair)]: Yeah. I'm gonna let legislative council go. We'll ask you this one last question and then we'll go to Blue Cross Blue Shield and then we'll come back to you probably with more questions. Hi, Kyle. Thanks for joining us.

[Kyle Stepp, So Everybody Can Move (National advocate)]: Hi, representatives. Hi, members of the committee. To give you some examples, so an orthosis is a device that's needed to stabilize a part of the body that is often has a mobility impairment. So you see so the bill is required for custom orthosis. I think there's often a confusion of an orthosis where it's your off the shelf, like, shoe insert. These are very customized devices that brace the feet for them to allow for the mobility. So what happens is a lot of times the daily orthosis is in a stagnant position and for them to be physically active, it's customized to the patient. So the clinician actually fabricates it and designs it for that patient to either cycle for them to run. They often have special hinges, but they're all custom made by the certified orthotist that is trained, that has a master's level degree. So these aren't your off the shelf devices. And so that's where you see the utilization rate is a lot lower because the physician needs to prescribe it. And then the clinician then needs to determine the exact style that device for them to achieve the health goal and the physical activity intended. So you often see these customized for cycling, you see them for running, or you see them possibly for strength training. But if the participant is doing all three of those activities, that orthosis can often do all three of those. So they'll only need that additional orthotic for physical activity.

[Rep. Alyssa Black (Chair)]: Thank you. That's helpful. Allen, well, wait a minute. Let's go to Blue Cross and then we'll keep them here and we'll ask questions.

[Rep. Allen “Penny” Demar (Member)]: Well, this might help with Blue Cross Blue Shield with this So say a teen missing a limb and at this time he wants to swim, so he gets his insurance to pay for a waterproof prosthetic limb and then decides in six months he's grown out of that, so he can apply for another one to replace that. Then I'll be a devil's advocate here. And then all of sudden he decides I want to be a jogger and that's a different limb of some sort. So is the insurance company going be required to purchase all these? To have these guys, because it says for each individual to have a whole body health. How many possibilities is there going to be here?

[Rep. Alyssa Black (Chair)]: I think those are great questions. I'm going to ask that we hold that because that's a great question. We'll make sure that we take additional If we decide to move forward with this, I really wanted to get Blue Cross in because we were all sort of And I'm thinking, how much is this? So Courtney, if you want to come up. And thank you so much, Kyle and David, for being here. I hope you stick around because I think we're going to have some more questions.

[Courtney Harness, Blue Cross and Blue Shield of Vermont]: Hi, thanks for having us. For the record, Courtney Harness, Blue Cross and Blue Shield of Vermont. I'll start by saying we actually spoke with David and Kyle last week for about an hour, mostly so we could understand more about the bill, the proposed legislation, and their goal and vision. It was really nice to be informed by people that frankly live this every day. Kyle and I have some mutual friends in the Paralympic space, which is unexpected. But all that to say, there's a lot of stuff in this bill that frankly we want to support. And we were pretty open with David and Kyle last week in saying this particular session represents some pretty specific financial challenges. And I'm happy that Jen invoked the issue with the essential health benefit mandate, so I didn't have to, honestly. But I think as we went through discussion and first, there's three parts of the bill that we've talked about or that Jen walked us through. The first one was what's medically necessary that everyone gets. And so that's what we do anyway for anyone that files a claim. The second one around physical activity, I think, was specific to Rep. Demar's question around who gets what and how often and how many. And then the last piece was showering and bathing. And David gave us some really helpful sight line into his own experience. And without a waterproof prosthetic, what might happen if you decide for example, if it's a leg, what might happen if you decide you want to go in a shower and try to balance? Given our current cost of care in the system, it's actually more expensive just for an ambulance ride than it would be for us to pay for the prosthetic. And so I think that's important for the committee to know. On the third component around showering and bathing, we actually see that as a preventative component of this bill that more than likely speculation, more than likely has the opportunity to save money over time. As to the second part around physical activity, I think we fundamentally agree with everything in the bill from the perspective of every person, every Vermonter that we cover or not, should have the opportunity to participate in whatever physical activity they want, however they want to do it. We actually don't have the data as far as how many members of ours would qualify and then want any of these items. And so what I'll do today is give you all a range of how much some of the prosthetics cost so that you have sight lining to the potential costs, either to Blue Cross or to the state in this case.

[Rep. Alyssa Black (Chair)]: I know you don't have It would be nearly impossible to come up with the numbers of how many people who would want to take advantage, how many orthotics or how many prosthetics or orthotics they would want. But do you have a figure right now of just how many members you have currently that have a prosthetic? I can

[Courtney Harness, Blue Cross and Blue Shield of Vermont]: tell you the number of claims over the last seven years. So it's two twenty three total claims in the last seven years, and that covers full prosthetic devices and repairs. So that's what we have processed and approved. In those seven years, there's only been three that we've denied.

[Rep. Alyssa Black (Chair)]: Two twenty three. Two twenty three, but those are not necessarily individual members. They're both repair and Total claims.

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

[Rep. Alyssa Black (Chair)]: Two twenty three over two twenty three, seven years. Seven years. So

[Courtney Harness, Blue Cross and Blue Shield of Vermont]: now I'll try to dig in on that to say none of those are for physical activity beyond what's medically necessary. So that's two twenty three what I would consider to be in the first of the three components of this proposed legislation. So folks looking to get a device for everyday medical necessity. That said and I would love if David and Kyle and their team could get some more data for Vermonters around who might be eligible, how many people would take advantage. That might give us more sight line ended total cost. But for the devices that we have and codes that we have for devices, they range and again, I'm just talking for the physical activity they range anywhere from about $40,000 to $110,000 So I think Debra has already done a good job of playing devil's advocate. But when we get up into that price range and I just want to be really open and honest with the committee.

[Rep. Francis “Topper” McFaun (Vice Chair)]: We would

[Courtney Harness, Blue Cross and Blue Shield of Vermont]: love to give everyone 10 of these. The reality of it is when we get into the 100 to 6 figure range, potentially multiple per person, without knowing the magnitude, we end up in a position to think about premium increases. We are really, really trying with every ounce of our existence to not do that. And it's not a particularly fun place to sit in today to say, Hey, it just might be really expensive this year. We did share that with David and Kyle and say, this happens to be a

[Rep. Alyssa Black (Chair)]: not typical financial I will say that this committee is also committed, has been committed I doing see Brian has a question and topper, but can I ask you really quickly? How much would you said that you see the waterproof before a shower or bathing? How much would those be? Because If you saw

[Courtney Harness, Blue Cross and Blue Shield of Vermont]: I remember correctly, so I'm going back, and so don't use this as a quote, but more of a guide. I think there was around 20 claims on that particular piece, and I think the average of all of them was about 15,000. So that's over seven years, and that was the average. And again, those are ballparks. I think, depending on the person, it could be less or more in their medical needs and the processing. But I think that's a good average.

[Rep. Leslie Goldman (Member)]: Heatproof device.

[Courtney Harness, Blue Cross and Blue Shield of Vermont]: Yeah, I think Chair Black was asking specifically on the showering and bathing.

[Rep. Leslie Goldman (Member)]: Was 15,000 per device,

[Rep. Alyssa Black (Chair)]: waterproof device. This is really I have Brian and then Tucker and then Karen.

[Rep. Brian Cina (Member)]: Yeah. I'm wondering how hard it would be to get a range of options to look at because maybe we can't do everything at once, but maybe we take a step forward. For example, I'm just throwing this out as an example, I'm not saying this is what I would do yet, but everyone can have two, one regular and one and one special. And then we see how that goes, so that if someone can, even though it's not ideal, someone could say, I'm gonna choose the one that I can go in the water with so I can take a shower or go in the river or what have you. Or someone else might say, I'm fine taking showers without my prosthesis or my orthotic device, so I'm gonna get this running one. But just if there was a way to kind of estimate giving someone their basic model and their, like, special one or whatever you want to call it, their extra, you know, the advanced, you know, the specialized, maybe that's Your basic and your specialized tool or, I don't know, I'm just wondering if there's a way to get a closer estimate. Because if we were talking about everyone's premium going up 2¢, someone who testified said 5¢, I don't know who said that.

[Courtney Harness, Blue Cross and Blue Shield of Vermont]: Yeah, I think that was wrong. Yeah, I would say we would leave that language up to the committee in terms of what you want to decide. I would say on a state specific basis, and again, this is up to you all, we've had a lot of conversation about this internally. I don't say it lightly when I say this is really something that we feel compelled to try our best at. The Kelly Brush Foundation, I think, in my opinion, would be a great organization to have come in to talk about Vermont as a whole in terms of what some of those numbers might be. It's work that they do every day across a lot of these different areas. From the perspective of maybe only doing one, that I wouldn't have a recommendation.

[Rep. Brian Cina (Member)]: Yeah. I guess what I was getting at is not recommendation, but the Like, if we knew that it's giving everyone access to one, even if they every single person who could possibly be in the Blue Cross Blue Shield system got a 6 figure one as their one, that the cost per person was a cent per person, that's something I would support. I'd like, if everyone's paying 1p more, so that 30 people can have this thing, maybe it's worth it. But without any numbers, it's hard to know. Whereas if you were like, their premiums are gonna go up 25 percent if you do this, that's significant.

[Courtney Harness, Blue Cross and Blue Shield of Vermont]: What I can commit to is trying to get that number. And just for us, right? So of the 200,000 ish Vermonters that we cover, how many or what percent? And again, it's a little tricky in terms of what we're allowed to share and not. But I can try to

[Rep. Brian Cina (Member)]: get you. For example, even if it was like, we estimate that 100 to 300 of our members would be eligible for this service, the minimum it would cost and maximum for an additional thing would be 10,000 to 700,000. And then we can look at that and we can calculate, oh, if we give everyone the 700,000 one out of the 30 people, it's gonna cost this much or that much. And then if you can't translate it into a premium, I think that's okay. But I think it would give us some scale or some idea of the magnitude of the expense, that would just be helpful.

[Rep. Alyssa Black (Chair)]: We can,

[Courtney Harness, Blue Cross and Blue Shield of Vermont]: yeah, we could do that.

[Rep. Francis “Topper” McFaun (Vice Chair)]: My question was a simple one. The orthotics that feeling you're

[Rep. Alyssa Black (Chair)]: getting at 23,

[Rep. Francis “Topper” McFaun (Vice Chair)]: they're not in there, they? So it's just prosthetic.

[Rep. Karen Lueders (Member)]: Karen? Yeah, my follow-up was simple too. If you had the one that was waterproof shower worthy, is that also like ocean swimming worthy? Is that a similar

[Courtney Harness, Blue Cross and Blue Shield of Vermont]: That's probably a better question for David and Kyle. Wouldn't be able to answer that.

[Rep. Karen Lueders (Member)]: And so just to follow-up, if there's two twenty three claimants over seven years, that's about 32 people a year. So even assuming 32 people a year would choose to have a second one, I don't know if there's a way to run that.

[Courtney Harness, Blue Cross and Blue Shield of Vermont]: Well, I think part of and again, I don't want to talk my way into saying

[Rep. Alyssa Black (Chair)]: But we

[Courtney Harness, Blue Cross and Blue Shield of Vermont]: did have this conversation with David and Kyle, and so I'm going to mention it because I think what they said to us was really important. It's not like we don't anticipate that this would create a tidal wave of claims where it would go from 30 to 300. We don't anticipate that. And frankly and this came from David and Kyle access to an appointment and the length of time that it takes to go through this process would just by default limit it. So, I'll say that. But as far as the specifics, what it limits it to, I wouldn't be able to tell you.

[Rep. Alyssa Black (Chair)]: We have Allen.

[Rep. Allen “Penny” Demar (Member)]: I might be wrong, but when we first talked about this, I think I remembered a figure of like 3,000 people.

[Rep. Alyssa Black (Chair)]: I think that was the estimate of people in Vermont who are missing A limb. I don't think it was missing a limb, I think it was an amputation. It could be fender.

[Courtney Harness, Blue Cross and Blue Shield of Vermont]: I think the total is nine thousand. So, the total that I remember from conversation with So Everybody Can Move is 9,000 Vermonters. And I'll again say that doesn't mean 9,000 Vermonters are all going to qualify for any of the specific pieces of the legislation. So when I say it's hard for us to give an estimate, because all we have is historic claims at it, it's hard for us to really say, here's what we might

[Rep. Allen “Penny” Demar (Member)]: see. And I guess my other concern is, too, we're talking about MVP and Blue Cross. I think the other thing is we've mentioned here a minute ago that we might have to kick in some of the premiums for this. And the other thing is I want to make sure how Medicaid is involved in this because that is kind of an insurance plan. That would concern me.

[Rep. Alyssa Black (Chair)]: We would absolutely have Medicaid in to discuss the issues around having coverage for Medicaid, because I think there are special concerns with them in regards to federal and CMS.

[Rep. Leslie Goldman (Member)]: Leslie, very quick, I just didn't hear you. Did you say it was between 40,000 and 200 and 10,000 or $201,110,000.

[Rep. Brian Cina (Member)]: Okay, thank you. Wendy?

[Rep. Wendy Critchlow (Member)]: I would assume that if somebody is going to ask for a second one, that they're going to have to come up with a reason. You're not going to give a running limb to somebody who is never going to run. So it would have to be some sort of letter to the insurance company.

[Courtney Harness, Blue Cross and Blue Shield of Vermont]: Well, this is my understanding, again, from talking with David and Kyle. You're exactly right. So you take that $9,000 and then you back into if this legislation moves forward, essentially, we don't have the ability to deny any of the claims. And again, this is my understanding of the process. If I am looking for a running blade, I go to a clinician and they say, Well, you actually wouldn't be able to run even if you got a running blade, so we're not going to recommend it. That happens. The other thing that happens is they go, Yeah, absolutely. Here you go. And so to Kyle's point and this was a really good piece of the conversation that we had with them the level of training that the clinicians are at brings them to be the folks that say, Courtney is going to be able to run or not. And if not, then we're not going to recommend that you go through the process. And that goes with all of the activities skiing, swimming, biking, whatever it may be. And so as I read it with this bill, we would be taken out of that equation, which for the daily device we are anyway. So I think to leave that in a clinician's hand from my perspective, is perfectly acceptable.

[Rep. Wendy Critchlow (Member)]: And I have a second question on this, as far as limitations. I don't see where we've included any kind of limitations as to if you get a second one, that you can get a third one and a fourth one. I don't see any we need to have.

[Rep. Alyssa Black (Chair)]: Allen, I think you had a question, and I do want to acknowledge that Kyle, who's with us on Zoom, wanted to weigh in on something. And then if Courtney doesn't mind. This is just a quick one.

[Rep. Allen “Penny” Demar (Member)]: The figure you gave us, 40,000 to 110,000, is that cost included with physical therapy and everything goes along with the new limb?

[Courtney Harness, Blue Cross and Blue Shield of Vermont]: Yeah, and Kyle might be able to speak to this, but again, my understanding is that's the whole process. So that's the initial visit through the creation of the device, through the fitting, that includes the whole process. Everything's wrapped up in. Yep, that's a good question.

[Rep. Alyssa Black (Chair)]: Kyle, did you wanna?

[Kyle Stepp, So Everybody Can Move (National advocate)]: Yeah. Absolutely. I I just wanna give yeah. I would love to give just some thank you to Courtney to step to start off. I think as legislators, it's important for you to hear. I work with insurance companies all across the country as we're navigating this process, and I wanna say I've been the most impressive I've ever experienced with the leaders of Blue Cross Blue Shield of Vermont. The level of compassion

[Rep. Alyssa Black (Chair)]: that they've shown for us. No.

[Kyle Stepp, So Everybody Can Move (National advocate)]: No. Courtney, I I think it's important to say that as an advocate with the lived experience as me living with the disability alongside David, it is really special to sit across from the insurer that has often denied you access to these things and saying, let's let's work together. Let's figure this out. And so I just wanna start off with that. So let's kinda go through just some data. So the the number you hear, 40 to 100,000, that is often for the daily device for an above knee amputee. The physical activity device, Maryland is the one that did the cost study on this as well. The average cost of a activity specific prosthesis or orthosis is 11,250. So that 40,000, I'm an above knee amputee. I'm just gonna show you my knee for a second. This guy, for walking, that is 40 to 100,000, but that's already covered. That's my daily device. So for an activity specific device doesn't have the technology that a walking leg does. And so that's where you see that cost of 11,250. The percentage that actually will access this. So the medical necessity, I wanna make note on this. The insurers still have the process of utilization review. That is really important to us. The we're the physician and the clinician have to be able to create their case to the health plan of why does the person need to access physical activity? Are they willing to access physical activity? And are they going to be able to safely use the device? So the physician and the clinician have to basically create a case to the health plan to say, this is why they need it. This is how they're gonna use it, this is the right device for them. And then the health plan says, okay. You've created your case. This is approved. We have had in some states where they have created limitations, and I think this is an opportunity for us to discuss that. We've seen, for physical activity, often individuals receive one device for daily, one device for physical activity, and not everyone uses a showering device. And then the key thing about physical activity is only about fifteen percent will medically qualify to access the physical activity device. So the where we get that number from is a couple of things. They to be willing and able. They also have to be able to safely use the device. And so the clinicians have to be able to justify that they're at a level. So there's a term called K levels. And so when when a person with limb loss or limb difference gets diagnosed or has their injury, the physician will give them a level of ability. And in order to access a physical activity device, they have to be a level called the k level three or four. It goes zero, one, two, three, four. The individuals that can access these devices are k level three and four. That means they can safely ambulate. They can safely use it. And you hear that number of 9,009 is comprised of you're missing a toe, you're missing maybe a finger. But if you think about the numbers of actual amputees, as you notice that claim number that Courtney used, that is a little bit more realistic. About two hundred and thirty three individuals will be the ones that actually utilize a prosthesis. What we see is about thirty percent of the entire disability community from limb loss and limb difference actually use a prosthesis or orthosis. They use a device, thirty percent. You break down that number and that's how we get to that ten-fifteen percent of utilization are the ones that would access a physical activity device. The other thing to note about the showering and bathing device, not everyone's gonna need it. I often I don't need a showering device. I feel that I'm a lot I'm fine. I have I have a handrail in my shower. I use it. And so I think when you look at these numbers, again, the physician has to prescribe it and they have to be willing and able to use it. I just wanted to make sure you all got that clarity of that information as well.

[Rep. Alyssa Black (Chair)]: May I ask some very ignorant questions?

[Mike Fisher, Chief Health Care Advocate (Vermont Legal Aid)]: I'm sorry.

[Kyle Stepp, So Everybody Can Move (National advocate)]: That's fine. No. It's okay. This is why we have this conversation.

[Rep. Alyssa Black (Chair)]: This is obviously a subject matter I know nothing about.

[Kyle Stepp, So Everybody Can Move (National advocate)]: Yeah.

[Rep. Alyssa Black (Chair)]: So, first of all, we heard testimony from some individuals who were frustrated because they couldn't go swimming in the river with their friends. I'm not sure why anyone wants to swim in the Winooski, but that's not the river.

[Rep. Leslie Goldman (Member)]: Leave that aside.

[Rep. Alyssa Black (Chair)]: There a device for swimming or is there just a waterproof device which would be sort of the same device that you would use shower or bathing?

[Kyle Stepp, So Everybody Can Move (National advocate)]: The latter. So often those devices can be used for both. So for example, the swimming, often the ones that use it for, like, record like, let's say, I'm swimming in lap pools. The ones that often use that would be, like, a below knee amputee, because they'll put a fin on it, and that is honestly that connects to the terminal that connects to the socket. The socket is what's customized to the human body. And what's nice about these activity devices for a lot of the below knee amputees, you can swap them out, but that terminal socket stays the same. The piece that's fabricated to the body and allows them to switch out, let's say you have a running foot or you have a fin for swimming, often. But thinking about that example of the river or the example of the beach, you'll need a waterproof walking device. That could be Sorry. The emojis. Wow. We're trying to celebrate already. That can be used for showering and for that can also be used for their lake or the beach. It can be used for both.

[Rep. Alyssa Black (Chair)]: And and I under I I keep you you're describing this, and I'm just, like, thinking about interchangeable parts.

[Rep. Francis “Topper” McFaun (Vice Chair)]: Yep.

[Rep. Alyssa Black (Chair)]: But, so we heard, and to Allen's question, which is what I was thinking about, I was thinking about my son would switch sports like every Is there a different, you know, we heard from some witnesses who were talking about playing hockey and, you know, lacrosse. And is each sport sort of like an individualized, transformed No. That you play?

[Kyle Stepp, So Everybody Can Move (National advocate)]: You play. That's a great question. So you often so the devices are multipurposed. A lot of times, your physical activity device, like a running blade, can be used for multiple sports. Or let's say the device for snowboarding is often very similar for strength training because of how the componentry is designed. You often see a lot of these devices are used for multiple purposes. I will say, to give you an example, we've recently did a limitation in my home state, New Mexico, because we also added wheelchair coverage this year. We did a we did a we did a limitation of no more than three devices per missing limb. And then for the physical activity, it was at three years. If the person's physical activity goals and health goals have changed, the health plans can consider a new device. So let's say I think it's we're also trying to be reasonable within limitation. Let's say in in three years, like, thinking about you're describing your son and your child. I apologize. Let's say in three years, they, you know, they switch from a device that was for running, and they, you know, they're opting to switch to more snowboarding because those two would be slightly different, they would consider now the opportunity to switch to a new device for their physical activity goals. But I think that it is reasonable for us to discuss limitations. I think our goal is to give people with limb loss and limb difference the opportunity to access an option of physical activity.

[Rep. Alyssa Black (Chair)]: David, did you want to weigh in on that, on my ignorant questions? Again, I apologize for the naivete.

[David Heiler, So Everybody Can Move]: Yeah. No problem. I just wanted to add in too that there was a question about the different prosthetics. I purchased my own running blade at one point, and it was a total of $2,000, which know, it's not the state of the art one, but I think even the state of the art one is about 15,000. That, again, as Kyle mentioned, does not include a socket, but I can switch that out. I also, you know, have I received a grant for a snowboarding leg, which I can use for paddle boarding, or I can use it in the water. I can walk into the ocean with it because I know that was a big question. A lot of these prosthetics are not ocean approved even if they're waterproof, but you can you know, that one in in particular, I can use for multiple purposes. So just wanted to add that in.

[Rep. Alyssa Black (Chair)]: Really getting an education here. Leslie, did you have a question?

[Rep. Leslie Goldman (Member)]: I do. Thank you. I'm curious. There is a provision in here regarding prior authorization, so I'm wondering what the role of prior PAs would be in here.

[Courtney Harness, Blue Cross and Blue Shield of Vermont]: Really interesting because that came up in conversation about Act 111 prior authorizations. And I think the way that we get around that is what Kyle mentioned in the process, which is it comes to us anyway. I meant to write about that.

[Rep. Alyssa Black (Chair)]: The DME was exempted from 11 Correct.

[Courtney Harness, Blue Cross and Blue Shield of Vermont]: So in the process, when they click to make the determination, then it comes to us for approval, because what we said in conversation with David and Kyle was, well, if you didn't know, we don't have a prior auth in Vermont on certain things, and it is exempted.

[Rep. Leslie Goldman (Member)]: Okay, so even though it's in here, it's exempted?

[Rep. Alyssa Black (Chair)]: Yeah. Oh, just

[Courtney Harness, Blue Cross and Blue Shield of Vermont]: No, DME is exempted. DMEs. Yeah, it's still that language is good. There's still a prior authorization process.

[Rep. Leslie Goldman (Member)]: Oh, exempted from not getting prior. Correct. Sorry.

[Rep. Alyssa Black (Chair)]: I got

[Rep. Leslie Goldman (Member)]: my double negatives. Thank you.

[Rep. Alyssa Black (Chair)]: Kyle, did you wanna Yeah. And because I think

[Kyle Stepp, So Everybody Can Move (National advocate)]: one of the representatives made a comment about, the total billing. So when you think about prosthetics or orthotics, that cost of that $1,520,000, that's the entirety of care. So unfortunately, prosthetists and orthotists can't bill for every visit like a physician does. So every time you go into the clinic and you see your doctor, they can bill the insurance company every single time. With prosthetics or orthotics, it is billed by device. The entirety of care that exists, so every time I go in to see my prosthetist to get it fixed, to get it adjusted, to get it fabricated, to get the alignment, the entirety process of before and after receiving the device is built into that singular device. When you hear that number and it sounds like a lot, that's the entirety of care. And the reason why

[Rep. Karen Lueders (Member)]: The bundle

[Kyle Stepp, So Everybody Can Move (National advocate)]: payment. Yeah. Bundle yep. Bundle global bundle payment. Thank you. Yeah. And the reason why we are fans of prior authorizations for a couple of reasons. So thinking about a small practitioner office, $15,000 is a lot. And, unfortunately, let's say there's a situation where they go through the process to purchase that device and they start the process of fabricating the socket and all the cost comes out to that $15,000 The insurance company comes back and says, You didn't prove your medical necessity and it's now denied. They're on the hook for that $15,000 And so they go through the process to ensure that the plans will cover it, will pay for it. And so then they can then start the process of providing that care so that they can make sure that it's gonna be covered and paid for.

[Rep. Alyssa Black (Chair)]: Can I ask a follow-up on this?

[Rep. Leslie Goldman (Member)]: So Blue Cross Blue Shield has people who would be expert in dealing with these kinds of devices in order to manage a PA. How would that work?

[Courtney Harness, Blue Cross and Blue Shield of Vermont]: Yeah, lots of emails with them in the last week. Yeah, we have our whole team that does all of the claim review and all of their authorizations, we had quite a bit of conversation about it.

[Rep. Leslie Goldman (Member)]: So you're saying that you have experts in that world advising you? You contract with people? Or how does that work? I've been on the other end of PAs, so I know it the clinician point

[Courtney Harness, Blue Cross and Blue Shield of Vermont]: of view. We have internal experts that review regardless of what it is. We have folks that would

[Rep. Leslie Goldman (Member)]: This seems fairly specialized, I would imagine. Maybe no more so than what else you do. Yeah.

[Rep. Alyssa Black (Chair)]: Any other questions? I have one, and I think it's for all of you. Sounds like you guys have had some really great conversations over the last week. I'm wondering, and I know we don't have MVP here, but we have two insurers in our QHP market. And I'm wondering if there would be any thoughts on whether whether you would even need legislation for this, I don't know, or if you would just prefer to do this on your own. I'm wondering if maybe you could come back to us and report back to us possibly. I'm very serious when I said we are incredibly concerned about affordability. We have done nothing in this committee. I guarantee you, if it's about expanding coverage, I have not addressed it and I have not. And we are very serious about that. I'm wondering if you would be willing to work together with the community to come up with either coverage determinations or whether you would need legislation. I mean, sounds like it's maybe an issue that insurers should look at. You just mentioned the waterproof would cost less than the ambulance for somebody who falls. And wondering if maybe work together, you know, we've talked about limits on physical or who would need them, maybe ages, number, limiting it to a number of devices so you don't have the my son thing who wants to change everything every single wanted to change everything every six months. If you all would be willing to work together in the next year and then maybe come back to the legislature with recommendations and possible costs.

[Courtney Harness, Blue Cross and Blue Shield of Vermont]: Yeah, we can do that. And I think to rep Cina's question, we can come back with some ranges just for our members of what we see as the potential opportunity or number of folks. And then we can certainly have some more internal discussion about to what extent we would ask the committee for support versus what we might just be able to do.

[Rep. Alyssa Black (Chair)]: Is that something you feel as though you need a short bill asking for a report back? Or do you think that's something you all can work on on your own? I

[Courtney Harness, Blue Cross and Blue Shield of Vermont]: think we can work on it on our own.

[Jennifer Carbee, Office of Legislative Counsel]: Well, given that we're at the

[Rep. Leslie Goldman (Member)]: end of the session, or everything is over by the Nothing. So I wouldn't mind having something that we can say

[Rep. Alyssa Black (Chair)]: Would you like to, can you say that? Can we write a letter?

[Jennifer Carbee, Office of Legislative Counsel]: Yes, would the committee like to write a letter asking to address an MVP to work with funding to fund this?

[Rep. Brian Cina (Member)]: In a timeframe, yeah. Because, Does Medicaid need to be involved in this or not?

[Rep. Alyssa Black (Chair)]: I think we should ask Medicaid to be involved in discussions.

[Rep. Brian Cina (Member)]: So then maybe it's asking AHS know, AHS diva, Blue Cross Blue Shield MVP, and maybe other to work with stakeholders or some general term, so that then you could include in the discussion advocates or the healthcare advocate or whoever you need to talk with, but something like that asking, I don't know.

[Rep. Alyssa Black (Chair)]: Can you help me? I think I would limit it to Medicaid and our qualified health plans, probably.

[Rep. Brian Cina (Member)]: But aren't they going to need to talk to people? I guess they could just do that without And us work with interested parties. That's what I meant. Yeah, yeah, yeah. Just like saying, asking them to do it, but to include stakeholders so then they can choose and let people in and okay.

[Rep. Leslie Goldman (Member)]: I just want understand the distinction between writing a letter and having a short term order of statute in enforceability or holding people accountable to do the work? I don't understand that.

[Jennifer Carbee, Office of Legislative Counsel]: I think from a practical standpoint, it would be difficult to enforce if you did it legislatively, difficult to enforce having a conversation with people or not interested in having a conversation. Committees have often written letters asking what seemed like willing or stakeholders to work together and come back with a proposal or at least explore a topic together. So I mean, it's less visible in the sense that when there's a letter, would be placed under committee webpage, but it wouldn't go into the actual results. But it's another option. Sometimes I think the idea of legislation can feel intimidating to parties who are being directed by state law to go have a conversation versus being asked by a committee.

[Rep. Leslie Goldman (Member)]: Can we copy the sponsor of the bill on that, on the letter? They know that we're taking action on this.

[Rep. Brian Cina (Member)]: I have seen other committees do this or do memos, but it's usually only when there's an agreement that's been reached on the record on YouTube. We're hearing here, there's some agreement. So it's a way of documenting the agreement without the expense of a bill moving through the legislative process, which takes a lot of time and money. So I actually think if everyone's willing to do it, this is a great compromise.

[Rep. Alyssa Black (Chair)]: I think that's And we'll ensure that we talk to MVP as well. But it sounds like this was a conversation that started that Blue Cross was really interested in. Go ahead. Both

[Rep. Francis “Topper” McFaun (Vice Chair)]: were talking about incentives and products. I

[Rep. Alyssa Black (Chair)]: think we would be asking for you all to explore how something, what coverage would look like, what it could look like and the cost of it.

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

[Rep. Alyssa Black (Chair)]: you know, what the best course of action and then come back with us with recommendations sounds. Great. Karen? I just want

[Rep. Karen Lueders (Member)]: to say the sense of the testimony in your conversations is that the people who need it, it just makes such a difference in their lives,

[Rep. Alyssa Black (Chair)]: the quality of their lives,

[Rep. Karen Lueders (Member)]: the completeness of their lives. So anyways, thank you for engaging and getting us

[Rep. Alyssa Black (Chair)]: members. Work with.

[Mike Fisher, Chief Health Care Advocate (Vermont Legal Aid)]: Appreciate it. All

[Rep. Alyssa Black (Chair)]: right. Thank you, Courtney. Thank you so much, Kyle and David for joining us. I know you weren't on the agenda, but we're so glad that you joined us because you're a wealth of information. Another great emoji. Our pleasure.

[David Heiler, So Everybody Can Move]: Thank you.

[Rep. Alyssa Black (Chair)]: Thank you. All right, so on the agenda we have next, Jen, do you want to come back up? I think we're going do a budget letter or we could do it after I see that Oh, I thought I just saw her, but she's gone. Okay, so we're going do budgets by there then.

[Jennifer Carbee, Office of Legislative Counsel]: Either Oh yes, yes, and then

[Rep. Alyssa Black (Chair)]: you can join us when you're ready. Question?

[Mike Fisher, Chief Health Care Advocate (Vermont Legal Aid)]: My question is how great I get. I have some more information about how co pays play out. I understand how late and how other states do it. What the Mainland states do it. I understand how late it is and you're about to hand the letter. So if you're gonna say, if you feel like you've had enough and you don't want hear anything more, I totally understand it, but also it's been. Guys don't.

[Rep. Alyssa Black (Chair)]: Would you like to sit up here and convey information for just a brief moment? Then we can choose whether or not to ignore you and tell you to go to appropriation. Because Jen already wrote the letter.

[Mike Fisher, Chief Health Care Advocate (Vermont Legal Aid)]: Like, future health care advocates. I thought I would share with you that New York has a 50¢ co pay for over the counter and $1 for genetic and $3 for preferred. Maine has a zero co pay for ninety day mail order and $3 for other. Massachusetts has no co pays. And New Hampshire has zero for under 100% FPL and $4 for over 100% FPL. So in the New England, we would be matched with New Hampshire as having the highest co pays. And MABD, FYI, follows the list co pay rules, not not touched by this. Medicaid co pays are banned for pregnancies and kids. And then there's another dynamic that I think is new altogether for you that I think it's just worth saying out loud is to recognize that per HCAR rules, the copay is part of the payment to the pharmacy. And the pharmacy is required, may not deny met medical services if the person doesn't have the co pay. And so what that means is, for some, that doesn't relieve the person of the bill. They still owe the money, and the pharmacy can continue to try and collect it. I suppose theoretically could deny services to somebody who owes them money. But

[Rep. Alyssa Black (Chair)]: Future services.

[Mike Fisher, Chief Health Care Advocate (Vermont Legal Aid)]: Yes. But, the cost of this lands on the Medicaid beneficiary who forks out the money or on the pharmacy in reduced monies to the pharmacy. That's where it actually plays out.

[Rep. Alyssa Black (Chair)]: So the person, if they are unable to pay, the pharmacy still must give them the prescription, and the pharmacy essentially eats that.

[Mike Fisher, Chief Health Care Advocate (Vermont Legal Aid)]: And those committees had concerns about dinging pharmacies at that starting pharmacies. This has that potential. And I don't know I'm not sure anybody knows to what degree

[Rep. Alyssa Black (Chair)]: where it actually Well, I'm not sure you would know this, but because you've gotten this great information in just less than twenty four hours, I wonder if pharmacies would have any idea of how much they essentially have to write off for uncompensated. Karen, go ahead.

[Rep. Karen Lueders (Member)]: On the budget line item on this, it showed a savings to the state from what you just said. I'm confused. Is that would it generate a savings

[Rep. Alyssa Black (Chair)]: to the state? I

[Mike Fisher, Chief Health Care Advocate (Vermont Legal Aid)]: think that there's been some discussion about how the savings to the state I I actually like the way Nolan said it reduces the cost of the program and therefore also reduces the Medicaid match for the program. So it it it has the same effect of the savings to the state or or play out according to the match rate effect the FMAP match rate.

[Rep. Alyssa Black (Chair)]: Thank you. I have a question. Oh, sure.

[Rep. Wendy Critchlow (Member)]: Just quickly. We heard a testimony that the CMS

[Rep. Alyssa Black (Chair)]: is not

[Rep. Wendy Critchlow (Member)]: gonna require people to have a premium. So those ones Oh, cool. Okay. So Massachusetts.

[Mike Fisher, Chief Health Care Advocate (Vermont Legal Aid)]: I I suppose we'll, at some point, have to have some.

[Rep. Wendy Critchlow (Member)]: Okay. And then the other thing you said to me about children not getting so doctor Dinosaur has suspended premiums right now.

[Mike Fisher, Chief Health Care Advocate (Vermont Legal Aid)]: Right. But we're talking co pays at the moment.

[Rep. Wendy Critchlow (Member)]: Okay. Okay.

[Mike Fisher, Chief Health Care Advocate (Vermont Legal Aid)]: And that they're are Oh, okay.

[Rep. Wendy Critchlow (Member)]: So they don't have to pay.

[Rep. Karen Lueders (Member)]: Do they? They don't pay now? Didn't know that. Okay. That was my fault.

[Rep. Alyssa Black (Chair)]: Oh, bullshit. Thanks. Thanks, Mike.

[Rep. Karen Lueders (Member)]: Okay. Again,

[Jennifer Carbee, Office of Legislative Counsel]: Jen Kirby from the Office of Lueders and Counsel. For now, I am going to share with you the draft budget letter or memo from this committee to the Appropriations Committee. Starts out with our usual language about your committee appreciating the opportunity to provide your fiscal year 2027, in this case, recommendations to house appropriations. And that you recognize that developing the budget for this year is particularly challenging, and you understand that many difficult decisions went into the governor's recommended budget. As you can accept most of the proposals in the governor's recommended budget as presented with certain exceptions as described in more detail below. It also recognizes that the committee received several requests from advocates to fund proposals that were not included in the Governor's recommended budget, some of which you strongly encourage the committee and appropriations to include in the budget bill. In addition, and here's the copay piece, while the committee is not comfortable with DEVA's proposal in Section B. Three zero seven to increase prescription drug copays from the current $1 for preferred drugs from $3 for non preferred to $4 for preferred drugs and $8 for non preferred. If an increase is deemed to be necessary, the committee can support an increase to not more than $2 for preferred drugs and $4 for non preferred. So as in previous years, your committee ranked your recommended funding priorities. Committee members chose their top five priorities, which were ranked by weight to arrive at a list of the committee's top 10 priorities. These priorities represent a mix of new proposals from advocates and the committee's request to maintain monies that would be cut in the governor's recommended budget. An additional request, which can be supported with monies available from the Health IT Fund, is described in Section A of the language sections following the table. So I put in the table. I am not capable of using Excel, so this is a word table. And so this was going through in your order, order of priority, including the tie at four, which then goes on to six. Think the proposal has pointed out, so that's how I'm familiar with handling ties. So it should be brief description of what the proposal is, which agency or department would be affected, the gross amount, the state or general fund amount, and then whether this was in a part of the governor's recommend or a new proposal. So we had the home health, free and referral clinics, SASH, we're still working out exactly which department, that agency or department that is, maintain the AHEC programs, support Vermont Care Partners, the increase to Medicaid rates for the DAs and SSAs, maintain community outreach for Chittenden County, the Bridges to Health transition to the free and referral clinics, Office of the Healthcare Advocate increase, maintain the Team two mental health training for first responders, and maintain the SAC education loan repayment. So I tried to indicate when they were in the bill that they were cuts. A couple of just asterisks Nolan asked me to put in indicating that he has not verified these numbers. He's working on that. And it says, In addition to your requests above, the committee has four language requests for inclusion in the budget bill sections. I've described them and then have the language. Section A would maintain funding to Vermont two eleven using monies from the Health IT Fund to enable that resource to establish a closed loop referral pathway with the University of Vermont Health to better connect Vermonters with appropriate health care services. Section B would eliminate the 2027 sunset on an existing scholarship program for medical students planning a career in primary care. There's no additional cost to this request as the statute already allows funds to be carried forward and $476,770 remains from prior appropriations. Based on the information that's provided to you, removing the sunset would allow approximately 11 more awards to be made to students in fiscal years '27 and '28. Section C expresses legislative intent that the Department of Vermont Health Access figure out how to implement a coding change that would enable the state to receive ninetyten federal matching funds for certain family planning services. And Section D would replace language in the Governor's recommended budget that requires pursuit of a Section thirteen thirty two waiver for reinsurance with language from H-five 85 as introduced with a technical revision. That's when Addison told us that we didn't get to pass through on cost sharing reductions, which would authorize but not require pursuit of the waiver. Then I added the committee does not want to mandate that the state devote time and resources to seeking a waiver if it does not make sense to do so. Then we have the language, which I've made sections A through D. The first is integration of EPIC and the MNOT-two 11 for direct closed loop referral pathway appropriating 332,000 from the Health IT Fund to DMH in fiscal year twenty seven for a grant to Vermont two eleven to establish a closed loop referral system between Vermont two eleven and healthcare providers at University of Vermont Health. Section B removes the sunset on 18 BSA Section 33, which is the medical students' primary care program that is currently scheduled to be repealed on 07/01/2027.

[Rep. Karen Lueders (Member)]: You said that? Yep.

[Jennifer Carbee, Office of Legislative Counsel]: Does that mean it goes on in perpetuity? It means the program itself does, but the funding, unless new funding is added, the funding would run out as I understand

[Rep. Leslie Goldman (Member)]: it after FY That 20 fund is over, then we decide whether to be, yeah. Right.

[Jennifer Carbee, Office of Legislative Counsel]: You can always put more money into the fund, the program would remain on the books. Section C is the DIVA Family Planning Code Implementation and a Report specifying that it is the intent of the General Assembly that DIVA determine the steps necessary to implement the Family Planning Codes in Vermont Medicaid that are eligible for a 90% federal match, promptly take those steps and deploy the appropriate codes. And on or before, and I just picked a date before you come back, 10/01/2026, the Department would report to the Health Reform Oversight Committee and Joint Fiscal Committee regarding the steps it determined were necessary, whether and how it implemented the codes, and the funding impacts that will need to be reflected in the FY 'twenty seven budget adjustment. And then Section seven is the reinsurance language, and this would authorize DEVA in consultation with DFR, authorize them to submit a state innovation waiver pursuant to section thirteen thirty two of the Patient Protection and Affordable Care Act as amended by a related act to establish a program for reinsurance and seek federal pass through funding of amounts attributable to premium tax credits under 26 USC Section 36 without the reference to the cost sharing reductions. And that's it.

[Rep. Alyssa Black (Chair)]: Can I flag I hate to make changes here, but we really should send appropriations all of the asks that we received? So would it be possible to include a sentence saying, making reference to, we have attached a spreadsheet of all requests that were received. Here below is rankings of one through 10.

[Rep. Brian Cina (Member)]: Would it be like an addendum or appendix or something? Yes. Which I don't know what it would be called.

[Jennifer Carbee, Office of Legislative Counsel]: It would be an addendum, but I'm not putting it in. I'm just saying we've attached a spreadsheet.

[Rep. Alyssa Black (Chair)]: That way they can see everything that we've looked at.

[Rep. Brian Cina (Member)]: I didn't say appendage. I

[Rep. Francis “Topper” McFaun (Vice Chair)]: mean, it's

[Rep. Brian Cina (Member)]: addendum or appendix.

[Jennifer Carbee, Office of Legislative Counsel]: So I said that I'll set this up, but I didn't want to type on live. I never this off. So I just added at the end of this paragraph, on the second paragraph on the first page, the committee has attached a spreadsheet showing all of the funding requests we received, some of which are included in our top 10 priorities below.

[Rep. Alyssa Black (Chair)]: And I will also say that I will go in next Thursday to Appropriations to present our budget recommendations, and I will ensure that I offer the information from our healthcare advocate that he just had on the prescription co pay. Any questions? Oh, Brian, go ahead.

[Rep. Brian Cina (Member)]: Have two questions. One is, it looks like by expanding the scope of the prioritization process to 10, We have expressed a broader range of recommendations, which I think is good. I'm glad we did that. I'm curious, how much were we able to save and how much none? Like in other words, out of those 10 things, we covered a lot. And then the language is like, we found a lot of fixes. What is going to be cut, What remains? Because some of those cuts were things that weren't like a program being cut. It was like, you know, like how they reallocate funding or something is naturally shutting down. And I'm just curious what the casualties were. That's like a harsh way to put it. Like, What didn't make it?

[Rep. Alyssa Black (Chair)]: Think we would have to take that spreadsheet and add

[Rep. Brian Cina (Member)]: I could just look at it later. Everything. Yeah. Maybe I'll look at the final product, because it will have that attached, just to know. Because it would just be good to acknowledge what those things are. I'm just curious how much of them were things that it's not really a program cut, but rather like a restructuring. Because some of them were like, they're cutting it, but they're not cutting it because something is being cut. They're cutting it because it's no longer needed or it's being done in a different way or I'm just curious. And the second thing is that this is a letter to appropriations, which is why people really don't want to talk about revenue. I'm curious if we are going have an opportunity to send a revenue letter to the Ways and Means Committee, because we've never done that before. But if a committee can't give policy recommendations to the revenue committee, but we give it to the appropriations committee, it seems like unbalanced. And so it would just be like an idea to take to leadership or whatever is maybe committees could start having the opportunity to give a revenue letter if they choose.

[Rep. Alyssa Black (Chair)]: That's a great idea. Would you like to speak to our leadership?

[Rep. Brian Cina (Member)]: If you designate me to be the one so that I'm not, once again, this random person asking them to do some radical thing, yes, I will speak to them. But as long as they know I'm doing that as the blessing of the committee, it's not me once again asking for a meeting to ask them to create universal health care or something.

[Rep. Wendy Critchlow (Member)]: I want to say that.

[Rep. Alyssa Black (Chair)]: What revenue are you

[Jennifer Carbee, Office of Legislative Counsel]: referring

[Rep. Brian Cina (Member)]: Well, to? For example, in my objection, I pointed out that the big beautiful bill, HR1, not our HR1, but the federal HR1, gave tax cuts to all of us, to all of us. But that if we just looked at the top 1%, that's $2.00 8,000,000, the top people over $500,000 $280,000,000, to top 20%

[Rep. Wendy Critchlow (Member)]: So it's revenue, like it's generalized. It's not like this committee somehow made cuts that No. No. State funding. No. Would be

[Rep. Brian Cina (Member)]: more like imagine if every just like every committee is asked to write a letter to appropriations by a certain date every year for them to take into account in the big bill, our big beautiful bill, know, then that there's a tax bill, there's a tax bill every year, and we're never asked to give feedback into that. What if we're given a chance, and then we could say things like, I'm just making this up.

[Rep. Alyssa Black (Chair)]: This is

[Rep. Brian Cina (Member)]: not right. We wanna eliminate the health care provider tax, or we wanna create a new tax in the health care system, or we want the state to recapture the the Trump tax cuts for the highest, or, like, it gives us, as a committee, a voice in that bill, which we don't currently have, which I was told we could not put in this letter, and I actually respect that because this is appropriations. So why would we tell appropriations to include a tax? Although sometimes the budget does have tax to pay.

[Rep. Alyssa Black (Chair)]: I will say that I will communicate with leadership. I encourage you to communicate with leadership and remind you that every single time we do a bill around policy, we make recommendations for the policy as well as how to pay for it, which goes to ways in So the we do weigh in on, yeah, we think you should collect this fee or something like that. Pepper?

[Rep. Francis “Topper” McFaun (Vice Chair)]: I need my memory refreshed. I get down to, on the chart, I get down to six and I remember all of that. How did seven, eight, nine, ten, how did they get their rankings? Because the last ranking is VSAC and I thought-

[Rep. Alyssa Black (Chair)]: Okay, so I gave each member of the committee five votes to rank their five. I did not say we were going to send five things only to appropriations. We took the 10 top vote getters. We ranked them in order of the committee's earnestness about them. And we are submitting here are the top 10 things of this spreadsheet that we're including of all the asks that we had. These were the ones that rose to the interest and the endorsement of the committee ranked in order. Okay, now. That's how they got out there.

[Rep. Francis “Topper” McFaun (Vice Chair)]: Okay, well, I'm still confused. Okay. So what you're saying, this is when all the numbers were added up, that VSAC education loan program came in tenth?

[Rep. Alyssa Black (Chair)]: It came in tenth. That was pretty good. We had 20 something things, how many items were I

[Rep. Francis “Topper” McFaun (Vice Chair)]: thought VSAC was higher than that, at least on the piece of paper I had.

[Rep. Alyssa Black (Chair)]: Ahack came in, Ahack came at number four, a tie, with Vermont Care Partners. Daisy sent an email that breaks it off. Daisy sent an email that had the total votes.

[Rep. Brian Cina (Member)]: Yeah. Did see. Yeah. Okay. I can forward it to you if you want.

[Rep. Alyssa Black (Chair)]: Any concerns, questions? I just want to straddle on whether or not the committee supports sending this letter and recommendations to our House Committee on Appropriations. Can somebody remind me if somebody is absent for a straw poll, are they able to weigh in? I think they're able to weigh in at a later time.

[Rep. Brian Cina (Member)]: That has been the case in the past. That's what the delivery used to do.

[Rep. Alyssa Black (Chair)]: That day. I think it was

[Rep. Brian Cina (Member)]: the dead He was called the straw co vote, but we can't do that one with the roll call.

[Rep. Alyssa Black (Chair)]: Daisy's not able to get here at the at this moment, so I will get her. Okay, so all those in favor of sending this letter and information to appropriations, I still have the answer if you approve it. Ten-one, and I will ask Daisy Berbeco. Hopefully we'll have an eleven zero.

[Mike Fisher, Chief Health Care Advocate (Vermont Legal Aid)]: She's the one.

[Jennifer Carbee, Office of Legislative Counsel]: I'll send the updated version of that sentence to Pasha, and then I can send it if you want to, preparations can be made.

[Rep. Alyssa Black (Chair)]: That would be fantastic. And I will be there Thursday of next week.

[Jennifer Carbee, Office of Legislative Counsel]: Thank you for taking that additional information about the prescription reimbursement statistics. Appreciate that.

[Rep. Alyssa Black (Chair)]: Could they keep walking in and out and I keep missing? I'm to ask our healthcare advocate if you can write all that down for me. No, hold on. All right, we need to take a break, right?

[Rep. Francis “Topper” McFaun (Vice Chair)]: Yes.

[Rep. Alyssa Black (Chair)]: Yeah, let's be back there. When do we think Mary will be able to be here? She should be here soon.

[Courtney Harness, Blue Cross and Blue Shield of Vermont]: The previous testimony is scheduled to end at 02:45.

[Rep. Alyssa Black (Chair)]: Okay, so let's be back here at 02:50, Okay? And I keep going up plenty of time before floor. Okay? So 02:50.