Vermont Legislature SmartTranscripts:

[Alyssa Black (Chair)]: Hi, welcome back. So

[Alyssa Black (Chair)]: I've had Jen draft some language coming from me. And while she's putting that up, I just want to

[Alyssa Black (Chair)]: 190? We're on 190.

[Alyssa Black (Chair)]: I'm sorry. I didn't hear you talk. We're still on 190. We haven't finished on 190. I just want to level set that as this bill has been winding through and as this session has been going on, there are lots of stakeholders, all the people that we've been talking to, to sort of figure out what to do. And I think the general consensus has been we need to do something. I think there's just disagreements among the parties of what would do to get us all equally to the same destination. So I think there's general agreement that S-one 190 as currently configured, while there's nothing particularly bad about it. And there's not great stuff in it, but the two fifty cap on the QHP, I think needed a little bit more fleshing out. So I've asked Jen to draft some legislation, which is a strike all amendment. And

[Alyssa Black (Chair)]: so I'm putting this forward as my idea, and I'm interested in how the committee feels about it based upon all the testimony that we've heard essentially through the year. Lots of testimony. So thank you, Jen. Sure. Good afternoon. Jen Carvey from the Office of Legislative Counsel. I'm putting the language up, and I believe it is on the web page. So this is presented as a strike also, I can show you what would change. And it starts off without any changes to the first section on reference based pricing. The second section would change a bit for one thing, it would not be codified.

[Jen Carvey (Office of Legislative Counsel)]: So section two is in the bill that came over to you, is the limitations on hospital reimbursements for qualified health plans and putting that into statute as sort of an ongoing requirement and less than until the board sets different reference based prices for them. This would make a change, some changes. It would keep some of the definitions, Medicare adjusted base rates, not going to include critical access hospitals. So it strikes out that reference. It adds in some new definitions with all with cross references to existing statute. So we have Health Benefit Association is of the statute under what BIHI it exists. So it's in the Intermunicipal Insurance Association subchapter entitled 24, and it is specific to health benefit associations offering plans to educational entities, I think is what it's called. So it defines health benefit association there. Hospital, I'm defining as a general hospital licensed under our hospital statutes, that is not a critical access hospital. Qualified Health Benefit Plan is our exchange plans, our QHPs. Registered Carrier is a carrier that offers QHP in the individual or small group market. So that's that definition. And a school employee has the same meaning as in Title 16 in the chapter on the Public School Employee Benefits Commission. That's where we get all of our definitions from. And it starts out by directing the Green Mountain Care Board to determine the amount of hospital spending that can be reduced for hospital fiscal year 2027.

[Alyssa Black (Chair)]: I think you need to scroll.

[Jen Carvey (Office of Legislative Counsel)]: I'm right here. I'm sorry. Sorry.

[Unidentified Committee Member (former AHS staff)]: My bad. Go ahead. Sometimes it's I'm sorry. Mike's okay.

[Jen Carvey (Office of Legislative Counsel)]: Sometimes I don't even have it up on the screen. Can be reduced for hospital fiscal year twenty twenty seven using criteria that are consistent with ongoing hospital transformation efforts and the goals set forth in last year's Act 68 without jeopardizing the sustainability of Vermont's hospitals, reducing spending across all hospitals by more than 2.5%. In establishing fiscal year 'twenty seven hospital budget orders, it directs the Board or requires the Board to direct each hospital to implement its required spending reductions through limitations on the hospital's commercial reimbursement rates for qualified health benefit plans and for, these are the Beehive Plans. So and for health benefit plans offered to school employees by a health benefit association pursuant to 24 BSA 4,947, based on a percentage of the Medicare adjusted base rate determined by the Board for each item provided and service delivered in Vermont to enrollees in these plans. So pausing here for a moment, it's basically directing the Board to set reference based prices for the QHPs and Beehive Plans and have the hospitals implement their spending reductions through those limitations on the rates they charge to the QHPs and the BI plans. And then it says, For hospital fiscal years after 2027, the Board shall determine up to 2.5% in hospital spending reductions annually as set forth in Subdivision 1A and shall direct hospitals to implement those reductions through limitations on their commercial reimbursement rates as set forth in Subdivision 1B until such time as reference based pricing is fully implemented and is safe in accordance with the statutory provision on reference based pricing. So it would set this up specifically for plan year 2020, hospital fiscal year 2027. It might continue on to future years if reference based pricing has not been fully implemented. And then it prohibits a registered carrier or health benefit association from reimbursing or agreeing to reimburse a hospital more than, and here's where we're taking out the 250%, the percentage of the Medicare adjusted base rate specified by the Green Mountain Care Board pursuant to subsection B. So this is making it work on the payout side as well. For the applicable hospital fiscal year, for any item provided or service delivered in Vermont to an enrollee in a qualified health benefit plan, I should say, or a health benefit plan offered to school employees by a health benefit association.

[Brian Cina (Member)]: You said it's a missing or? Yeah. Okay.

[Alyssa Black (Chair)]: Leslie, did you have a question? Well, I'm just not

[Leslie Goldman (Member)]: sure I understand, and you may go through this later, but in two, hospital for school years after 2027, that means that the board is limited only to a 2.5% up to two increase reductions.

[Jen Carvey (Office of Legislative Counsel)]: Right, they're identifying up to 2.5% in reductions and directing the hospitals to implement those through limitations on commercial rates. Do we know where that number came from?

[Alyssa Black (Chair)]: Actually, it came out of SX68 of last year. If you recall, there was a, we call it the carrot stick, where we provided funds for hospitals to move ahead with transformation. And then we required AHS to bring 2.5%, reduce 2.5% hospital spending.

[Unidentified Committee Member (former AHS staff)]: And it started at ten?

[Alyssa Black (Chair)]: Yeah, it started at ten.

[Unidentified Committee Member (former AHS staff)]: And then 2.5.

[Alyssa Black (Chair)]: That's where the 2.5 came from.

[Leslie Goldman (Member)]: And how does it mean, like in perpetuity or how does that work?

[Jen Carvey (Office of Legislative Counsel)]: Well, would continue until reference based pricing is fully implemented in the state.

[Leslie Goldman (Member)]: How does that change the font? What is fully implemented, Amy?

[Alyssa Black (Chair)]: When they have been completed?

[Leslie Goldman (Member)]: Every charge master block. Everything on the charge master.

[Unidentified Committee Member]: Well, we asked

[Brian Cina (Member)]: them to do that plan.

[Alyssa Black (Chair)]: Which is twenty third, I'm sorry. Twenty third. Elena, do you, what year did we tell you you had to be done with reference based

[Jen Carvey (Office of Legislative Counsel)]: don't think you told them when they had to be done. You told them they had to, they're supposed to begin implementing it by this hospital fiscal year. And in 2030, I think they start doing the global hospital budgets.

[Alyssa Black (Chair)]: Between now and global hospital budgets then? Well,

[Leslie Goldman (Member)]: 2028.

[Jen Carvey (Office of Legislative Counsel)]: But I think all of them.

[Elena (Green Mountain Care Board staff)]: That

[Jen Carvey (Office of Legislative Counsel)]: might be true. 2028 is the first global hospital budget. 2030 is all.

[Alyssa Black (Chair)]: What was it down for me? You're just adding BHI into the first round. Is that what this is? Yes.

[Jen Carvey (Office of Legislative Counsel)]: Adding BHI to the first round, it's not checking the percentage of Medicare for the weapons space, but allowing the board to identify the spending and sort of back into the Medicare percentage, the percentage of Medicare based on the amount to be drawn out of the system.

[Alyssa Black (Chair)]: So it's not the legislature trying to figure out how much can be drawn out safely or what the percentage is because we've heard a great deal of concern over if you put it at two fifty, okay, it means this for know, Blue Cross, what does it mean for every P, how much are we really drawing out? So instead, what it does is it tells the board to determine how much they feel in their regulatory process that they already have and for them to come up with that rate and apply it to the QHP market and the V high. Are we done with that section or do you want to finish that section?

[Jen Carvey (Office of Legislative Counsel)]: And there's still more in that section. That hasn't changed.

[Leslie Goldman (Member)]: Higher than two point? What if they want to go I mean, the past, they've had other

[Brian Cina (Member)]: It sounds like

[Leslie Goldman (Member)]: I think Not every year

[Alyssa Black (Chair)]: has been a reduction. I'm just wondering, but we don't have to answer

[Jen Carvey (Office of Legislative Counsel)]: that now.

[Brian Cina (Member)]: I don't remember what the language said.

[Elena (Green Mountain Care Board staff)]: I was

[Brian Cina (Member)]: just up there.

[Jen Carvey (Office of Legislative Counsel)]: I will put it up in a second. I just wanted to put the of the fixie missing or in the I

[Brian Cina (Member)]: just wanted to clarify something about the second part that Deb put up. Sure. So the first part we just discussed, the second part asks the hospitals to, I've got that language in front of me, I'm winging this. You don't have to put it up yet, I'm just trying to make sure I understand it, you could correct me, but it's asking the hospitals when they negotiate reimbursement rates with commercial insurers to keep them under a threshold. Is that

[Unidentified Committee Member]: what it was?

[Jen Carvey (Office of Legislative Counsel)]: So it's basically, I was trying to do sort of both sides of it. So the hospital is identifying the amount directing the hospitals to implement the reductions through their limitations on commercial rates, but also directing the carriers not to, or the payers not to reimburse or agree to reimburse more than the specified.

[Elena (Green Mountain Care Board staff)]: I haven't got to that yet. See that. Thank you.

[Jen Carvey (Office of Legislative Counsel)]: Then carrying over this concept from S-one hundred ninety and passed by the Senate, which is if there's reimbursement that is being done on a capitated or other non fee for service basis, and just make sure that that so I'm just adding any VIHI as the payer here, ensure that the reimbursement method is adjusted to account for that limit. Taking out the language about group Medicare board establishing a different reference based price that was in with the $2.50 cap, still prohibiting balanced bay billing, and then having the review of premium rates. And I wasn't sure which I put in APSA 4026 and the Intermediate School Insurance Association subchapter and expanded to both Green Mountain Care Board and DFR doing rate reviews and ensuring that the limitations on reimbursements are appropriately reflected in the the premium rates for the QHPs and BHI plans. That was it for that section. Section three, I just made some conforming changes. This is in the hospital budgets and budget review. So, again, instead of having the hospital implement their commercial reimbursement rate reductions ordered by the board as part of the hospital budget process through the limitations on specifically the QHPs under the statutory reference, limitations on the reimbursement rates for QHPs and the Beehive plans, and I said as directed by the board.

[Brian Cina (Member)]: Wait. Wait. Wait. I'm I'm trying to digest it. Just like me Slowly pass.

[Elena (Green Mountain Care Board staff)]: Okay, thank you.

[Jen Carvey (Office of Legislative Counsel)]: And then I kept in language saying if the hospital is required by the board's budget order to reduce its commercial rates by an amount greater than what they achieved pursuant to subsection A, then they would target those rates that are more than 500% of the Medicare adjusted base rate or if they don't have any of those, any that are whatever the highest ones are in relation to Medicare adjusted base rate And striking the reference here to 33 VSA eighteen fifteen because that's what we took out of statute. But otherwise saying a hospital, except as provided in the limitations we've established, a hospital may increase the rates that it charges for one or more of its service lines, such as primary care, as long as it's doing so it remains compliant with its total budget order.

[Alyssa Black (Chair)]: So let's stop there for a minute. So, again, it's sort of been agreed by all payers that we need to do some. And if you remember the board, the reason they can't start implementing reference based pricing in hospital budget year '27 is because of the rule making process that they're currently going through and we'll take them through. So that is why the legislature, much like what we did with the prescription drug cap last year, we put that in place. And so I'll tell you my thinking. I think that the QHP market is the most vulnerable market. These small businesses that are in the QHP market have no other place to be. I think that they've borne the brunt of increases. You know, I mean, we just heard about the self funded and the self funded have had option. I don't want to say they've been insulated necessarily from the huge increases that we've had in spending, but they've I don't think it's been quite as dramatic for them. I guess it's, you know, they're starting from different levels. And as we've heard everybody, it's not like we can say two fifty across the board for everyone, that would be disastrous for our hospitals. From the day one in here, when we all went around the room on what we were talking about and what we wanted to concentrate on, we talked about affordability for Vermonters. And I think by extending early reference based pricing, allowing the board in their expertise and purview over hospitals, hospital budgets, insurance rate review, that we allow them and give them the flexibility to design and calculate the savings. And all we're saying is for the first couple years, we'd like you to make, until you finish reference based pricing, which will benefit everybody, all markets, well, not Medicare, Medicaid, but you get the gist, that you concentrate it on these two vulnerable markets. These are taxpayers, property taxpayers with education spending. It will lower education spending. And it also concentrates on the small group and the individual market where I want to remind everybody. I want to remind everybody that a plan that last year, a family plan that you might have paid $12,000 $13,000 for for your family is currently you would be paying $53,000 for.

[Unidentified Committee Member (former AHS staff)]: That's why we're saying you need to pay 50.

[Alyssa Black (Chair)]: Leslie and then Brian. This is really great. Want to

[Leslie Goldman (Member)]: you might imagine at the time. Let me talk about property taxes and those loans. When will this bill, let's say we pass

[Elena (Green Mountain Care Board staff)]: the lawsuit,

[Alyssa Black (Chair)]: would have an impact? 01/01/2027 or 10/01/2026. I'm looking to the board.

[Leslie Goldman (Member)]: Yeah, major hospital orders.

[Elena (Green Mountain Care Board staff)]: Sure. If this were to pass, it would be reflected back up. So last year's Act 68, with the drug price cap, took effect immediately and we saw a median reduction in that year's rates. This one has the board making a determination as to how much money there is. So it wouldn't be reflected in the rates unless we had some sort

[Brian Cina (Member)]: of anticipation as to where

[Elena (Green Mountain Care Board staff)]: the board might have gone on the profits. However, you can actually put in a condition where you ask the insurer to come back. Should we do this? We'll make it more complicated, but I think it's probably doable with the project to do cross labor. But I think the financial impact would be great, so

[Leslie Goldman (Member)]: So school budgets for?

[Elena (Green Mountain Care Board staff)]: School budgets. 2027,

[Leslie Goldman (Member)]: '28?

[Elena (Green Mountain Care Board staff)]: We don't do school budgets. No.

[Alyssa Black (Chair)]: Vote for them in March. Yeah.

[Leslie Goldman (Member)]: They vote for them in January '28.

[Alyssa Black (Chair)]: Well, it would help them build back their reserves. And it

[Brian Cina (Member)]: would lower the prices of the hospitals before the insurance premiums get affected too, wouldn't it?

[Leslie Goldman (Member)]: I'd be curious to know if that kind of time It would affect

[Brian Cina (Member)]: the hospital budgets first? Correct. Yeah, so the hospital prices will be lower before the premiums go down. So it's like the impact rolls out over What I like about this is it's like you're building a better ramp onto the reference based pricing freeway.

[Alyssa Black (Chair)]: I love that. This is like

[Brian Cina (Member)]: a better designed ramp And onto the

[Alyssa Black (Chair)]: I want to remind everyone that VHI plan, typically, most of them have high deductibles that are through and funded through an HRA. So January 27, it would immediately reduce out of pocket costs, which in turn would reduce. So they would see savings immediately just because of They schools. The employees, the beneficiaries.

[Leslie Goldman (Member)]: I'm thinking about taxpayers.

[Alyssa Black (Chair)]: Taxpayers are funding those HRAs. Well true. Have, wait, I've had some, did I? Did

[Brian Cina (Member)]: you make your My comment, I threw it in there. It was that ramp analogy. I like this. Yeah, I like this. Like where we're going.

[Unidentified Committee Member (former AHS staff)]: Comment is the choo choo train.

[Alyssa Black (Chair)]: We're on a reference based pricing highway. I just had a quick question for you. I have Dave first. It's David, then you. Just

[Unidentified Committee Member ('David')]: going to put more pressure on the hospitals. I know you're probably not the right person to be asking. It's a concern.

[Alyssa Black (Chair)]: Well, it is a concern, which is actually why I took out anything to That the legislature is doing that. I mean, it's the board. And the board is going to be putting pressure on the hospitals anyways in their rate review. This just gives them a mechanism where we can target that to these groups. So nothing we do here or in this bill is going to insulate. Well, actually, no. If we did what is currently in 01/1990, a 250% cap, that would have the effect of us hurting hospitals. This puts it on the board to figure out what can they do that won't hurt hospitals and then using this form of reference based pricing to enforce their budget orders. Okay. Wait, Tara.

[Jen Carvey (Office of Legislative Counsel)]: It's sort of related. When you think about delegating the expertise and authority to the Green Mountain category, Do you envision that the reference based pricing would be uniform across the board? Does it necessarily work that way, or can

[Alyssa Black (Chair)]: it be calibrated to different hospitals? Well, based pricing that we currently have that we are moving towards that the board is working on, they have the ability to develop it in any way they They have flexibility. It could be targeted to each individual hospital. Thoughts on reference based pricing when we did it last year was that it's done in concert with the healthcare strategic plan that is for hospitals and hospital transformation in trying to incentivize hospitals to do the services that their communities need, and so that they're receiving the money for those services rather than others. So the board has enormous flexibility on how they design, which is why it takes some time. Oh, go ahead.

[Elena (Green Mountain Care Board staff)]: One comment to answer the question, well, it hurt hospitals. Anytime there's less money to hospitals than canary hospitals, at the same time, what we're seeing is the drop in insured lives. That also hurts hospitals. Fewer lives that are insured hurts hospitals. As the prices go up, it hurts hospitals too, which I think, as I'm reading this, the balance is really hard to strike. You're either hurting hospitals by charging too much or hurting by charging too little. You're hurting the people who pay the insurance, you're hurting the taxpayer, you're hurting the non hospital, there's just hurt everywhere is really the point that's challenging. So I think the goal of this, with the language about consistent transformation is important because we know transformation is going on, especially an input that we could take in considering where

[Brian Cina (Member)]: You know,

[Unidentified Committee Member ('David')]: there's the hospital transformation plan, which is about two years out or whatever, right?

[Elena (Green Mountain Care Board staff)]: There's transformation going on right now.

[Unidentified Committee Member ('David')]: In individual hospitals?

[Jen Carvey (Office of Legislative Counsel)]: Two years out is the healthcare delivery strategic plan. There no transformation

[Unidentified Committee Member (former AHS staff)]: date.

[Unidentified Committee Member ('David')]: That's too bad.

[Alyssa Black (Chair)]: Yes, it is date, actually.

[Elena (Green Mountain Care Board staff)]: Thank you.

[Brian Cina (Member)]: Not too late to add one.

[Alyssa Black (Chair)]: Brian, and then I want to We are

[Brian Cina (Member)]: I wrote it down so I can be focused that the way I'm seeing this, and so I can be corrected if I'm misunderstanding this, but sometimes it helps to repeat it back and make sure I understand it, and I think it actually helps others understand it sometimes. We're increasing the amount of patients impacted by this policy decision, because we're expanding the pool that we're going to apply the reference based pricing to. We are, I think, protecting the providers more, because we're empowering the Green Mountain Care Board to work with them to determine the right rate. We're not forcing a rate on them based on the limited knowledge we have. We're giving them time and space to work that out. So I feel like that's a benefit. And I think that what I'm hearing is that as the price goes down, utilization may go up because people are avoiding utilization because the price is high. There might be a way that Green Mountain Care Board and the hospitals can figure that out. I think that's Green Mountain Care Board's job, and I'm glad that they seem up to the task. And then the last thing is that I like about this, well, it's the last thing I'm gonna say that I like about it, is that I feel like we're empowering the payers and the providers to negotiate a better deal for the patients and for the state, versus imposing it on them. We're asking them to do something, but we're not just locking them into it. I like that there's a negotiation aspect, and I believe that in good faith, can improve things. So I think this is an improvement to the bill. I'm excited that you had Jen write it.

[Alyssa Black (Chair)]: I'm not

[Jen Carvey (Office of Legislative Counsel)]: sure there's a negotiation aspect. That's the only piece I wanna

[Brian Cina (Member)]: Yeah, can you clarify that?

[Jen Carvey (Office of Legislative Counsel)]: I think the amount is determined, the percentage of Medicare is determined by the Green Mountain Care Board and applied by the payers and providers.

[Brian Cina (Member)]: Is that, that's the part where it talks about them setting the reimbursement rates? Well, says they I do want to understand it properly. So if I'm not, it

[Elena (Green Mountain Care Board staff)]: would be good for you to clarify.

[Jen Carvey (Office of Legislative Counsel)]: I don't believe there is a negotiation. Just want to be

[Alyssa Black (Chair)]: Can I, in a really basic, basic kind of way, explain how? So let's say the Green Mountain Care Board says, we think comfortably we can remove $50,000,000 from the system. The Green Mountain Care Board will make an assessment on where they've set the cap for these two markets that will draw 15,000,000 out of the system, the hospital system. It could be, they'll say, oh, well, this year we're gonna do 400%. And then next year they can say, We feel as though another 50,000,000 can safely be done. And they can say, We're going to reduce it to 300%. So they're using the reference based pricing on these two markets as the tool to bring down, bring money out of the system that they determine is a I keep using the word safe, but I want to say safe, in their estimation, reasonable. I mean, I

[Jen Carvey (Office of Legislative Counsel)]: think you're right that it is a cap. Yeah. So it's possible there could be a negotiation that results in a lesser payment?

[Brian Cina (Member)]: That's what was hoping it's like the prices of the specific services. There may be some negotiation on that, but maybe I'm wrong.

[Jen Carvey (Office of Legislative Counsel)]: But they're going to have a cap. Mean, throughout it, it's the limitation on the rates based on a percentage of the Medicare adjusted base rate.

[Elena (Green Mountain Care Board staff)]: It's

[Jen Carvey (Office of Legislative Counsel)]: prohibiting payers from reimbursing or going to reimburse more than those rates. But I don't know that realistically, it's going to result in a big negotiation. They'll be negotiating below the cap to the extent

[Unidentified Committee Member]: that- That's what I

[Brian Cina (Member)]: was thinking. It's like, this is a problem. Just what I was getting at is like, the Green Mountain Care Board sets a limit, but are we giving the carriers and the hospitals the freedom to say, is this price going to be $10 or $15 and this one going be $10 or $15 and determine how they set the rates under the cap? That's what I was getting at.

[Jen Carvey (Office of Legislative Counsel)]: Well, they're setting a reference based price for each item and service.

[Brian Cina (Member)]: There has to be a specific percentage set by the Green Mountain Care Board.

[Jen Carvey (Office of Legislative Counsel)]: Well, it's limitation on rates based on a percentage of Medicare. So that the Medicare does face rate. So I think technically it is a cap. I just don't know how much actual negotiation would But I've not been involved in those, I should stop the pining.

[Brian Cina (Member)]: I don't need to belabor the point. I think it's good enough, even if I don't fully understand it.

[Alyssa Black (Chair)]: I mean, if right now they pay under that, it's not like you would go up to that. It's just a cap

[Brian Cina (Member)]: You cannot go above this. Yeah, we're tightening the belt.

[Unidentified Committee Member (former AHS staff)]: Did I

[Alyssa Black (Chair)]: see another hand? I don't remember.

[Elena (Green Mountain Care Board staff)]: Do you want to

[Alyssa Black (Chair)]: keep Yeah, we need to pen continue. And Now

[Jen Carvey (Office of Legislative Counsel)]: we have some additional cost cost containment and health benefit plans for sole employees. So these are two new sections, section four and four a. Section four amends the public employees public school employee benefit commission duties, where they, under current law, determine the amount of participating employees' calendar year out of pocket expenses for which the school employer and participating employees will be responsible and whether the school employees will establish a school employers will establish a health reimbursement arrangement, HRA, health savings account, HSA, both or neither, for their participating employees. This would add language saying, provided, however, that the actuarial value of any health benefit plan offered to school employees, inclusive of any out of pocket expenses for which the school employer is responsible, shall not exceed that of the qualified health benefit plan with the highest actuarial value offered through the Exchange in accordance with the Exchange subchapter. It also strikes language giving the Commission the discretion to determine the extent to which the employer or employee will bear first dollar responsibility for out of pocket expenses if using a health reimbursement arrangement to require participating employees to bear first dollar responsibility. It does still give the Commission the authority over whether the balance in an HRA would roll over from year to year. Under existing law, directs the Commission to or allows the Commission to make recommendations regarding the health benefit plan design to VIHI, to any Intermunus Full Insurance Association that offers health benefit plans to entities providing educational services. My understanding is we just have one, that's VHI. And it would direct them to coordinate with the association or associations to ensure that the actuarial value of the plans complies with requirements in subdivision B1. And then similar language would go into that BIHI statute, the health benefit plans offered to entities providing educational services in Title 24, where it requires the Health Benefit Association to solicit the input of the Commission on Public School Employee Health Benefits on the design of the health benefit plan or plans to be offered to school employers for coverage of their school's employee needs. It would require them to coordinate with the Commission to ensure that, as specified in that provision in the last section, the actuarial value of the plan or plans inclusive of any out of pocket expenses for which the school employer is responsible do not exceed that of the qualified health benefit plan with the highest actuarial value offered through the exchange. Struck the report on implementation of reference based pricing for certain public employee health plans. So obviously, we'll get more testimony on this.

[Alyssa Black (Chair)]: I included this based upon the testimony that we heard the other day, plus testimony that we took last year on the plans. And, you know, it's often suggested that we do reference based pricing as a pilot to and relegate it to DeHyde. And essentially with this bill, with the reference based pricing piece of it, it extends this early adoption of reference based pricing to VIHI. However, I think we heard the other day that their current plan has an actuarial value of between 96 and 97. And this would essentially make it and they said that they are starting negotiations and starting planning for the 2029 year. This would take effect 2029. So this would be for their next iteration of design that it could not exceed highest actuarial value on the exchange, which I believe currently is

[Jen Carvey (Office of Legislative Counsel)]: 90. Under the changes. Right, because there's the potential 90 is the platinum, but there's a plus or minus 2%, I think on all plans except bronze, which has a broader one. So it could be as high as 92%. Right.

[Brian Cina (Member)]: So the first sections of this, I still enthusiastically support. This part, I think we need to hear more about labor law and make sure that we're not going too far into the process of negotiations.

[Jen Carvey (Office of Legislative Counsel)]: Because you're applying this prospectively for contracts that have not been negotiated, I don't believe there's a problem. I have run it by my colleague who handles labor. That was

[Brian Cina (Member)]: exactly my question. We can hear from witnesses and figure it out, but that's my concern.

[Alyssa Black (Chair)]: Jen thought of that because Jen thinks of it.

[Brian Cina (Member)]: Thank you for thinking of it.

[Unidentified Committee Member (former AHS staff)]: How many lives?

[Alyssa Black (Chair)]: There's about 20,000, I looked it up.

[Brian Cina (Member)]: I looked it up about, oh, it's worn out. Okay, sorry. Old news.

[Alyssa Black (Chair)]: 40 families

[Brian Cina (Member)]: and 35. I might have missed a category. I was trying to add them all together.

[Alyssa Black (Chair)]: That was my question.

[Leslie Goldman (Member)]: How did it affect our established contracts going forward?

[Jen Carvey (Office of Legislative Counsel)]: That's why the timing is what it is. Oh, I

[Elena (Green Mountain Care Board staff)]: have one other quick question.

[Brian Cina (Member)]: And if you don't know it, another person in the room might be considering all the brains in here right now, but I'm not being sarcastic. One of you has to know this. If not, I'll be shocked. It's how many people or how many lives are in the QHP market?

[Jen Carvey (Office of Legislative Counsel)]: That's a Mike Fisher question. 30,000

[Elena (Green Mountain Care Board staff)]: ish in that small group, and maybe it's down to 28,000.

[Brian Cina (Member)]: About 58,000?

[Leslie Goldman (Member)]: Well, 70,000, yeah. So what I'm getting

[Brian Cina (Member)]: at is that we could potentially affect 90,000 lives. That's almost a sixth of the state with this action. That's pretty significant. I'm just acknowledging that that feels meaningful to me, that that many people would be quickly impacted. Well, maybe not quickly, but in the grand scheme of government quickly.

[Alyssa Black (Chair)]: I think, you know, I mean, largely I was thinking, again, we keep talking about affordability and well, yes, obviously educators contribute to their health plan, that is taxpayers paying for that. So property taxpayers and other taxpayers.

[Jen Carvey (Office of Legislative Counsel)]: Shall we go? I'll keep going. Yep. Yep. Alright. There. So as I've mentioned, it would strike out this report on implementation of reference based pricing for certain public employee health plans. And report back. Then no changes to the next several sections. So no changes in hospital outsourcing, the health care professional bargaining groups, bills agreement and care board orders, or data infrastructure. It would strike the Public Employee Health Benefit Authority Study Committee in the next several pages. And I don't know if you

[Alyssa Black (Chair)]: want to speak to that. Oh, this was the section 10. To be honest with you, the original amount appropriated for this, I think was Nolan put 30 to 50 because they hadn't gotten back to the treasurer came back that it would be 350,000 for them to do this. And We don't have $350,000 That's me, though. Brian?

[Brian Cina (Member)]: I support taking this out for an example, because if we do reference based pricing, this may be irrelevant. And I just feel like we have enough studies going on right now. There's only the capacity, we're hitting the threshold. I've seen us do too many studies in ten years that we don't even look at. Well, I don't want to be that dismissive. We look at it, and then we don't We look at them. Some of us read it carefully. Some of us fight for it. Others don't. But I don't feel like we do what the studies say a lot

[Elena (Green Mountain Care Board staff)]: of the time.

[Brian Cina (Member)]: So I'd rather not waste money. Not to be harsh, but I

[Elena (Green Mountain Care Board staff)]: think it was a good move. Thanks.

[Jen Carvey (Office of Legislative Counsel)]: I'll add a couple of pages. And then there are changes in the last section as well. So this is the critical access hospitals and Medicare outpatient cost sharing. So it starts out by acknowledging that the General Assembly and the Green Mountain Care Board have recently become aware of a federal requirement that Medicare beneficiaries must bear financial responsibility for 20% of the amount charged for outpatient services delivered by critical access hospitals, not 20% of the amount that Medicare pays for the service. While the General Assembly understands that it cannot invalidate this federal requirement, it also recognizes that both that this requirement has a significant unfair and negative financial impact on Medicare beneficiaries in the state's most rural communities and that Vermont's critical access hospitals are some of the state's most financially vulnerable health care facilities. Expresses the intent of this section to begin to provide some relief for Vermont seniors and other Medicare beneficiaries the consequences of the federal requirement promptly, while a working group of interested stakeholders endeavors to develop appropriate and enduring solutions that do not undermine the financial sustainability of our critical access hospitals. It has by September 1, each critical access hospital identifying all the outpatient services for which the amount that the hospital charges equals five or more times Medicare allowed amount for that service. And for each outpatient service identified, the hospital shall reduce its charge for that service in hospital fiscal year twenty twenty seven to be less than or equal to five times the Medicare allowed amount. It then says that to the extent that the Green Mountain Care Board engages in efforts to address the Medicare outpatient cost sharing issue in hospital fiscal year twenty twenty seven, the Board shall consider any proposals from the critical access hospitals and other interested stakeholders and shall ensure that its actions are consistent with ongoing hospital transformation efforts and the principles for health care reform expressed in statute. And it gets rid of this working group. It's my understanding there is a non legislatively created working group happening now, and it takes out the report back and the prohibition on the board taking steps to address.

[Alyssa Black (Chair)]: So the thoughts behind this, I will say, this is the cost sharing issue that we've heard about. While this does not address it, we heard about those extreme outliers in which when a patient, I mean, it's not going to get to the cost share where they're paying 40 some or 50 some or 60 some or even 90 some. But there were those extreme instances where if the price was more than five times what the cost of care was, then the patient would actually end up paying more than 100% and that money is returned to the federal government. So, makes it so that no patient cost share would ever be more than 100%. It's not perfect, but working groups are working on it. And I just want to remind, in the first section on reference based pricing, critical access hospitals are exempt from that QHP and ZHI thing. And so I thought, okay, people are looking at it, but can we at least this year, can we at least identify just the truly egregious examples and at least reduce them so that people are not paying more money and that money is just going to Medicare. I've got Leslie and then.

[Leslie Goldman (Member)]: I'm just curious to know where the five times came from and what that amounts to.

[Alyssa Black (Chair)]: It has to do with the 20%. And if it's two times, then the person would pay 40%. If it's three times, the person would pay 60%. If it's four times, Yes. The person would pay 80 And then at five times, they would be paying 100%. But there are cases where sometimes it is six times, and so the person would be paying 120%, and the critical access hospital doesn't even get that 20%. No, get that piece.

[Leslie Goldman (Member)]: That's where the five times scope starts. Just wondering if five times is the right number. What is the right number?

[Alyssa Black (Chair)]: It's a first step. That's why I put it in. But we can argue or not argue, but we can discuss Yeah, I'm

[Leslie Goldman (Member)]: just curious if there's a better number. Is there a fair number or not? Maybe this is the best number ever. Is there a fair number?

[Alyssa Black (Chair)]: I don't know that. I think that this is year one and the working group, what is the language that essentially figure out?

[Jen Carvey (Office of Legislative Counsel)]: We're developing appropriate and enduring solutions. Don't Yes. Undermine the financial system.

[Leslie Goldman (Member)]: No, I get that piece and that's great. But I'm just thinking about the people that in the meantime are paying to the critical access hospitals that five times amount. I don't know how many people. I don't know what that amount is. It'll be different for different procedures,

[Alyssa Black (Chair)]: I'm sure, or whatever it is. But I think the intent language we put in there, understanding that we have some critical access hospitals that are financially vulnerable.

[Leslie Goldman (Member)]: Once again, problem is our rural Medicare payers responsible for that.

[Alyssa Black (Chair)]: This doesn't mean that the Green Mountain Care Board isn't going

[Jen Carvey (Office of Legislative Counsel)]: to go through their regular hospital budget. Right. It strikes the language saying they cannot, and it just says to the extent that they do undertake additional efforts this year, they must consider proposals from the critical access hospitals and other interested stakeholders to make sure they're being consistent with hospital transformation and the principles for health care.

[Leslie Goldman (Member)]: So they could say not five times. They could say less than five. Is that what you're saying?

[Jen Carvey (Office of Legislative Counsel)]: They regulate hospital budgets. So to the extent that that authority flows through to additional directives they give to the hospitals and what they charge, yes.

[Leslie Goldman (Member)]: I guess because they're just identifying at that point.

[Jen Carvey (Office of Legislative Counsel)]: They're identifying, and then they're reducing their charges for all of those to five times.

[Leslie Goldman (Member)]: So five times.

[Jen Carvey (Office of Legislative Counsel)]: The board may

[Alyssa Black (Chair)]: do other things. This is I'm just gonna say, this section is just around this issue. It doesn't mean that the Green Mountain Care Board isn't doing their regular hospital. I want you to understand that.

[Unidentified Committee Member]: Look,

[Alyssa Black (Chair)]: I'm not going off.

[Jen Carvey (Office of Legislative Counsel)]: It's just

[Leslie Goldman (Member)]: we're thinking about that section, and that was the section 11 that came previously, and now here's a new version, and it's still addressing the Medicare critical access hospital problem. I get that.

[Brian Cina (Member)]: So maybe there's a witness we can ask about the number five and get their opinion as we take further testing.

[Unidentified Committee Member (former AHS staff)]: All right, so just as

[Jen Carvey (Office of Legislative Counsel)]: far as the effective dates, most of it would still take effect on passage, The changes to the health benefit plans for school employees in sections four a four and four a would be applicable for plan year 2029 and thereafter. And if you make changes to the contents of the bill, you will want to we may want to update the title accordingly since it currently respond refers to the public employee health benefit authority.

[Brian Cina (Member)]: Are you gonna change the name? Is that what you just said?

[Jen Carvey (Office of Legislative Counsel)]: That's what I'm flagging here. Okay. That we will need to figure out what that is once we know what all is going and going.

[Brian Cina (Member)]: Can we come up with something really creative?

[Unidentified Committee Member (former AHS staff)]: No. Some committees do.

[Alyssa Black (Chair)]: So can I get general thoughts from the committee on either general support, on whether I'm just putting this forward? So we haven't done anything to the bill yet. This is a proposal for a strike ball amendment. And I just wondered if anyone had general thoughts on this compared to what we currently have. And how do people feel about these things that Jen has just read to us? Sure. I am very, very grateful

[Jen Carvey (Office of Legislative Counsel)]: to you and anyone else that has thought this through in this way. It's a wonderful improvement. I'm very supportive of this work, and I

[Alyssa Black (Chair)]: appreciate It's great. Yep, go ahead. I was worried about this part of it, because it felt like we owed it to the public to speak on this, and

[Elena (Green Mountain Care Board staff)]: am part

[Unidentified Committee Member (former AHS staff)]: of it.

[Brian Cina (Member)]: On the other part were you talking about?

[Alyssa Black (Chair)]: The disparage in the reimbursement with Medicaid. And I like it. I know that the Cream Mountain Care Board is working on it. My only question about this is, this directly to you, Alyssa, because you are somebody who did the charge master thing. How many are going to identify people who are not getting charged correctly? They know what their charge is, and they know what their there's an

[Unidentified Committee Member (former AHS staff)]: easier way to do this.

[Alyssa Black (Chair)]: So know Medicare costs. Remember, these are only outpatient. So it's only on outpatient charges. Yeah. Okay, I just don't want to see an administrative burden. That is it. I would say that all hospitals and all healthcare facilities should be evaluating all their charges all the time, but, you know, okay. Any other thoughts on this? Yeah, go ahead. I, My thoughts, Warren.

[Unidentified Committee Member ('David')]: Again, I'm concerned about the hospitals. I don't wanna put too much pressure on them. I know it's up to two and a half percent, but that's a lot. The Green Mountain Care Board, I'm sure, is going to look at it closely. But is it possible for us to hear from the hospital one more time of whether they can

[Alyssa Black (Chair)]: That was going be my next question. Did anyone have any other thoughts?

[Brian Cina (Member)]: Brian? So I support the reference based pricing piece. I said that already. I think giving my understanding is that the percentage that we're saying is the highest they will go and that Green Mountain Care will have the freedom to go low, can go 0.01%, that's what's safe, they determine that. And we're not going to meddle, which we were meddling in the previous one more. So I think that's a straight shot, so I like that. I like that we expand the pool. I'm not convinced, it's not that I don't believe Jen, but I had a union publicly transparent text me concerns about collective bargaining. So if any union is reaching out to me with that, I think we at least need to hear more testimony before we move forward with that piece around the actuarial value piece. So that's what I would ask for is if we hear from the unions and maybe from our alleged counsel Jen consulted with and get a few perspectives on that before we make that decision, That's my feedback. But other than that, think the Medicare part, I want to respect Leslie's concern about why we're choosing the number five and maybe hear about that, but I like the idea.

[Alyssa Black (Chair)]: You. Great. And that's perfect for me to be able to say, if you think we're not going to take any testimony on this, you can think again. However, we are running out

[Unidentified Committee Member]: of it.

[Brian Cina (Member)]: Yeah, we are.

[Alyssa Black (Chair)]: So I, instead of me sitting around saying, did we talk to this person? Did we talk to that person? I'm asking anybody listening or anybody in the room, get on the list and we're going to get you on the list. And we want to hear from you. We want to hear from everybody who this affects. Absolutely.

[Brian Cina (Member)]: Like this is their notice.

[Alyssa Black (Chair)]: They'll raise people. Here's your notice.

[Brian Cina (Member)]: Last call for testimony.

[Alyssa Black (Chair)]: So it would just help us out with planning if you would come to us and tell us. Am going to since Jen's sitting there, I'm going to have Jen walk us through some language on S-sixty four. I was going to have the language that Jen, I'm going have her introduce that. I wanted to talk about that, see how far we got. I will tell everyone, I'm sorry, I don't think we can get to a vote today, but Jen is with us tomorrow at nine and we can push 197, which we have on our current agenda, and we will put S-sixty four on the current agenda. I mean, the agenda for tomorrow morning at 9AM. That

[Elena (Green Mountain Care Board staff)]: Sorry, you're not getting that set. What's that? I'm

[Alyssa Black (Chair)]: going to see how far we can get. But yeah, I don't think so, because we have a hard stop at, seriously, like 04:25, 04:30.

[Brian Cina (Member)]: Which is in seventeen minutes. Yeah.

[Jen Carvey (Office of Legislative Counsel)]: Dan, and I'm going to be, I'm trying to

[Elena (Green Mountain Care Board staff)]: Are we doing S-sixty four?

[Brian Cina (Member)]: Is that what I heard? Yes. Okay.

[Alyssa Black (Chair)]: This is, Jen has prepared two amendments. One is around what we're doing about with the SPA State Plan Amendment, because we did learn the course of this that getting a State Plan Amendment wasn't in the bill that came over from the Senate, Ashley and Berbeco testified. So Jen has done some language with that. And then I also have some language which Tasha will post, and we can talk about that. And then obviously tomorrow that'll give us something to think about overnight.

[Brian Cina (Member)]: We don't have plenty to think about. Is it here or is it getting moist in here?

[Alyssa Black (Chair)]: It is. It's wet. The interested parties around the world. I'm not sure because I'm not following but can you help us any professional need this yet? Oh, that's right. That's one of the reasons you can't be with us because you're running the box. Just to let you know, this bill has to go to GovOps, but GovOps has already started taking testimony on it, or they're starting their testimony. So it's not like they're waiting for this to go through know, go on notice and then get referred, that sort of thing.

[Brian Cina (Member)]: But it could die in

[Alyssa Black (Chair)]: the box if we don't get it. And they're able to do that, by the way, because they actually have a bill on there, a companion bill on the wall. So they're taking testimony on that bill. Yeah. Go ahead. Hey.

[Jen Carvey (Office of Legislative Counsel)]: Put up the word Virgin for now. This is s 64, an act relating to amendments to the scope of practice for optometrists. It would strike out the effective date section and then put that and two new sections in. So, Section six would become a new provision in Title 33 in the Medicaid Chapter on Medicaid coverage for services delivered by an optometrist holding an advanced therapeutic procedure specialty. This would direct Vermont Medicaid to cover services that are within the scope of an optometrist holding an Advanced Therapeutic Procedure Specialty issued pursuant to the new sub chapter in the bill, to the same extent that the services will be covered if they were delivered by a physician licensed under either of our physician licensure statutes. So by effectively by an ophthalmologist. Section seven directs the Department of Vermont Health Access to seek a state plan amendment from the Centers for Medicare and Medicaid Services take effect on 07/01/2028, which is when the specialty takes effect to allow Vermont's Medicaid program to provide coverage for services delivered by an optometrist who is a Medicaid participating provider and holds an advanced therapeutic procedure specialty as set forth in the new section as added by this Act. And then we have the effective dates. So the Medicaid coverage, the State Plan Amendment section would take effect on passage. Section six, which is the Medicaid coverage itself, would take effect on the later of 07/01/2028, or approval of the State Plan Amendment requested pursuant to Section seven. The remaining sections would still take effect on 07/01/2028.

[Alyssa Black (Chair)]: Yeah. Hope that's easy.

[Unidentified Committee Member (former AHS staff)]: This might be a stupid question, but why do we need legislation for these two things? Because we do spas all the time, and we don't they don't all run through this committee.

[Jen Carvey (Office of Legislative Counsel)]: There's not so, in this case, if we want Medicaid to cover these services, they are not currently covered. So we would be directing coverage of them. And in order to get coverage, we would have to amend the state plan. So in my mind, it's almost less about specifically legislating the state plan as it is the coverage. Without this, Medicaid does not cover these services by an option. Right? Because of the limitations of the state plan amendment. That's my understanding from Ashton's testimony. And I don't know the extent to which we amend the state plan, but often we amend it to reflect changes in legislation.

[Elena (Green Mountain Care Board staff)]: I think we do it often,

[Unidentified Committee Member (former AHS staff)]: so I'm just trying to understand that process better. I think we run all of them.

[Alyssa Black (Chair)]: I just feel like every time we've expanded any sort of coverage to Medicaid, we always have the little state plan amendment. Yes.

[Jen Carvey (Office of Legislative Counsel)]: And we're asking that usually when we're asking them to cover something new or if we're looking to get federal financial participation for something, we may look to amend the global commitment demonstration, which we don't don't need to do that here because it's a it's a covered service. It's just not a covered service by this provider.

[Unidentified Committee Member ('David')]: Can the governor's office change this state plan?

[Jen Carvey (Office of Legislative Counsel)]: I mean, the executive branch.

[Unidentified Committee Member ('David')]: Executive branch plan?

[Jen Carvey (Office of Legislative Counsel)]: Yes. They're the ones who apply for it.

[Unidentified Committee Member ('David')]: So it doesn't necessarily have to go through the legislature. Could go through

[Leslie Goldman (Member)]: Not everything needs to be.

[Jen Carvey (Office of Legislative Counsel)]: To no, it wouldn't have to go through the legislature. I suppose it wouldn't have to go through the legislature if that was a something that the executive branch was interested in pursuing as a policy on their own.

[Unidentified Committee Member ('David')]: Who else can manage the state plan?

[Jen Carvey (Office of Legislative Counsel)]: It really has. I mean, the agency of human services is the single state agency for Medicaid. So they are the ones who can change the state plan and through them, Department of Vermont Health Access.

[Brian Cina (Member)]: Can the federal government also change state plan on us?

[Jen Carvey (Office of Legislative Counsel)]: I don't know. Depends what's on the page.

[Unidentified Committee Member (former AHS staff)]: I wouldn't read

[Alyssa Black (Chair)]: Well, a state

[Jen Carvey (Office of Legislative Counsel)]: mean, a state plan is our, I believe is our agreement with the federal government for how we implement our Medicaid program. So I know if they can unilaterally change our state plan, but they can change policies that have the effect of For negating things that are

[Brian Cina (Member)]: example, they could say Medicaid cannot cover gender affirming healthcare, and even if it's in our state plan, if they do that, then our state plan can't cover it.

[Jen Carvey (Office of Legislative Counsel)]: Our state plan cannot override federal law.

[Brian Cina (Member)]: Yeah, that's what I thought. So that's the power they have then, is they could change federal law and it would affect our state law.

[Jen Carvey (Office of Legislative Counsel)]: Yes, that's fair. So this is

[Unidentified Committee Member (former AHS staff)]: just to ensure that we move forward with coverage of these services and that the SPA is initiated, regardless of what the executive branch or the Medicaid office prioritizes. We're making sure that there is a timeline for coverage of these services with this amendment, correct?

[Jen Carvey (Office of Legislative Counsel)]: Yes, and that they will be covered by Medicaid. Without legislation, they are not covered now, and there would be no requirement that they be covered.

[Alyssa Black (Chair)]: I see another

[Jen Carvey (Office of Legislative Counsel)]: This is covered in other states. Do we need it specifically for Vermont? Because we do not cover it per our state. Our Medicaid state plan does not include coverage of advanced therapeutic procedures performed by optometrists. So each individual state has their own state plan? Yeah.

[Alyssa Black (Chair)]: What was it? How many pages when you were looking at

[Unidentified Committee Member (former AHS staff)]: If you remember when we

[Jen Carvey (Office of Legislative Counsel)]: were working last year, for those of you who are here on the freestanding birth centers, I looked in our Medicaid state plan and you could see that there was an X saying we did not cover services provided at a birth center because we didn't have any birth centers. So that was something that needed to be amended to reflect that change in the state's policy. Someone

[Unidentified Committee Member]: correct me if I'm wrong, but if we go on this amendment and it passes this levy, then it goes where? It's

[Jen Carvey (Office of Legislative Counsel)]: it's adding sections six and seven to the what happens to the bill? Yeah. I mean, I think I'm not sure if it is going officially to DevOps or if it is going unofficially to GovOps and officially to Ways and Means.

[Alyssa Black (Chair)]: I think the clerk is We telling

[Elena (Green Mountain Care Board staff)]: knew this. But

[Jen Carvey (Office of Legislative Counsel)]: it doesn't mean it's going to Ways and Means anyway.

[Unidentified Committee Member]: Okay, so then that's going to take time. Then it goes to the Senate.

[Alyssa Black (Chair)]: It will stay on the wall. Go back to the Senate as amended. This bill will be dead,

[Unidentified Committee Member]: and I've had too many friends and people at home who want to see this pass.

[Alyssa Black (Chair)]: It has to go to ways and means anyways. And I assure you, it has to go to GovOps. Betsy Hahn is not sending

[Elena (Green Mountain Care Board staff)]: it

[Alyssa Black (Chair)]: to GovOps because they 20 passed the professional

[Unidentified Committee Member]: seven to three? Yes. And we're trying to amend it? We're

[Alyssa Black (Chair)]: trying to get Medicaid coverage. As it came from the Senate, it is the epitome of that wall behind you.

[Unidentified Committee Member (former AHS staff)]: But this strengthens that because it ensures

[Alyssa Black (Chair)]: But it that won't go anywhere. Why? Because it will have to go back to the Senate and it will get stuck on the wall. We need to pass it as is. So we can get this. There's one optometrist in the Northeast Kingdom. We need this bill. We need this bill as it is. The governor can add domestic.

[Brian Cina (Member)]: Oh, see your point. They can, the AHS can do it.

[Alyssa Black (Chair)]: They don't do it. We don't have to tell them to.

[Brian Cina (Member)]: I think I hear you. You're saying like, if we amend it, it's gonna kill it because if we pass it

[Elena (Green Mountain Care Board staff)]: as is, it'll just pass. I see your see your point.

[Jen Carvey (Office of Legislative Counsel)]: I think what I would want to ask Ashley, I don't know the extent to which they do or do not need to be directed by the legislature. To do a spot. To have to require Medicaid coverage. But it could be delayed a year. That's already '20 what? 2028.

[Alyssa Black (Chair)]: Right, but

[Leslie Goldman (Member)]: we could do that in the meantime.

[Brian Cina (Member)]: We could do that next year, the state plan thing. Let's pass this so they can

[Elena (Green Mountain Care Board staff)]: get moving.

[Brian Cina (Member)]: Hear your point. Is that

[Leslie Goldman (Member)]: a possibility? No, I'm just wondering.

[Alyssa Black (Chair)]: Moving like the Medicaid coverage? Well, you'd have to put a bill in next year.

[Brian Cina (Member)]: Right. We're tacking on to an omnibus bill. Yeah, We could stick it on

[Alyssa Black (Chair)]: the ground.

[Brian Cina (Member)]: Six seven. Sorry.

[Elena (Green Mountain Care Board staff)]: The kids

[Brian Cina (Member)]: are rubbing off. But six eleven's

[Elena (Green Mountain Care Board staff)]: a vehicle where we can do an extra. We could

[Brian Cina (Member)]: put it in the budget, like everything else that people sneak in.

[Alyssa Black (Chair)]: Yeah, let's just get stuff

[Elena (Green Mountain Care Board staff)]: out I of don't care.

[Brian Cina (Member)]: That's the most passionate I've seen you, yeah, I appreciate it.

[Unidentified Committee Member (former AHS staff)]: No one wants to add this

[Alyssa Black (Chair)]: to it, So we're not gonna have Medicaid coverage of it.

[Brian Cina (Member)]: I wouldn't say I don't want to, I would say I'm honoring the concern that it'll kill it if it gets delayed.

[Unidentified Committee Member ('David')]: I would say that we request either from the executive branch, and I don't know how exactly that works, or AHS to include in kind of Cina and Innsco.

[Unidentified Committee Member]: I think in general Listen. This isn't gonna go in effect till 2028. We can put a bill in That's right. Next year upon passage, and it'd be ready to go.

[Brian Cina (Member)]: But in the meantime, OPR and others can get moving. I hear your point 100%, having-

[Alyssa Black (Chair)]: Not that you sound bad. No, but you articulated it I need to say it loud.

[Unidentified Committee Member]: No, no,

[Brian Cina (Member)]: you articulated it clearly and it was shocking to me to learn you only have one optometrist available to your constituents. Oops. The point is there's a lack

[Elena (Green Mountain Care Board staff)]: of access and we need to create access. I'll send an email to Ashley, so I

[Jen Carvey (Office of Legislative Counsel)]: will at least have that information for you.

[Unidentified Committee Member (former AHS staff)]: I don't understand why this would help. That's why I say I don't,

[Alyssa Black (Chair)]: it doesn't matter to me. If it passed the Senate 27 to three, why would you think it would get held up in the Senate? I think there's some

[Unidentified Committee Member]: politics involved in this chair of the mic.

[Alyssa Black (Chair)]: Yes, but

[Unidentified Committee Member (former AHS staff)]: I want

[Alyssa Black (Chair)]: to remind everybody what happens when a bill moves that's been amended, and it goes onto the calendar. It doesn't get referred to a committee, so it doesn't go onto a wall. It it goes on the calendar on notice, and then the next day, it comes up for a vote. It doesn't have time to go back to the senate. How does it not have time to go back to the senate? Gotta go to go box and

[Unidentified Committee Member]: Oh, we to know any

[Alyssa Black (Chair)]: raise the raise and appropriations. That's gonna take they're gonna want testimony. We need this bill today. How do we kill the biometrics fence? How are we going to get, because we're amending 197, one hundred eighty nine and one hundred and ninety, How are 187, 189, and 190 going to? Probably not willing to.

[Unidentified Committee Member ('David')]: Well, because some of those are studies that aren't gonna be coming to play as soon as this one will. And we can get this out of committee. And if we need to go to AHS or the executive branch to change the state plan, we can do that. Just going to the through the legislature, just another layer and another step that will slow this down and then get this out of committee.

[Alyssa Black (Chair)]: Jen, can Medicaid add coverage for new things on their own or? Yes, they can. Just turn a code on.

[Jen Carvey (Office of Legislative Counsel)]: I have to defer to Ashley or to IHS. I don't know how they make their coverage. I don't know what's involved in making coverage decisions. I mean, yes, there are certainly some things that they do because Clinical Utilization Review Board recommends it to the commissioner and they make modifications. But I don't know how new coverage gets added. I don't know if others have direct experience with that. Brian?

[Brian Cina (Member)]: Yeah, was thinking more about it, and I want to acknowledge the chair's point that the way the process works, it would go to the Senate, the committee would weigh in on it, but I think to the member from Teach them now. I can't

[Elena (Green Mountain Care Board staff)]: remember your

[Brian Cina (Member)]: town. Waterford. Waterford, my bad. Deb, I was trying to not be so casual. To your point though, I'm surprised how politicized this bill is out of all the bills. There's such a concerted effort, a constant effort to stop it. I can see why you're worried, because every stop, every additional stop is another point of which something go wrong. So I just want to acknowledge that, but I do think Alyssa's right that if that wasn't the case, when we send those other bills over, if we don't do anything too controversial, it'll happen quickly at this point, or it'll come back to us quickly with an amendment or there'll be a conference committee. And that we do have at least two weeks left. Know the speaker's trying to end by the fifteenth, but I would be shocked if we ended by the fifteenth. I hope we're out by Memorial Day. I'm being honest, governor threatening to veto the budget and all that, I've seen this before, it holds us up. So I say that because I don't think the urgency is as bad as it feels, but I think the politicization of it makes it harder, because it's like every day, it's another dramatic email. I could see why you're worrying if you want your constituents to have this, I just want to honor that. But the more I think about it, I don't think there's the urgency I was feeling a second ago, because you're right. So I'm torn, I can go either way. I could pass it as it is, or I could pass it with the amendment.

[Unidentified Committee Member (former AHS staff)]: I support the bill as it came to us. Literally counted emails. And I've done that on one other bill where I had to count the house because I feel like I need to be accountable to my colleagues, and I need to be accountable to my constituents for the way that I vote. And when it came down to it on this one, I went by the numbers because we heard incredibly compelling testimony on both And I'm not going to weigh in on a clinical opinion. I'm going listen to the experts, and they both had equally convincing points. So I went to the numbers, and I support the bill as it came from the Senate. And

[Alyssa Black (Chair)]: if putting this amendment on it is going

[Unidentified Committee Member (former AHS staff)]: to stop it. I'm very confused. I don't know why it would because Medicaid coverage is something that I want for every piece of care. I think parity is very important in this state, and I think especially to our policies behind us. And the timeline of everything, I don't understand. I would follow the chair's lead on the urgency of timeliness and whatnot because the process is I not can't wrap my brain around at all. But anyway, I don't have a problem with this bill. I support passing it. And we do not need legislative action to add this to a state plan amendment. I know that. I've worked with the Medicaid office. I used to work at AHS. We don't need it. And if anything has changed since my time there, which is entirely possible, then we won't have Medicaid members for a while, we can add it later. But I think to be responsible to my constituents and to my colleagues sitting around this table who I know want this bill for their folks, I'm fine to vote it out of here and move on to the next bills that are, frankly a little more

[Alyssa Black (Chair)]: impactful. Well, I will tell you, it is 04:32, and I am now too late, two minutes late for a meeting. We're going to 04:30. We will vote on this at 9AM tomorrow morning.

[Brian Cina (Member)]: Give or take a minute.

[Alyssa Black (Chair)]: As I said- Don't wait for me

[Unidentified Committee Member]: if I'm off No, of the that is

[Alyssa Black (Chair)]: already starting their testimony on this. Ways and means and probes know that it will that it's coming to them. Everybody's waiting for it to come to them. So we'll vote on it tomorrow morning. Sorry. We're gonna end committee

[Unidentified Committee Member (former AHS staff)]: now.