Vermont Legislature SmartTranscripts:

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: We are live.

[Sen. Andrew Perchlik (Chair)]: This is the Senate Appropriations Committee's March 10, and we're doing FY '27 budget presentations. We have the entire agency of human services here or a good portion of the key people. So I'll let you introduce yourself and give us your presentation.

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: Thank you, Chair. Good afternoon, I'm Ginny Samuelson. I'm secretary for the Agency of Human Services and appreciate the opportunity to bring our executive leadership team to the Senate Appropriations Committee today. I'm here with our Chief Financial Officer, Tracy O'Connell. I'll let you introduce yourself. Yes. Good afternoon. Tracy O'Connell, chief financial officer with Agency of Human Services. So we'll go ahead and we'll get started. As everyone here knows, the agency of human services includes six departments, including the Department for Vermont Health Access, the Department for Health, Department for Mental Health, Department for Children and Families, Department for Disabilities, Aging and Independent Living and the Department of Corrections. It also includes the Secretary's Office, which houses the Office of Healthcare Reform, the blueprint for the blueprint for health, and the Vermont chronic and the refugee resettlement program and other programs. Overall, the agency of human services budget as proposed is $3,750,000,000 across the agency. In the first slide which we're pulling up now just give us a second you can see the distribution of those funds across the departments.

[Sen. Andrew Perchlik (Chair)]: I'm sure you have to somewhere but what's the percentage increase from last year? Did you say within the 3% goal or?

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: Yeah. So our percentage increase over the over the last year, was two slides up, is 6.1% for the general fund budget. So as a reminder the Agency of the Human Services is one of the largest agencies in state government in addition to our budget being $3,750,000,000 we have a total of 4,136 positions across all departments. For our budget this year, what you're seeing is an increase of $86,100,000 That's a 6.1 increase, as I said previously. The way that that's split out is just under $75,000,000 or 5.3% of that is an increase in order to keep our current programs that we have running and on the ground. In addition to that, there's an $11,200,000 increase or a point 8% increase in directed towards the base for base initiatives.

[Sen. Andrew Perchlik (Chair)]: Is that a 28% of general fund or base? 28%

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: of general fund.

[Sen. Andrew Perchlik (Chair)]: From last year's base that I can sort of

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: Into this year's into next year's 2027 space. So one of the things that's going to be key to our discussions today is how we did how we came to our budget this year, which differed significantly to the process that we've done in the past. The team that you have here today is the executive leadership team from the Agency of Human Services. They are the ones who are responsible for developing our budget. The executive leadership team includes myself, the secretary, our deputy secretary, our Medicaid director, and our six commissioners across the department. And we view it's an important role for them to for this group to play in both identifying their priorities and programs, and allocating the resources, both human and financial resources across the department in the budget development and policy process. So the way that that group budget this year is we started in early in the year identifying what our priorities were. First, we started with the governor's priorities, which won't surprise any of you. They included growing the economy, making Vermont more affordable and protecting the most vulnerable. The agency of human services also then went and identified based on the governor's priorities, what the priorities for this coming year would be for the agency. They included housing with a particular focus on addressing homelessness, looking at substance use and mental health integration across the full continuum, and particularly looking at co occurring care, treatment, and prevention. So all the way across the continuum, making sure that we were both stabilizing that system and creating a co occurring system. We looked at healthcare affordability with sustainability and quality in mind, and looked at making sure that we had a strong and resilient workforce within the agency. One of the things that was key that was different once we identified what those priorities were, we worked to evaluate the programs across departments and present that data to the to the commissioners and the executive leadership team. And to identify that with we have the Medicaid, our Medicaid director and policy director can be in the Medicaid program so that we're looking at the Medicaid program across the departments because it sits in almost every department. In that, we work to evaluate which programs were the most effective and which were no longer effective in that initial take.

[Sen. Andrew Perchlik (Chair)]: We have two different effective, maybe you're gonna talk about it later, effective measurements for different programs? Is it was it just some like general effectiveness?

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: Yeah, so we looked at effectiveness and were they achieving their outcomes that they were intended to achieve? We also looked at where they equitably distributed across the state. The agency on multiple occasions has started a pilot program and not run it all the way to to scale. And so we have pockets of where Vermonters could get services, but they weren't equitably distributed across the state. We also looked at where there was a creation of duplication over time. So for example, as we one of the programs that you'll see noted this year that we looked at carefully, with the fact that over the last few years, we've worked to stabilize the mental health crisis system of care. Since the pandemic, we put in place nine eighty eight, mobile crisis, and alternatives to emergency departments or mental health urgent cares, they've really strengthened that system of care. And so where there were individual programs on the ground, but were not scaled across the state, there were some duplication in some of those efforts. And so we looked carefully at where we could we could evaluate duplication. When we started the budget process, so once we identified the priorities and looked at evaluations of programs, we took an inventory of our current services and looked across across the state. In order to keep our current programs going, it was going to be an increase of $117,000,000 As that compared to the 3% budget target, which

[Sen. Andrew Perchlik (Chair)]: we

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: anticipated before because that's what it's been for the last few years. During the summer, we estimated that our total target would be a reduction of $42,400,000 the increase was $42,000,000 excuse me, and it meant we were looking for a reduction of almost $75,000,000 just to keep the lights on in our current programs. At that point, departments and the agency came forward with opportunities for savings and reductions. We really looked at that in several different ways. Where were the revenue offsets some of the things to keep current services going we knew were actually revenue declines, but there were places that we saw increases in revenue. We looked for administrative and program efficiencies, and we'll go through each of these and what we identified in the final budget. And then we looked, finally, we went and looked at places where we could do programs and services reductions based on that evaluation that I just talked about prioritizing where

[Sen. Richard Westman]: we

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: could make reductions. There were some hard, I want to acknowledge there were some hard choices that we needed to make, but we feel like we really balanced what the needs were of Vermonters as well as our fiscal responsibility.

[Sen. Anne Watson]: Thank you. So on your slide, in that last point, talked about the potential savings for nonessential, non mandatory, non statewide. I'm wondering about the non statewide aspect just because of what you said earlier, you know, like you looked at how services were distributed across the state. I'm wondering if if a program was not equally distributed across the state, was that just eliminated?

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: So What we took and evaluated whether the program was, like, what were the reasons that it wasn't statewide? Mhmm. So for example, some of the programs that we don't have statewide is because we don't need everything in every community. Some things need to be at the state level, the region or the regional level. We don't need it across the state. In other cases, they were programs that for certain reasons, chose not to scale, but which we felt like we needed to have that weren't necessarily as effective. And so for equity reasons, we may have chosen to eliminate them. There were other places that you'll see it, for example, in rural health transformation, where we had mental health urgent care, we knew we needed to get to scale. Mhmm. So these were programs that were orphan programs that were out there that had not had not gotten to scale for for specific reasons, and we didn't think would ever get to scale and were inequitably distributed and not achieving their outcome.

[Sen. Virginia “Ginny” Lyons]: So it

[Sen. Anne Watson]: sounds like there was just a whole variety of situations. Of factors. Yeah. With those non statewide. Yeah. Because I I was worried that I mean, it sounds like this was the case for some of them, but that if there were services that were being offered but they weren't statewide, that, you know, because that's inequitable, closing it down for everyone.

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: We looked at the why. Why wasn't it statewide before we made that made those decisions? And we spent the majority of the summer working through this several hours looking to really carefully evaluate it. And this year, I think what's different is it was the entire executive leadership team of the agency. At the times that I've been at the agency, we've taken and we've had one department propose a solution they knew was gonna have inordinate impact on another department. We, our executive leadership team took seriously that they have two major responsibilities. One is to be an executive leadership team member for the agency, making decisions that are right across all programs, and the other is to be for their for their center of excellence for them to run their departments. And they take both of those roles incredibly seriously, and made sure that as they were making decisions this year, it was based on what was in the best interest of Vermonters across the entirety of the agency. And that was a fundamental difference in the way that the budget worked in the past. They've each developed their own silo budgets based on a projection. And then based on that, it's kind of unlike a shark tank, where they brought come to the secretary and propose those and at times we've had to figure out where it was going have an impact and it's just not the best way to

[Sen. Andrew Perchlik (Chair)]: do it. So each department did this evaluation then brought it to the whole team and decided as a whole team what customer?

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: So the evaluation of the Medicaid program was done across the Medicaid program with almost all of the commissioners minus DOC who has less Medicaid. And then the evaluation and that presentation of that evaluation data was brought up to the executive leadership team and proposed and and demonstrated and shown to them. That makes sense?

[Sen. Philip Baruth]: Yeah. Sounds good.

[Sen. Virginia “Ginny” Lyons]: K.

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: Okay. So now we'll get into the numbers. Here, this slide shows the different categories of the current services that we were witnessing for pressures. The two biggest areas, revenue loss and caseload and utilization.

[Sen. Andrew Perchlik (Chair)]: What do you mean by revenue loss?

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: Loss of federal funding, mainly or special funds. We're gonna go right through that. Yeah, we're gonna get right into that. So $26,600,000 general fund is needed to backfill a loss of revenue in for number one, global commitment, the base FMAP change. In 2026, the federal matching percentage was 58.81%. And in '27, it will be 58.07%. So a loss of point 74%, which equates to 13,000,000 general funding need to backfill that loss. We want to acknowledge that this one is a usual and normal change that happens in the Medicaid program every year. We've gotten the question often, is this something that has to do with a change in the federal administration? And the answer is no. This goes up and down every year. It's just the last couple of years, it's gone up and our FMAP rate is higher than it's just about ever been.

[Sen. Richard Westman]: The next two more.

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: The next two, yeah, the second one is

[Sen. Andrew Perchlik (Chair)]: Rate, definite rate meaning our share.

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: Yes, federal FMAP stands for Federal Medical Assistance Percentage. So that's the federal share. So the state share will go up or down depending on the formula. Yes. That's correct. And and that formula hasn't changed. So last year, it was 58.8%. And this year, it's 58.07%. And the way that they calculate that has been consistent year over year for many years.

[Sen. Andrew Perchlik (Chair)]: Is that part of our waiver? Yes.

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: Well, it's part of the Medicaid program. Yeah, each state has a different FMAP rate and it is based on a formula across the entire country. Some states are, the minimum is 50%, which a lot of states just get the minimum, but we get 58.07.

[Sen. Andrew Perchlik (Chair)]: No, and you're just It's based on a three year average per capita income relative to other states. That's the high level explanation of the formula. And it doesn't have to do with our, I thought there was a connection to our waiver. Like we give them more flexibility but we could pay more. No. If you wanna do a thirty minute presentation, all that FMAPs and Better line.

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: It's not specific to our waiver. Okay. It is the way that they set the matching rate for all Medicaid

[Sen. Richard Westman]: programs regardless of waiver. We did get bonuses during COVID.

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: That is correct. Across the country. Yes. Where

[Sen. Andrew Perchlik (Chair)]: does that put us in the grand scheme of things with other states?

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: I don't have that information. We can But compared to where we've been over the last several years is Vermont. So the second area is $4,500,000 general fund to backfill loss of SNAP federal match that's related to administrative costs only. Previously, the federal government would pitch in 50% match and now they will only do 25%. So this represents the backfill for that 25%. And this is a recent federal change from last summer. And then the third item is for the childcare special fund revenue downgrade. So the last e board meeting, there was a downgrade for the collection of the payroll tax. And so we need to backfill $8,700,000 in general fund for that. Now moving on to caseload and utilization.

[Sen. Philip Baruth]: Before we go on there, I remembering right that uptake for the childcare program is now where it needs to be the

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: Correct. We did not adjust utilization for the budget because it's showing right where it needs to be.

[Sen. Andrew Perchlik (Chair)]: Okay. You mean needs to be a well, where it needs to be as far as what the making revenue and expenses would be? So

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: the whole based on the whole program. Mhmm. If that's what you're asking. Like, because there's our there's general fund, there's special fund, there's federal funds.

[Sen. Philip Baruth]: And there was a ramp up in terms of Correct. And so for a while, we were doing things with that unused revenue. Now we're putting it all into the chapter. Correct. Yeah.

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: For case load and utilization, 27,800,000.0 general fund. The bulk of this is related to Medicaid consensus. This is a similar number that we saw in budget adjustment. 14,900,000 general fund or 33,300,000.0 global commitment. We are requesting 1,500,000.0 for the clawback payment to the federal government. And for developmental services in Dale, dollars 4,100,000.0 general fund or 9,900,000.0 global commitment. And also in Dale, choices for care related to nursing home med days and HCBS spending $4,400,000 general fund or

[Sen. Richard Westman]: 10,600,000.0 global commitment.

[Sen. Andrew Perchlik (Chair)]: Are those also similar to other years? These kind of adjust?

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: In terms of increases, we can look at getting the departments to bring in year over year, but they're not outside of

[Sen. Andrew Perchlik (Chair)]: the room. Right.

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: Moving on to salary and fringe for the entire agency, 21,300,000.0 general fund. This does include almost half $1,000,000 for 12 new HEU staff at NOVA that will work on the Medicaid work requirements and biannual redeterminations as a result of HR one. And then for operating expenses, we need $6,500,000 general fund, the bulk of which is for the internal service funds, which is HR, the insurances, ADS, and then 192,000 for the Diva Pilbara Park lease, and then about a million dollars for DOC vehicles, uniforms and

[Sen. Anne Watson]: Sorry, I just need the acronym there. You. Hey, you.

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: Oh, I'm sorry. Medicaid enrollment and eligibility unit. Okay. I can accept that. It's the best so what this one is is that in HR redetermining individuals for Medicaid from every twelve months to every six months for those who are in the new adults. So those adults who were childless adults. And so, Hey New is the unit that actually actively does eligibility and enrollment. Okay.

[Sen. Anne Watson]: Thank you.

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: Contracts $17,000,000 general fund of many of these are the same pressures that we saw in budget adjustment. I think the only new one is related to the last item, the DOC transitional housing, 247,000. Represents a lot, DOC already funds this program, but the program lost federal funding and so we're seeking to help backfill that with this request. The next request is for $10,600,000 to annualize multi year programs that have already started. So for example, with the Medicare Savings Plan, we need $2,800,000 general fund or $11,200,000 global commitment to annualize that program.

[Sen. Virginia “Ginny” Lyons]: I'm on the previous slide looking at the DMH forensic evaluations there. And so what all is included in that? And what if anything will be affected with the current forensic facility bill? Is

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: that something that maybe Commissioner wants to comment on that? The record.

[Emily Hawes, Commissioner, Vermont Department of Mental Health]: Sure. The record, Emily Haas, commissioner for the Department of Mental Health. Related to the DMH forensic evaluations, those are specific evaluations for competency that are ordered from the court. And so BMH is a sort of a pass through, the court manages how much of the ordering that they do or don't do, and that would not have a direct impact on the forensic facility proposal in S-one hundred ninety three.

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: Can you explain the increases? Sure,

[Emily Hawes, Commissioner, Vermont Department of Mental Health]: so a couple of reasons why we've seen an increase with our branded evaluations. One that the state of Vermont orders more forensic evaluations. We order more forensic evaluations nationally. So quite a few come through our court system. We've also seen a shift in who is ordered for a competency evaluation. Traditionally it was individuals with a severe and persistent mental illness. It is now individuals with chronic substance use, perhaps traumatic brain injury, dementia, all sorts of complex issues that can impact somebody's competency outside of mental illness.

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: In addition to that, you're seeing a significant number for minor crimes, for Correct. And a significant number of 3P evaluations.

[Emily Hawes, Commissioner, Vermont Department of Mental Health]: That's true. From a charge perspective Vermont orders several competency evaluations that they relate to individuals who have been accused of a misdemeanor crime. And often times someone may engage in that behavior multiple times over the year. If those cases aren't combined, a court system often orders multiple competency evaluations for multiple misdemeanors. In some other states, there's not the ability to order a competency evaluation for misdemeanors, those individuals need to go through a court diversion process versus the competency route. And that's usually because competency or not competency doesn't necessarily put in someone's engagement with treatment. It can often delay someone's interaction with the treatment system.

[Sen. Philip Baruth]: Just a quick question about

[Sen. Andrew Perchlik (Chair)]: the overall

[Sen. Philip Baruth]: presentation. So I understood you to be saying you had to cut a huge amount

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: We're getting there.

[Sen. Philip Baruth]: Of your budget. Okay. So these are things that you can't cut that that are driving the increase, but then you're later detailed cuts.

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: That is that is correct.

[Sen. Andrew Perchlik (Chair)]: Okay. Good. Yep. You have to make the cuts to make the to meet these needs.

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: We had to make the cuts to go back to the beginning. We had to make the cuts just to do base to make current services, many of which are these fresh which include these pressures. So caseloader utilization pressure, as you remember, was one of the highest. And the second one was lost revenue. And so in these areas, you're beginning to see some of the current services pressures based on this. Back to the annualization of multi year programs, so the Medicare Savings Plan that went live in January, and so we have five months built into the base. And so this annualizes it in the state fiscal year '27. The DMH alternatives to EDs, this was previously funded by the HCBS spending plan that is about to expire and so this annualizes the backfill of some of those successful programs. And then 7,500,000.0 for shelter investments. 1,300,000.0 is related to the cold shelter investment, and then 6.2 for the hot These were that were started with one time funds. And so this builds it into the base. These aren't new, these are just one time funds in the base. Yep. 6,000,000 for provider rates. This list of rate increases is related to either federal federally required rates increases or state rule required rate increases. So for NFI, Northeast Institute, that rate is set is tied to the reference, it's a reference based pricing towards inpatient rates. And so we need to come up to speed on that for $600,000 gross. And then for the FQHC and the rural health clinics, 2.73%, that's federally required. The PNMI rate increase, that is state required. CCBHC that is also federally required. Once those providers come online as a CCBHC, we have to pay their actual costs, we have to rebase and set rates according to that. And then the nursing home inflation, that's a state rule. And so that's 2,300,000.0 general fund or 5.4 global commitment. So now we'll get into the areas of savings. This chart depicts the various categories, and we'll go over, we'll do a flyby on all of these. So we were able to identify revenue that could help offset some of the pressures. One is in the area of global commitment, the childless new adult group that's matched at a different FMAP. That's 90%. And so based on the utilization of that Medicaid eligibility group, we can reduce our general fund request by 3,000,000. With the CCBHCs that I just described, because we have new sites coming online, that is actually matched at an enhanced FMAP as well, that is at 70.65%. And so that is less general fund that we need to implement that program.

[Sen. Anne Watson]: Sorry, CCVHC.

[Emily Hawes, Commissioner, Vermont Department of Mental Health]: Sure, I'll answer that one. So CCBHCs stand for a certified community based integrated health center, and that is a federal model designed to increase access to both mental health and substance use services at the community level. Very similar to an FQHC model. Gotcha.

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: Thank you. Yeah. The great thing about that is it provides the standard set to integrated care so that they're getting both physical, mental health, and substance use treatment all in one place. FEDH substance use treatment revenue adjustment, department was able to maximize more dollars on the block grant, therefore reducing its reliance on general fund and global commitment. And then at DMH, we anticipate to be able to increase Medicaid billings for those lengths of stay under sixty days, we can actually get a global commitment for those dollars and for those days. And then with Diva, we are proposing to increase the prescription drug co pays. Currently, they are set at $1 for preferred and $3 for non preferred and we are proposing to go $4 preferred and $8 for non preferred. And these were initially put in place in 2001 and have not been modified since that since that point. In addition to that mandates doesn't mandate increases but it does mandate sharing required shared requirements with medically programmed surgeons.

[Sen. Virginia “Ginny” Lyons]: That's a pretty that's a big increase Going out to four and eight from one. We

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: have a few areas of caseload and utilization savings first at Rutland Regional Medical Center level one, those that not all the beds are being utilized. And so we are reducing by 718,000 general fund with 1,700,000.0 global commitment. And then in DCF, a few areas of caseload reductions reach up as substitute care. And then Dale with the adult day health and rehab services. We did find some administrative efficiencies within the agency. So all departments reduced their travel equipment supplies, fleet contract budgets, that's $811,000 general fund. DMH and DOC updated their vacancy savings numbers based on the vacancy savings chart that the secretary presented earlier. And then Dale made a technical correction for their other personal services.

[Sen. Andrew Perchlik (Chair)]: Are those vacancies positions that you can't fill or you're choosing to fill to meet the budget?

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: So while over the last several years, let's take VPCH, the Vermont Psychiatric Hospital, what we have seen is that their vacancy rates have gone from 65% to to 30%. So they've gone in the right direction, but they are now hovering at a relatively consistent place and space. The same thing with DOC, the the vacancies have gone down significantly, but they are now hovering at around this around the same place. I hope that we will be able to hire. We're not reducing positions in most cases.

[Sen. Andrew Perchlik (Chair)]: And you're not holding we're not holding Especially with corrections, if you're not holding up

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: We're not holding up hiring or recruitment, but this reflects this is a reflection of the reality of what we are currently seeing on the ground. The agency also identified some programmatic efficiencies, dollars 6,000,000. So the first item 450,000 general fund savings, the there's a proposal to move the school based services program from AOE and BDH over to DIVA. So this reflects the BDH portion that is no longer needed because there's a contract related to a random moment time study that helps administer the program and so that will no longer be needed and Diva will be able to pick up that work. Diva is proposing to implement utilization management for durable medical equipment, which will see about 922,000 general fund savings or 2,200,000.0 global commitment. The next item related to the applied behavioral analysis. This was already in budget adjustment. And so this is analyzing this reduction. In DMH, we are proposing to reduce the amount of beds at the PCH from 25 to 21. That's 1,400,000.0 and that's related to a unit that is already off line and reflects current utilization of the census of the program and what it has been since post the pandemic.

[Sen. Philip Baruth]: Would just, if I might insert a caution around Woodside. If you remember, when we closed Woodside, we did it because current utilization had gone down so low. And so we've saved $3,000,000, and we still don't have a replacement for that facility, and we we have need for it. So just a caution and I'm not telling you anything you don't Yeah.

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: I I appreciate that. The good thing about this that's slightly different is we're not closing the whole facility. We're just closing one way. So there is the opportunity if we start utilization shift. But I do think, Senator Baruth, that is a good cautionary statement. This does reflect the utilization that we've seen over the four years. And so we've been waiting, monitoring, and watching. But this also, we haven't, because of staffing, we haven't been able to open that unit fully and it doesn't make sense to continue to maintain some of the ancillary positions to have a 25 bed facility when really we're just going to sit at 21 unless we see utilization. But it is a very good caution. We're not flattening this

[Sen. Andrew Perchlik (Chair)]: one. And

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: then the last item is for the ARRIS payroll benefit percentage withholding $1,900,000 general fund. ARRIS is the fiscal processor of the payroll for the independent care workers. There's excess cash on hand there. Yeah. So in this case, there's no reduction to actual money going out the door. It's just money that's been sitting and held there for a period of time. So it won't change anyone's opinion. So here is where we highlight some of the program and service reductions or eliminations of $9,900,000 general fund And I will just also say that I think in these, there's a summary spreadsheet everybody should have that kind of lays out all of these in detail.

[Sen. Andrew Perchlik (Chair)]: I have them right here. This a good time to hand them out.

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: Sure. So this is

[Sen. Andrew Perchlik (Chair)]: We printed them on this.

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: This is a, like, a repackage of the AHS ups and downs. It's every line item, but more condensed for easier reference. So the whole list of the reductions and eliminations

[Sen. Andrew Perchlik (Chair)]: There are entirely reductions. The blue is the other two.

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: The blue are the reduction.

[Sen. Andrew Perchlik (Chair)]: The blue are other way around. Yeah. Yeah.

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: So we'll go over the high level reductions, but if anyone has any questions, you can look at those.

[Sen. Andrew Perchlik (Chair)]: And it's something you can look at over time. You don't have to do it now.

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: Yeah. This is just our presentation references just snippet, but there are a lot there are quite a few for what the secretary said. You know, there are lots of little ones, you know, that one was $5,000 So we're just being transparent and everything that we proposed for elimination, but it's on bigger sheet. So the first item is the refugee transitional housing program. There was $900,000 built into the base a couple of years ago, and due to less refugees arriving, we felt it was acceptable to reduce this by $500,000 still leaves 400,000 in the program for actual, we're gonna not use so much for transitional housing, but more for support services, wraparound services, language assistance, whatnot. The Diva Legal Aid Medicare Assistance contract. This is a proposed reduction that is not seeing results that it is intended for. It's actually in statute that this contract, the cost of the contract, they should recoup monies from Medicare at the same level that the contract is for and that we're just not seeing that to be the case. So we are requesting to repeal that.

[Sen. Anne Watson]: Sorry, I wanna go back to the refugee transitional housing So is that money that say a a refugee family who is here use and because it's transitional, they get into the

[Sen. Virginia “Ginny” Lyons]: long term housing and they

[Sen. Anne Watson]: so then they don't use it need it. So it's it's not this is not money that

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: It's not for long term housing. It's just for when they first arrived here in Vermont.

[Jill Mazza Olson, Vermont Medicaid Director]: Okay.

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: To get them on their feet on the ground. It's not the long term housing dollars because we are seeing a significant reduction in the number of people coming in. We're just unfortunately not seeing this program being utilized. And so this is a way for us to take and take what is reality on the ground and resize the budget. What we didn't do though is we didn't eliminate it. We just made sure that we had it so that it was there and available if things were to change. Okay. Thank you.

[Sen. Andrew Perchlik (Chair)]: In the Medicaid legal aid contract, is that the whole contract? Yes.

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: The ACO per member per month payment with the ACO sunsetting last year, this was an add on payment, dollars 2,100,000.0 general fund, so $5,000,000 global commitment that we're eliminating from the budget. The next two areas are at BDH, the AHEC reduction and also the education loan repayment. And we're hopeful that some of the education loan repayment money, we think it can be repurposed within RHDP. So

[Sen. Andrew Perchlik (Chair)]: Does eliminate the program or are you

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: just reducing the cost? This proposal is elimination.

[Sen. Andrew Perchlik (Chair)]: Is everything on this list elimination? Because it says reduction elimination.

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: Some of them are reductions so we can go through. Like two eleven, for example, if you go down, it's a reduction of the total of the hours because right now DCF funds two eleven to just to provide housing placement after 11:00 at night, there's no more ability to place folks into the GA program. And so they simply call they get told to call back in the morning, not a good use of resources.

[Sen. Andrew Perchlik (Chair)]: If they're calling for housing?

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: If they're yes. And they are calling for help. That is the primary reason that they are calling in. They're calling for housing.

[Sen. Andrew Perchlik (Chair)]: If you're calling in. Okay.

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: DMH, outpatient services for TBI, elder care and reach up, $1,000,000 general fund at $1,900,000 global commitment.

[Sen. Andrew Perchlik (Chair)]: So those three are connected because they're all outpatient because I was thinking what's the extra TBI and outreach, outpatient services for people in those. Correct, And

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: we believe that there's other areas that they can access services within the HS budget. A reduction of 248,000 for care formation at one family practice.

[Sen. Virginia “Ginny” Lyons]: One of those programs

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: that hadn't gotten scaled, there's only one family practice who receives us. And so we're adjusting that. We talked about 02/11, the DCF strengthening families 498,000 or $1,000,000 global commitment with Act 76 funding. We believe that there's the funding is meeting the needs of the families via other avenues with that funding.

[Sen. Andrew Perchlik (Chair)]: Can we go back to the education change, education loan repayment, which professions? Because that's the Department of Health, what professions were those?

[Sen. Philip Baruth]: Rachel Grant mentioned for the Department

[Sen. Andrew Perchlik (Chair)]: of Health. So the the

[Sen. Philip Baruth]: VSAC funds are primarily in nursing. There are some funds in small amount that are also important to hygienists, physicians,

[Sen. Andrew Perchlik (Chair)]: the entire workforce, but most of it goes to nursing. The

[Sen. Philip Baruth]: only funds that VSAC receives, but we're we're closing eliminating it from

[Sen. Andrew Perchlik (Chair)]: What was the reason for that?

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: Yeah. No. We had to make some really challenging decisions. I just wanna acknowledge that this year. We started the the budget process, as you'll remember, with $75,000,000 that we needed to find in the budget. In some cases, we were balancing, having things that were direct health services to Vermonters with with things like education. When we saw the opportunity for the rural health transformation funding, we realized that we could invest significantly in workforce initiatives that were similar. I'm not gonna say that they're the same, but they are very similar. For example, the Rural Health Transformation Funds allows us to pay for tuition for individuals while they're in school, as an option with a guarantee for them to continue to stay in Vermont. We felt like we were able to achieve some very similar outcomes, while also trying to make very difficult decisions.

[Sen. Virginia “Ginny” Lyons]: As long as it's not in Chittenden County.

[Sen. Andrew Perchlik (Chair)]: The I

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: definition of morality, we don't know what the definition of morality is. Here in Vermont, we are working within the in the bounds of the federal program. And so again, it's probably we can spend more time if folks want. But for individuals who are not living in rural communities, and for providers who are providing only services in or in more urban communities, there is some challenge with finding with funding for rural under rural health transformation. Again, rural health transformation is intended to put dollars to serve rural communities and rural providers. So I do wanna acknowledge we're working on that definition. And we're not have full clarity from the federal government about what

[Sen. Andrew Perchlik (Chair)]: this restriction.

[Sen. Philip Baruth]: Okay, Senator Baruth. So building off Senator Lyons question, is the money that you're foreseeing filling some of this need already available or is it anticipated?

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: Oh, we we received a $195,000,000 from the Feds Yeah. That we need to like, that first 195,000,000 needs to be spent before the end of the next federal fiscal year. It's available to us now Yeah. In most of the areas that we applied for, and then it needs to be spent by October year. So, yes, it is available in the state now. Those programs are being launched as

[Sen. Andrew Perchlik (Chair)]: we speak.

[Sen. Philip Baruth]: Okay. And then beyond what you have now, this is a revenue stream that will continue?

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: The revenue stream that we will have, we hope we will have for five years as long as we're able to get the funds out the door and show the outcomes. The state of Vermont has been approved for a $195,000,000. Every year, they will rebalance that that amount based on our ability to achieve our outcomes and and get the money out the door.

[Sen. Philip Baruth]: Okay. I would just echo Senator Lyons concern about Chittenden. If we lose out on that funding, although Chittenden County has many rural areas, if we lose out on that and this program goes away, it's just a net loss for our nurses, our nursing students.

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: Yeah, we have this funding for the next five years and for folks who will go into rural communities.

[Sen. Philip Baruth]: But if Chittenden is, as I understand it, Chittenden is currently excluded.

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: Yeah. Jill, you wanted to say pieces, but I wanna be really clear. We don't have the definition of rural yet. So I've heard a lot of providers in the building spending a lot of time saying that they that they know that they will not get payment until we actually have completed and gotten an approval for Vermont's definition of rural that is inaccurate. We're happy to come back to folks when we have that definition. Yes, there will be some challenges with paying for providers who primarily serve Vermont urban families. But again, that doesn't the new opportunity doesn't necessarily exclude all of Chittenden County. We are working on that definition again. I think providers actually want to make sure that they have access to as much funding as possible. But we need time to actually get Vermont's definition of rural. And we need time to be able to get that approved by the federal government.

[Sen. Philip Baruth]: Right. Take

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: your point. But don't care for Yeah. But students who are going to school in a Chittenden County like like the University of Vermont, if they are going to work in rural communities, that doesn't exclude them from from this funding. Okay.

[Sen. Andrew Perchlik (Chair)]: Yeah. Senator Westman and then we'll go to

[Sen. Richard Westman]: this one. So here's what it is hard. That 195 or whatever, 96 or whatever it is, it's elusive for us to know where it can go and what it is. So when you ask us to cut a program, when we don't know whether the money will be available for this or not, it it becomes hard for us to judge what to do around that. That's that's the first part. Where somebody gets taught to in a nursing program, the fear really is in all of that is we know the traveling nurses that are eating us alive in Dale, in in across the board, and we've done all sorts of emergency aid things that mostly are being cut in this budget, to do that. So how is anybody at this table supposed to make a decision about a cut like this when we can't we aren't guaranteed, that the money is gonna replace You just say to us, it's probably going to happen.

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: I hear your frustration. I want to be 100% clear. Rural Health Transformation funding cannot be used for loan repayment. We all in this room need to collaborate on very difficult decisions about where we prioritize and spend our funding.

[Sen. Andrew Perchlik (Chair)]: Or can it be used for supplanting something we're already doing?

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: It cannot be used for spending already, but regardless, the rural health transformation funds, wanna be 100% clear, cannot be used for loan repayment. We will not replace the loan repayment program. So I understand Senator Westman, your question, I am not asking you to buy into the fact that we will have a loan repayment program, we will not, we had to make some very difficult decisions to make sure that we were able to maintain services for Vermonters with the funding that we have in the state of Vermont. And this is a program that the agency of human services is putting forward to be cut. And I just want to be 100% clear that that's what this is. And we present our budget to you. And then you will have to make also very difficult decisions about how you balance the budget.

[Sen. Richard Westman]: There are programs that are not the same, but get at the nursing problem that we're facing. How are we going to know what those alternatives are? So we can make an informed decision about whether to keep this

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: happy to come back in and Jill can answer but happy to come back in and tell you what's in the rural health transformation budget. One of the things that's in there is tuition assistance. And that's one of the things that has been approved. You asked a very specific question, can we use it in Chittenden County? That we can't answer yet. But is that one of the approved programs that we're putting out the door? Absolutely. And again, Joe would be happy to come in and walk through the full set of what Rural Health Transformation will fund.

[Sen. Andrew Perchlik (Chair)]: Do you wanna say anything right now?

[Jill Mazza Olson, Vermont Medicaid Director]: I do wanna say one thing just to add on to what the secretary was saying in terms of this rural question, which I know is a concern. So we did get some sort of vague new guidance from CMS, which was that states have some flexibility about creating definitions. And yet we still expect that when we actually give them our specific projects to approve, which

[Sen. Anne Watson]: they will have to do

[Jill Mazza Olson, Vermont Medicaid Director]: before they'll let us spend the money, that they're gonna expect to see a credible definition. So that's what we're wrestling with. There isn't a definition we can use. We are planning to argue that for the workforce projects in particular, that workforce is something that affects the whole state, that increasing the workforce anywhere in Vermont is good for all of Vermont. That's what I'm planning to say, whether they will agree with me, it's a different question. But I feel like if you have a five year service commitment and you spend it in Vermont as provider, that should be reasonable because you might go to different communities. If you're serving Chittenden County, now you're not We don't need to pull someone else from Franklin County or Addison County to go to Chittenden County. So that's the plan. What we don't know is whether CMS will agree to it. So that's where we still have we still have some uncertainty. Okay.

[Sen. Andrew Perchlik (Chair)]: Thank you. Yeah. Continue what?

[Sen. Virginia “Ginny” Lyons]: I do wanna continue. At some point, I'd like to go back to durable medical equipment, which is on the previous page, but we don't have to do that right now.

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: And then in any case, believe that Diva is coming in to present their budget, and so you'll have an opportunity We can wait for that. Much deeper. I

[Sen. Richard Westman]: I would say the health department, I'm scheduled to sit down with the health department. And just as a warning, but I'm going to ask when you get to things like the Education Room, give me an idea of on the ground what's in the grant side by side so I can relate. And when people at this table ask about it, I can say, this is what is taking its place in in that because we don't have time to go through every inch of this in but you need to make it very clear about that. It it's unacceptable, the number of traveling nurses we still have.

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: Yeah, we all agree. And that's why we put significant funding in the workforce category of the rural health transformation funds to help bring us further.

[Sen. Richard Westman]: Totally get that, but, you know, we know that underlying in this budget, we could get rid of travelers. It's only in our best interest.

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: I hear you. I think we all have that same goal in mind. Okay. Okay. And then the last item on that list is DCF reach up agreements and reach first 623,000. Then these are the base insurance. Can you just talk about where that money is coming from?

[Sen. Virginia “Ginny” Lyons]: Yeah. Is it a direct appropriation to the families or is it something else?

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: There's a number of line items. DCF can speak more to it, but one example is with Lund, reducing the number of beds in that contract because again, underutilized for a number of years. The Social Security agreement with Labor, and then housing case management. We have housing case management and other areas within the agency. Things like the one bed there in Greenland, these are beds that they're. Okay. So we also, in addition to looking really hard, remember at the beginning, we said we've aligned our budget to our priority. We looked at what can what were some of our key our key priority areas. So those included housing, mental health and substance use as a number. And so here we took we looked at DCF sustained investments in emergency housing. So increasing investments in the moving them from one time to base for family specific housing, housing for those experiencing domestic violence, individuals who are medically vulnerable, increasing those shelter options in each one of those areas. Substance use recovery shelter, we're excited to see one of those up in Burlington yesterday, case management enhancements and rental assistance. There's also an in addition to those base investments that we're looking at to sustain those programs, we're looking at $2.21100000.0 dollars to sustain the general assistance housing program. That's right now we currently invest one time funds. This continues to maintain one time funds for that. Also whether and also looking at the staffing.

[Sen. Andrew Perchlik (Chair)]: The general fund that's I mean, the general housing that is general assistance. Is that 21 more or 21 total?

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: 21 total.

[Sen. Philip Baruth]: So if I could just ask, I I was keeping track of trying to count up to the 70 Mhmm. Something plus million that you need. To me that you broke off with more savings.

[Sen. Andrew Perchlik (Chair)]: That wasn't all of us. That wasn't all of us.

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: That was one

[Sen. Andrew Perchlik (Chair)]: of the highlights.

[Sen. Philip Baruth]: So these are initiatives though, right?

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: These are initiatives. And so what I would say is, remember, our original target was set based on us achieving a 3% target.

[Sen. Philip Baruth]: Yes.

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: We overall, we increased our budget over 6%.

[Sen. Philip Baruth]: I see.

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: And so what you will see is that there was point eight percentage of that 6% that was attributed to to prep high priority areas. We weren't looking I want to be really clear, these are not new things. These are things that we would look to continue to sustain. So another example of that is the opioid recovery employment program, which was covered by opioid settlement dollars left in the past. We are proposing to put that into a base. It was one of the things that we did not anticipate would get funded from the Opioid Subcommittee. And based on actually showing outcomes. So these aren't these initiatives aren't necessarily, as you saw new things, it's maintaining our general assistance housing program, maintaining our opioid recovery employment program.

[Sen. Philip Baruth]: Yeah, I'm just finding it a little hard because we're we've bounced a couple times from cuts to additions to now additions. So I I had it do you have a figure for how much you were able to cut? It seems like 50,000,000 or so.

[Sen. Andrew Perchlik (Chair)]: Just the the blue the blue sheet. One. Yes. What is that last number that 74 on that? AGS current services position.

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: So that is what our overall budget request is. This is a top of 70 almost 75000006%. The last, the last program on the initiatives was to have pre trial supervision in a few counties. I wanna emphasize that pre trial supervision has been also supported our accountability for this year. And so really what it is working, the pre trial supervision is both doing pre trial and supporting our supporting our future initiatives and rolling out across the state. It's been a this would bring it from the five current to 12 to scale across to make sure that it was scaled across the state. Again, not new new programs, you're not gonna see new programs here. This is just addressing what we've talked before where we don't wanna have pilot programs that don't that we aren't assessing and then bringing the scale up to successful.

[Sen. Andrew Perchlik (Chair)]: And now on this handout, what's the difference between these changes? This sheet, do you recognize that sheet? Correct. And the other

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: the gold sheet are it totals a $115,800,000, which are all the current services pressures that we saw in the budget. And then this thing? And then that the rose colored sheet is for the initiatives. Okay. The last slide that we just showed. Another lot of changes. So pressures, cuts, it rolls out.

[Sen. Andrew Perchlik (Chair)]: Okay. Yeah.

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: Yeah. Okay. So the AHS Central Office includes the sec as I mentioned before, the secretary's office, the office of health care reform, field services, refugee resettlement program, and so Vermont. The overall budget for the secretary's office is $30,100,000 with 12,100,000.0 general funds, 15,000,000 federal funds, 2.4 global commitment, and $338,000,000 of interdepartmental transfers. It includes a total of 78 positions. I wanna I think it's important for us to highlight in the secretary's office some of the accomplishments that we have achieved over the last couple of years. Field services was responsible for setting up the family shelters in Williston and in Waterbury initially. In addition, they've supported the Burlington accountability court, pulling together the providers in that in those areas provide the wraparound services for individuals. In health care reform, they have done hospitals they've been working with hospitals and hospital transformation plans, which we think will fundamentally shift those what hospitals offer and how they will evolve and change the rural health transformation program that team in record time applied for the $200,000,000 of programs and funding by going back and looking what over the last few years have outlined, we wanted to advance healthcare reform. And then in refugees, they've really helped with this year when the federal government funding to the refugees in the SNAP program. The refugee resettlement program ensured that there was a backfill at the start to help folks who were coming off of the program ramp ramp down. So there was a softer landing.

[Sen. Andrew Perchlik (Chair)]: So I

[Sen. Anne Watson]: can't let it go,

[Sen. Virginia “Ginny” Lyons]: and that is under health care reform.

[Sen. Anne Watson]: It would seem to me

[Sen. Virginia “Ginny” Lyons]: you wanna have the strategic plan, the action plan that you're also working on, which is significant for linking acute and chronic care community based services. So are you are you putting the rural health transformation program in there as a replacement

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: for that? I wanna be clear. These are accomplishments, things that we have done. We are still working on the on the strategic plan, and it's a high priority for the agency. But, you know, I think we spent a lot of time in the agency of human services across our department and our central office, talking about the challenges that we face. There's some amazing work that our staff do every single day. So one of the questions in the budget process that folks asked us to cover this year was, well, what are some of the outcomes? And these are some of the things that our team can be proud of. Vermont being what we are, we never anticipated that we would get nearly get one of the highest per capita amounts under the rural health transformation funds. I really wanna celebrate the team who did that. So so underlined, your point is well made. We there's a lot of work to still be done to still be done, and we are working on your priorities. Well, I think

[Sen. Virginia “Ginny” Lyons]: you should celebrate the work that you are doing on it because it is significant.

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: Yeah. Thank you. Appreciate that.

[Sen. Andrew Perchlik (Chair)]: It's a refugees still are not eligible for SNAP. I thought there was some question about whether that was the rule or not. Guess some other states have not done it, but from my head.

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: That is a deep

[Sen. Andrew Perchlik (Chair)]: legal question. We don't need to go into it.

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: Yes. And I'm sure DCF would be happy to answer it in some detail. But there are definitely groups that the federal government carved out. This next slide is just a snippet from the AHS ups and downs, which that is one of the supplemental documents that's uploaded on the website, the full packet of all AHS departments of the ups and downs.

[Sen. Andrew Perchlik (Chair)]: How many pages?

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: What's that?

[Sen. Andrew Perchlik (Chair)]: How many pages, like 80 pages?

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: I think it's in the 30s. This

[Sen. Andrew Perchlik (Chair)]: is just one of the best ones?

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: Yeah, this is just the Secretary's office. And then just to go in a little bit more detail of the budget changes in the central office, There's a $2,800,000 reduction for the ABS service level agreement. This is due to ABS shifting their billing model towards more towards core enterprise services. And so that's a reduction for central office. Dollars 158,000 reduction, the operating expense that we mentioned earlier, dollars 500,000 for the refugee transitional housing we mentioned earlier. The next two items we haven't mentioned yet, 17,000 for field service coordination, there were two districts within the field services realm that had extra support for complex cases. And so we're now treating all of the field services equitable. And so they have other resources that they can use for those cases. And then reduction of $19,000 for the foster grandparent program that ended at United Way. This was used as state match for one of their federal programs, but they ceased the program on their own, and so this match is no longer needed. There are two other areas that the central office provides support for the developmental disabilities council, which is 100% federally funded, three positions and the Human Services Board, which is split between general fund and federal funds and that has five positions. And so the only changes in those two appropriations are salary and fringe.

[Sen. Andrew Perchlik (Chair)]: So the seven members but only five of them are paid with them, why is

[Sen. Philip Baruth]: there seven members of the five divisions?

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: So these are the positions that support

[Sen. Richard Westman]: the board. They're not actually the board members, but just administrative staff or legal staff. Paid through your budget.

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: The per diems? Yes.

[Sen. Andrew Perchlik (Chair)]: Just the per diem?

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: Yeah. This is not the per diem. The per diem is part of the nine forty.

[Sen. Andrew Perchlik (Chair)]: So these are like the lower you have lawyers that have served the board. Do you know?

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: Yes. Well, like Joe Ryan or yeah. Mhmm. Okay. Yeah. There's attorneys. Yes. Okay. And then also within AHS Central Office is the a the global commitment appropriation, which serves as the mixing bowl that combines all the state and federal match for the eleven fifteen Global Commitment Waiver. We talked about the FMAP percentage earlier. Also, there's language in the governor's recommend budget to allow us to seek a renewal for our eleven fifteen waiver. We need to submit our application within the next year. And we will start negotiating with CMS. So the language authorizes us to seek that waiver. And the whole budget for global commitment is $2,200,000,000 and on the right side you'll see the breakdown of the various fund sources. So

[Sen. Andrew Perchlik (Chair)]: one of your ups and downs real quick. You did a good on the ADS SLA being going down 2,800,000.0. What we've seen in other agencies budget that there was an up somewhere else for ABS?

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: Yes.

[Sen. Richard Westman]: Yes. Do

[Sen. Andrew Perchlik (Chair)]: you guys explain that? Where so that up, what I'd have to look at the 30 page sheet to find that?

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: Yeah. For each department. Correct.

[Sen. Andrew Perchlik (Chair)]: Because it would be split between Correct. But the savings is here in Central.

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: Yeah. So our ABS allocation charge was up for the core enterprise services two months. All funds $203,000.

[Sen. Andrew Perchlik (Chair)]: Well, that's a pretty good job. If you say 2.8, you wanna point two.

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: But there's two caveat. The 2.8 is for all departments. So Right.

[Sen. Andrew Perchlik (Chair)]: So just review, just Yeah. Yeah. Yeah. Okay. That's what I've done. Okay. Go ahead.

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: Okay. There's a snippet of the global commitment ups and downs. And then this is everything we've already talked about earlier. All the changes related to FMAP, you know, the ups for the face FMAP change, decrease for childless new adult 90%, the CCBHC enhanced FMAP rate, and then all of the departmental changes for global commitments actually at $23,300,000 increase.

[Sen. Andrew Perchlik (Chair)]: And then in this next year, do you do the new eleven fifteen waiver? Yes. Is there a cost to that? Like is that are you just because you don't know what the waiver is gonna be, but is there a cost to do the negotiations?

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: There is a cost to do

[Sen. Philip Baruth]: the negotiation.

[Sen. Andrew Perchlik (Chair)]: That's not a major.

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: Yeah, we have a contract for both technical assistance and actuarial assistance. And we have that within our budget.

[Sen. Andrew Perchlik (Chair)]: And are there other risks to that?

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: The waiver process?

[Sen. Andrew Perchlik (Chair)]: Yeah, mean, like, if they could just come up with a new FMAP.

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: So, yeah, so it's not a new FMAP because FMAP is across all medications. There have been very few states that have gone through the eleven fifteen waiver negotiations in the last year and a half. And so we don't, there are areas that we can hypothesize, but we don't have enough information to show where there may or may be risks or not risks at this point in time.

[Sen. Andrew Perchlik (Chair)]: And that's probably the same throughout all parts, all your departments and how they're affected by the pandemic, you don't have any way to prepare for what next Correct, rate is gonna fall.

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: There are definitely some things that they have put out information that we know that they anticipate not funding. For example, they've been really clear that there are certain health related social needs. And by that, one example of that is the ability to pay for six months of someone's rent using Medicaid dollars. They don't consider that a health care service unless there's a specific health care need. So at this point, we have not implemented that portion of our waiver because we don't anticipate being successful. Other boogeymen, I don't know yet. There's just not enough information to know what the primaries are yet for this administration concretely based on what they've actually negotiated versus what we're hearing. Sure.

[Sen. Andrew Perchlik (Chair)]: Okay. Caroline, do you have a question?

[Sen. Virginia “Ginny” Lyons]: No. I'll stay on. Okay. Thank

[Sen. Andrew Perchlik (Chair)]: you.

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: Here here's a snippet of our grants out to that come out of the secretary's office. And then just a reference for the supplemental documents that are available on your website, our ups and downs, that summary budget sheet, our 25 carry forward and reversion list, a list of single audit findings from the previous year, and the 1% community based provider.

[Sen. Andrew Perchlik (Chair)]: We have four documents that are. Does one of these be done?

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: I think the last three items are all combined into one document.

[Sen. Andrew Perchlik (Chair)]: Correct.

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: The slides plus those.

[Sen. Philip Baruth]: Mr. Chair. Yes. I would be interested in more repayment program. In particular, you talked about the rural transformation money allowing tuition payment. I'd be interested to know what you expect that pop to look like compared to what you're eliminating and who might not be able to take advantage

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: of that. Absolutely, we can bring that back in. One of the questions I figured somebody would ask and then didn't and Jill, I'm gonna put you on the spot you may not know, we may have to come back. How much money is in the workforce bucket of the rural health transformation?

[Sen. Virginia “Ginny” Lyons]: I'll put it on a friend. About even.

[Sen. Philip Baruth]: Okay. And there are some specific things that we are not allowed to use on the board, specifically providers. That's one that's called out very explicitly in the Yeah.

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: Providers meaning physicians. Physicians and APUs. Yep.

[Sen. Philip Baruth]: Yep. Okay. Yeah. Whatever you can get us on that, that's Yep. That's the only thing that gives me

[Sen. Richard Westman]: some positive.

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: Thank you. We're hearing lots of questions about both workforce, what we're doing in rural health transformation, and about the decision for for repayment. So I appreciate everyone's helping us work through that. We'll definitely be back with more information.

[Sen. Virginia “Ginny” Lyons]: So I'm looking at the supplemental data on 1% increases. Do can we get can I get? I guess. I don't know. Probably would go to our committee, but it could we'll come here as well. 1% increase on primary care. What what would it be for an increase in primary care to right now, I think Blueprint is what? A 110% of Medicaid Medicare?

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: I'm not following with the I'm

[Sen. Virginia “Ginny” Lyons]: try I'd like to know how much more we'd have to invest to increase Medicaid reimbursement for primary care by 1%. 1%, 2%, 5%. Is that possible?

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: You're looking for Medicaid reimbursement increases. Yeah. I'd also like to be able to make sure to bring to you the dollar amounts that are that are coming from rural health transformation because there are significant dollars that are earmarked for primary care in the rural health transformation fund. Some of those we're just trying to figure out whether we can pay them out in a way we've got. But again, there's significant Okay. That would be $40,000,000 for primary care. Tracy's sick. Well, it was sick. She's getting better. She's stopping.

[Sen. Andrew Perchlik (Chair)]: Now we're all sick.

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: Saw everyone's alarm as she said she got up and stuff that.

[Sen. Virginia “Ginny” Lyons]: I can't compare it.

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: Good, thank you. Yeah, so we can provide that 1%, but I'd also like to make sure to provide with that how much funds are in the overall.

[Sen. Andrew Perchlik (Chair)]: Any other any other last comments or questions with

[Sen. Philip Baruth]: the commission secretary? Alright.

[Sen. Andrew Perchlik (Chair)]: Thanks for your time. Thank you.

[Sen. Richard Westman]: Thank you.

[Sen. Andrew Perchlik (Chair)]: It's a lot for us to look through.