Vermont Legislature SmartTranscripts:

[Sen. Ann Cummings (Chair)]: Ann, we're live. Welcome to Thomas Chittenden. We'd love to have you here because you're the only ones that are gonna like us all year. That's a wonderful treat for us. And just introduce yourself for the record, who you represent, and then the floor is yours.

[Ian Davis (President, Vermont Captive Insurance Association)]: Great. Well, thank you very much for the invitation. My name is Ian Davis, I'm the President of the Vermont Calfed Insurance Association. And I've had the privilege of being in front of this committee in a few different roles, actually. I started as President in August, but have worked in the captive insurance industry here in Vermont for the last ten years. First with the Department of Economic Development, helping to market and promote the state.

[Sen. Ann Cummings (Chair)]: Okay. That's

[Ian Davis (President, Vermont Captive Insurance Association)]: most recently, with M and T Bank. And I'm actually kind of a product, if you will, of the captive industry. My mom was the first president of the BCIA back in the late 90s, so it's very much a full circle moment for me to be now serving in this role, if you will. But, you know, truly, I've seen firsthand how important this industry is to Vermont, to its economy, and to its reputation with its business community. I know I'll be back in front of this committee at some point to talk about the captive bill.

[Sen. Ann Cummings (Chair)]: I believe the captive bill got sent to us today. Did it come down?

[Ian Davis (President, Vermont Captive Insurance Association)]: Our package came down, yeah.

[Sen. Ann Cummings (Chair)]: But then it arrived about the time you did it.

[Ian Davis (President, Vermont Captive Insurance Association)]: Wonderful. Well, figured I'd preserve

[Sen. Ann Cummings (Chair)]: kind of

[Ian Davis (President, Vermont Captive Insurance Association)]: some of my comments about how that bill was developed and contained with it for that time. But with the few minutes that I have, just wanted to provide a few quick updates and then get to Julie, who is Vice Chair of our Board and a Vermont domicile captive owner. Very interested to have you hear her directly as to why she chooses to be in Vermont and the work that her retention group does. Very quickly, today the association is really focused on three major priorities. We we refer to them as core pillars, should say, but strengthening our advocacy work both here in Vermont, more so at the federal level and within the National Association of Insurance Commissioners, the ALIC. As you can imagine, as the largest captive trade association representing the largest domicile in the world. We are still. We are still.

[Sen. Ann Cummings (Chair)]: Worked for that for a long time.

[Ian Davis (President, Vermont Captive Insurance Association)]: We have, yeah. And so, we really have the credibility and the responsibility to lead on all things legislative and regulatory things that touch, not just for long term active industry, but the broader industry as well. So that remains a key area of focus for us. The second would be just expanding our year round learning and professional development opportunities outside of just our annual conference, which as you'll recall is our signature event that we do every year. Last year we had eleven forty seven attendees here in Burlington for the course of four days. And that remains the association's biggest strategic asset, if you will. But we are very interested in building out our educational offerings to meet members' needs throughout the course of the year. That's a key area of focus for us as well. And then lastly would be, we refer to as member engagement. And by that we mean meeting members where they are at across the country. So we are an association that represents four thirty organizations, but that is a much larger number when you talk about the number of individuals who work for those member companies. By and large, the vast majority of the 3,000 or so individual members are major metros around the country. So we want to have a presence in those markets where there is a concentration of membership, but more importantly for Vermont, in areas where we are seeing new captive activity. So we, this past year, launched what we refer to as chapters, so similar to an alumni network, if you will, in Chicago, and we'll soon be launching a Philadelphia chapter. So there's a number of Vermont domicile captives today who have physical presence in those markets where those companies have headquarters. You'll be hearing from one of those companies, at least Julie herself is located in the greater Chicago area later in just a few minutes here. But it's really important, I think, again, while we continue to invest in Vermont, we are fully committed to remaining in Vermont and really being a big V, Vermont Association. We also recognize that it is important for us to be and have a sustained presence in some of these other key markets around the country. All in an effort, again, to make sure that Vermont remains the leading captive domicile and that we continue to drive new licensing activity here in Vermont. So I think I'll pause there and happy to answer any questions or do so at the end if that's more. So yeah.

[Sen. Ann Cummings (Chair)]: Committee, any questions? Thank you, Doctor. Sharon. Thank you, Ed. Sorry, came a

[Unidentified Committee Member]: little bit late, so I missed the beginning, but I guess I'm not sure what you mean by chapters. Like what did you Is it just a social kind of thing or is there a business aspect?

[Ian Davis (President, Vermont Captive Insurance Association)]: There's very much a business aspect. I think, you know, it may be helpful just to kind of share some context. We as an association have, since we were founded, done what are called road shows, where we go and kind of spread the captive gospel all around the country in an effort to bring regulators, bring service providers to areas where captive activity is growing and to talk about why, if if you're going to have a captive, you should do it in Vermont. And so the kind of thought process here is, it's almost a reimagined or modernized take on a roadshow and that we are still going to Chicago and Philadelphia in an effort to reach a wider audience of prospective captive owners, and to tout the benefits of being in Vermont. So it is about community and building community in those areas as well. So there is a social networking component to it, which is, again, a core tenant of who we are and what we do as an association, but it is very much educational. We are always joined by the Department Public Development, the Department of Financial Regulation, and we show up collectively to talk about why doing business in Vermont is so important.

[Unidentified Committee Member (male)]: Great, thank

[Sen. Ann Cummings (Chair)]: you. The questions. Thank you.

[Ian Davis (President, Vermont Captive Insurance Association)]: Great, thank you.

[Julie Bordo (President & CEO, PCH Mutual Risk Retention Group)]: Thank you very much. I do have

[Sen. Ann Cummings (Chair)]: a presentation to share. I

[Julie Bordo (President & CEO, PCH Mutual Risk Retention Group)]: requested to share. Good afternoon, everyone. My name is Julie Bordeaux and I'm the President and CEO of PCH Mutual. And I have to tell you, this is a very meaningful moment in my life. I have the utmost respect and admiration for your public service. And I know and I've been taught through my family and my mother who was a lobbyist in Michigan, believe it or not, very involved how important it is, your service. So, thank you so much for that. I really appreciate it. And part of this is, I think, filled with a lot of gratitude in my presentation. So I gave you a little background on myself. This isn't about me. This is about PCH Mutual, which is a risk retention group that was formed in 2004, and it was formed to serve non medical residential caregivers across The United States. As I'm sure you well know, one of the reasons that captive insurance was created and the Liability Risk Retention Act was enacted was to enable small businesses, which are the backbone of this country. 99% of employers are small businesses, And so they are the greatest employer in The United States. But not only that, but our businesses care for the most vulnerable adults. And that's the service they provide. And they were in need of affordable, professional and general liability insurance. You know today there's a greater imperative for that as we see our baby boomers going over the edge. There will be more people who are 65 than who are 18 or under in this country in a very few years, and they will need care. So we are there to serve them who are our members. They are all generally small, family owned. We do have some mid sized assisted living facilities, but they're owner operated community businesses. I can give you the numbers, which I will in an additional slide, but essentially one of our core missions is to serve those who serve the most vulnerable. And we do that by embracing a lot of free member benefits and resources and substantive ones. Not just PowerPoints on how you can get better care, but really substantive things that allow them to give the best care to their residents because our core mission ultimately serves those vulnerable adults. And this gives you a little idea of who we are. But what I really like to get to more than anything is how Vermont has allowed us to get there. So when I became president and CEO of PCH, my first act was to read domiciles in Vermont. And I have a great memory of going to my first VCIA conference. A little nervous and one of my jobs was to interview with the Department of Financial Regulation to see if we were candidates, if we were a match, if you will. And I remember sitting across from David Provost Sandy Bighlestone and being quite nervous about the interview and feeling immediately at ease and immediately like the expertise, the professionalism, the authenticity of these people from the top was so tremendous. And that was carried through once we became a Vermont style company. David Provost came to our first board meeting and my board members, some of whom are these caregivers, were off by that. And it was a tremendous connection. And it made them feel like this is not your traditional regulator business type of an environment. There's something more different. There's something deeper and richer about this environment. And he conveyed at that meeting something that you did as a legislature to help our industry, and that was we were struggling with having enough flexibility in our investment plans, you had passed some legislation that allowed us to have that flexibility. We were in need of that then. And so, it was a very clear connection between what we needed, the legislature listening, the Department of Legislation, financial regulation putting it together, the legislature listening, and giving us what we needed, which really tremendously served us. I can tell you that we've seen this time and time again with Vermont. So as we've grown, this is just a slide to show you, this is what we look like now that we're in Vermont. This is where it's gone for us. Membership, our surplus, our premium, we were able to thrive in Vermont. And with collaboration. And one of the things I really wanted to emphasize was in this time in our culture when it's almost a desert as far as community is concerned, I feel like the state of Vermont is a community. It's a community where business can thrive. And the Department of Financial Regulation is and and, of course, the legislature is leading that and it is showing it, epitomizing it in tremendous ways. So I say no tunnel vision because I visualize them as people with binoculars looking at the horizon and showing saying, this is what's coming down the pipe. So my story behind that is back when Bitcoin started becoming a thing and blockchain was blockchain. Ian Davis was with the economics. Was in his first role, right, at the economic development department. And they put him in charge of studying the blockchain, seeing how it could serve our industry. And I thought, that's amazing. They're ahead of the curve. They're seeing what's coming. They're not reacting. They're proactive. Right? And those kind of things that you do as a legislature and that the department does in that way help us to see what a strong environment it is for our businesses and to and to do business here. Kai Sansom talked earlier today about how you're not the cheapest domicile, you're not the most permissive. I don't want that. I want people who can make us better. We've had three examinations under my brain, if you will, and every one of them has made us better as a company. It's not an adversarial interaction. It's a collaborative interaction of how can we take the wealth of our experience, the depth of our knowledge, where we've seen people faltering or on the verge of failing, and how can we help you to not be that company? So I can name everyone. Brianne, Jen, Kara, Stacy, all the people on our examination committee, and they were tremendous, tremendously helpful. Everybody in the leadership who engages with us and says, What are your problems? How can we solve your problems? Then there are times when we've had an exchange where they've asked me, Do I have ideas how to help them? So we have engaged creative thinkers, the absolute opposite of every stereotype you have, the regulatory body. And that is another reason why we're in Vermont. I'd like to give you just a couple of other examples. I told you about the legislative change that you made that benefited us. We had a few years ago where you might remember everybody's portfolio was crater. So, all of a sudden, not by any other issues related to claims or other issues impacting our loss ratios, but we were put in a position where we were going to have to be in corrective action. And my first thought was, I have to speak to the leadership and tell them as soon as we saw that coming. And I sat down with Christine Brown and Sandra Biblestone and they said, We understand. We know this is coming. And of course you'll have to be in corrective action because that's the rule. Those are the rules, but we understand and we'll be there to support you. You'll get out of this. And those kind of interactions, the ability to interact with our regulators in that manner is absolutely priceless, for sure. And then the final concrete example of this was we had a problem with our, we offer evacuation coverage as an ancillary benefit because I think you might remember the hurricane scene with the elderly folks in wheelchairs with water up to their knees, right? Had a couple this year too with bikes. Exactly, right. And so, with the climate change issues, we need to offer evacuation coverage. We want them to feel safe and supported, to be able to evacuate before the storm hits. But we realized with some of these massive events that we might have some major exposure that couldn't be covered by reinsurance. So we put together a plan regarding essentially an aggregate coverage for a single event. And so we had kind of a creative plan that I put together, looked through and drafted with our attorneys, and we presented it to Vermont. And they took time with it, and then they said, Absolutely, this makes complete sense. And that was something that they said, It's alright, we can suggest this to other companies if they have a similar problem. So, that's the kind of collaboration and the kind of community that you and the department and the Department of Economic Development have put together to help our company truly thrive. And we are tremendously grateful for that. And I am happy to speak to anyone who will listen to me to talk to about the value of that. I'm an informal risk retention group leaders group. We talk about that and the benefits of Vermont. And so, it's with gratitude. I want to tell you that we bring a little bit to you. I hope you know that and we want it to be a mutually beneficial experience. So, these are some of the things that we see as what we can bring to you. I've actually lobbied in Washington on behalf of the VCIA and the cabinet industry, and that was another wonderful full circle moment. But please keep doing what you're doing. And the fact that there are long standing, loyal employees with this kind of tremendous foresight and vision. I don't know. I don't know if it's got anything brewing on AI, how you're going to help them do exams with AI, but whatever it is, keep doing what you're doing. Keep taking along with you because it truly does benefit us, and we're grateful. Thank you.

[Sen. Ann Cummings (Chair)]: We're grateful. I told the committee to get down here ASAP because there's some of the few people that actually like us. This is the most I've felt liked, and I have been in this building a year and a half. And it is good to know we do something right. I'd like to be able to clone this and move it into other departments. You guys wanna take over education? But thank you. You're welcome. Glad that we have helped. And, yes, this is an industry that this year, there's been a couple of really bad Right. I think mostly Yes. In homes. It's important that that that they have backup. Yeah. You're in public service for the people. Yes. And, ultimately, that's what everyone here that's what we have serves. And any any question?

[Unidentified Committee Member (male)]: What's GWP stand for on your

[Julie Bordo (President & CEO, PCH Mutual Risk Retention Group)]: Gross written premium. Some people will say gross premium written

[Unidentified Committee Member (male)]: or gross written premium. Yeah, that type of thing. Yeah.

[Julie Bordo (President & CEO, PCH Mutual Risk Retention Group)]: So, we like to say we're small but mighty. At 15,000,000. But when I started, you were

[Unidentified Committee Member (male)]: at 3. Oh, wow. Right direction.

[Julie Bordo (President & CEO, PCH Mutual Risk Retention Group)]: Right direction. But, you know, again, proceed with measured growth. You don't just go for the jackpot in a year. We've gotten a lot of good feedback at homes.

[Sen. Ann Cummings (Chair)]: Okay, thank you.

[Julie Bordo (President & CEO, PCH Mutual Risk Retention Group)]: Thank you very much for your time.

[Sen. Ann Cummings (Chair)]: Thank you. We will try and not mess with things.

[Julie Bordo (President & CEO, PCH Mutual Risk Retention Group)]: But again, any big ideas, those are good too. Well,

[Sen. Ann Cummings (Chair)]: we let those come from the folks that actually know what they're doing.

[Brittany Evans (Captive Insurance Economic Development Director, State of Vermont)]: Chairs, if you I

[Julie Bordo (President & CEO, PCH Mutual Risk Retention Group)]: think we technically Well, no. Think I'm not gonna do that.

[Sen. Ann Cummings (Chair)]: Kids can. Welcome.

[Brittany Evans (Captive Insurance Economic Development Director, State of Vermont)]: Thank you for having me. My name is Brittany Evans, and I am the captive insurance economic development director of the State of Vermont, and I am in the Department of Economic Development in the Agency of Commerce and Community Development. And I have just some brief remarks, but I wanted to just check on time

[Sen. Ann Cummings (Chair)]: since we're probably Can you do it

[Brittany Evans (Captive Insurance Economic Development Director, State of Vermont)]: by Yeah.

[Sen. Ann Cummings (Chair)]: Minute? And I I don't know if Ian was the first person to go to economic development, but at some point, DFR came to us and said, you know, we really shouldn't be regulating and promoting. And so the promotion got moved over to economic development so that DFR could just do the regulating because there is an inherent conflict there. And that has worked very well.

[Brittany Evans (Captive Insurance Economic Development Director, State of Vermont)]: Yes. Yeah. That is the current structure. So Ian was not the first, but there's at least one person before Ian. And I've been here alone.

[Unidentified Committee Member]: Yeah. So

[Brittany Evans (Captive Insurance Economic Development Director, State of Vermont)]: we've been having the structure for quite a lot for quite a while, and it's a structure that's been mimicked by quite a few other states at this point because it does work well. So it's really great to have someone just to focus on the marketing and business recruitment and not then have to, you know, bring in the companies and then regulate them. It can kind of create some potential conflicts there. So, yeah, I can definitely keep my remarks brief. And if you have questions that we can't get to, you can always reach out at any point. But I also have some colleagues from the Department of Financial Regulation here as well who hopefully will give an update or maybe already did, but I'll touch a little bit on some just kinda high level data points for how we're doing. So we released year end data this morning, actually, for 2025, and we had 51 new captives licensed last year. So that is our third highest year of growth in our forty five year history. The last six years have the last five years have been top ten years of growth. So we are on a very successful trajectory, which is incredible. And that really is due to what we call the the four legged stool the Department of Economic Development, the Department of Financial Regulation, the association, and the legislative side of things.

[Sen. Ann Cummings (Chair)]: And I also understand that because we had a time where we were declining, and it it is tied in some ways to whether or not the commercial insurance market is Yeah. Hard or soft. So I assume that the market is fairly hard right now.

[Brittany Evans (Captive Insurance Economic Development Director, State of Vermont)]: I know. Yes. Yeah. It's been a continuation of the hard market, but there has been some softening in some areas. But I think it's pretty interesting. We have had, like, in 1986 and then in in 2001, really big fluctuations because of certain events that were going on. But I do think it's becoming more and more clear that companies are turning to captive insurance as a risk financing tool for the long run, and they're recognizing that they'd have to stabilize their insurance and keep cost controlled and to control their their risk generally. So it's not as much of a reaction to a specific thing as it maybe once was and becoming more of a common practice. And that is worldwide. It's becoming more and more common. So yeah. So we are doing really well. We are estimating about $35,000,000 in tax revenue, at least again, from the last year. And as you are aware that those funds, they support the the whole regulatory program, my role, the marketing efforts, and the rest of that money, which is the vast majority of those funds, go to Vermont's general fund for our most essential programs. Yes. And last year, we won a national domicile of the year award for a fourth year in a row, which is amazing. And although we've had some changes in leadership over in recent years, we we had some talking points earlier at the board meeting, where Christine was actually talking about how the leadership in the captive insurance division all have 25 of experience in the department. So, even though we may have folks that are shifting, we have a really deep bench of expertise. Also, just wanted to mention that there's been a convention center task force that the department's been working on, and so that's great to see, so that we can continue to support the association with the conference that happens every year, which is the largest conference in Vermont. Just wanted to touch briefly on workforce challenges. I've been collecting data the last couple of years, and you may have recalled that from last year, but we're seeing a continuation of some trends that we saw last year. So we have now over 500 confirmed jobs that are available for Vermonters. That's an increase of at least 20 jobs from the last year. So the job growth is growing at the rate of our licensure growth, which is incredible. But unfortunately, the data is also showing that we saw a decrease in 4.5 positions being filled by Vermonters. So what that means is that these jobs are being created, but the skills are not quite in Vermont to fill these jobs. Also Vermonters are not as aware of the industry, so we're trying to create awareness. So that equates to four out of every 10 jobs for the captive insurance industry are being filled by Vermonters. And this puts a strain on the service providers that work in Vermont, and so what we're really focused on is continuing the Captive Insurance Emerging Leaders program with the association. And that is really an effort that's industry wide to raise awareness about Captive Insurance as a career path. But we are definitely facing a a challenge with the discontinuation of some accounting programs. So yeah. So that's I guess I'll stop there because it's been Yeah.

[Sen. Ann Cummings (Chair)]: Getting a sense. We have our next set of witnesses have a hard stop. Okay. And we know we can have you back. Yeah. Yeah. And we still have the cancer insurance bill. Yep. So we will be hearing from everyone when we take that up. And that's usually not controversial, and I'll try and get it out of here as quickly as we can. If you'd me to have something that isn't controversial. Yeah.

[Brittany Evans (Captive Insurance Economic Development Director, State of Vermont)]: I don't typically come to that, or at least I haven't in recent years. Yeah. If you'd like me to join for that and

[Sen. Ann Cummings (Chair)]: get more get another briefing.

[Brittany Evans (Captive Insurance Economic Development Director, State of Vermont)]: Yes. Definitely.

[Unidentified Committee Member (male)]: Yeah.

[Sen. Ann Cummings (Chair)]: Yeah. That sounds great. You're Yeah. Young this session. Sounds good. Yeah. But everything's going well,

[Brittany Evans (Captive Insurance Economic Development Director, State of Vermont)]: but some challenges. It's good for you to be aware of.

[Sen. Ann Cummings (Chair)]: Thank you. Thank you. Thank you for your time. Thank you all. I hope you get a chance to enjoy Vermont, and then get out of here before it's minus 13 and get snow. Thank you. But we do fly a runway.

[Unidentified Committee Member (male)]: You very

[Unidentified Committee Member]: much. You got lucky with good weather. I'm taking So you have

[Sen. Ann Cummings (Chair)]: you actually pop us. Okay. And you have a hard job at 02:30? Yes. I'm sorry

[Unidentified Committee Member]: about that. No. It's okay.

[Sen. Ann Cummings (Chair)]: We got laid on the floor, and I'm sorry, but you are not gonna love us the way those people love us. That's captive insurance.

[Unidentified Committee Member (male)]: You can probably wanna do them if you want.

[Unidentified Committee Member]: Yeah. Well, we're just giving you a little one on one, we think. So we think we're telling you No money federal insurance. Far as

[Sen. Ann Cummings (Chair)]: captive insurance.

[Unidentified Committee Member]: Okay. Well

[Unidentified Committee Member]: And they also bring money.

[Sen. Ann Cummings (Chair)]: Medicaid, no one

[Ian Davis (President, Vermont Captive Insurance Association)]: loved that.

[Unidentified Committee Member]: They bring us money.

[Unidentified Committee Member]: Don't think. Here, why don't you take the good share? Glad I

[Sen. Ann Cummings (Chair)]: didn't. Go ahead, Patty. Just do not come this way. Alright, so

[Unidentified Committee Member]: we have Addy with the start. We deal with the chart. Yes. Okay. We're actually Okay.

[Sen. Ann Cummings (Chair)]: Let me turn it on. Should I go ahead? Okay. Here's Addy. Great. Good afternoon. Already snowing where Addy is. We

[Unidentified Committee Member]: all have different Vermont winter scenes behind us right now.

[Sen. Ann Cummings (Chair)]: There's some people that have

[Unidentified Committee Member]: palm trees. Yeah. Some of them are actually. Okay, good afternoon. I am Jill Mazza Olson.

[Jill Mazza Olson (Medicaid and Health Systems Director, AHS)]: Am the Medicaid and Health Systems Director for the Agency of Human Services. So, some of

[Brittany Evans (Captive Insurance Economic Development Director, State of Vermont)]: you may recognize me.

[Jill Mazza Olson (Medicaid and Health Systems Director, AHS)]: I've been around schooling for a long time, about twenty five years, but all in the provider policy and advocacy space. So, this is pretty new for me to be in this role. You'll see today, I am really mostly here to facilitate, and this presentation has been done both with and without me, and I'm really not central to it. So, I have our expert team members here, and what we think we're talking about is HR1 and the impacts to Vermont. That's the presentation we have prepared. We've been to health committees and to appropriations as well. I'm sorry, Sue of you

[Sen. Ann Cummings (Chair)]: have seen it. We are responsible for health insurance. Yes. That's our view of context. Great.

[Jill Mazza Olson (Medicaid and Health Systems Director, AHS)]: Okay. Ashley's going to actually start with some of the impacts that some of them are directly insurance related, some of them aren't, but I think you'll want to hear the whole thing. Great. For the record, Ashley Bergener, I'm the Director of Medicaid Policy for the Agency of Human Services. I'm trying to join on Zoom so I can share slides, but I believe we also shared slides yesterday.

[Ashley Bergener (Director of Medicaid Policy, AHS)]: It's on our website. Okay, great.

[Sen. Ann Cummings (Chair)]: But we can get that. It helps anyone that's talking.

[Ashley Bergener (Director of Medicaid Policy, AHS)]: I should have talked quite a lot. I introed a minute. No. I have to say this change to have to do this tech in front of the committee as the witness is a stress change. I always see, it's a new element since my group started in.

[Addison “Addy” [last name unknown], Deputy Commissioner, Department of Vermont Health Access]: I can introduce myself also. Addison District. I'm the Deputy Commissioner at the Department of Vermont Health Access. I'll be doing kind of the second half of the presentation once Ashley's done when we focus on eligibility and enrollment.

[Ashley Bergener (Director of Medicaid Policy, AHS)]: Ann is joining, but it's taking a second. So, I'll just start with Planned Parenthood funding, which is the very first provision in HR1 that was put into effect on 07/04/2025. And it is a provision that prohibits federal Medicaid for Planned Parenthood and Planned Parenthood like entities for one year. So, this provision sunsets on 07/03/2026. And what it means practically is that we cannot claim federal funding for Planned Parenthood or Medicaid for this full fiscal year. There have been many, many lawsuits. You might have heard of the little ping pong back and forth between injunctions that allow federal funding, then they pause the bar, then they unpause the bar. And we have made a decision to backfill with general fund during this one year period. And while the courts are still going back and forth deciding whether or not the ban will ultimately be upheld, we are sticking with that state general fund. If final decision occurs that federal participation is permitted over the past year, we'll make sure that we go back and claim that, but because of all the back and forth, we are just sticking with straight general fund dollars. And that's about 1,100,000.0 gross, so both the state share and federal share that we expect in that one year. So about $600,000 in federal funding that we're backfilling with general funding for this one year period.

[Sen. Ann Cummings (Chair)]: And that is my understanding that there are quite a few women in a in a time when it is hard to get primary care that do use Planned Parenthood as primary care. I think the issue is over abortion nationally, but that is not all that they The only service. Yeah. That is not the only service that you got.

[Ashley Bergener (Director of Medicaid Policy, AHS)]: Yes, good job there. Wow, we're up. Okay. And absolutely, we really think of it in Medicaid as a critical safety net provider, so we're very happy that we can sustain it during this one year period. The next provision that I'm going talk about is related to provider taxes, and hospital provider taxes are specifically implicated in this purchase end. HR1 prohibits the creation of any new provider taxes, and then beginning in November 2027, it requires existing hospital provider taxes to be reduced from a maximum of 6% to eventually 3.5% in 2032. They're asking states to reduce from 6% by point five percentage points each year until it's a full reduction in 2032 to get to 3.5% overall hospital provider tax. In Vermont, that point 5% reduction in provider taxes equates to a loss in state general fund of about $18,000,000 a year in today's dollars. Cumulatively, over the course of five years, going from six percent to 3.5%, we anticipate that being about $87,000,000 in lost general fund revenue in today's dollars. We're really looking at this carefully to understand everything we can about this and really figure out where our levers lie. This is kind of this year budget concern, but we're really wanting to make sure that legislators are forecasted on what is to come, because this is surely going to be a topic of conversation in the future. The next provision I want to talk about is Medicaid state directed payments. State directed payment is a term of art in Medicaid that is when Medicaid is required by the state to pay in a certain way. This normally applies to a private managed care like organization in Vermont. It applies to DIVA, the Department of Vermont that does us. So, what this means is that on 07/04/2025, when this was enacted, Medicaid state directed payments are not permitted to grow, and no new state directed payments can be established. They are requiring existing state directed payments to be reduced by 10% per year until they reach 100% of Medicare. So, essentially, they don't want any state directed payments to be above Medicare rates. And in Vermont, this specifically impacts Medicaid rates where we are instructed by the state legislature to pay above a particular payment or pay a specific methodology. We know that the Blueprint for Health payments around patient centered medical homes and community health teams are written in statute to pay a certain way. Primary care, I believe in 2024, was established at 110% of Medicare rates. And there are a couple of other payment provisions and statute that require Medicaid to pay in a certain way above Medicare limits. What this provision means is that if we put Medicaid, those payments will have to be reduced to 100% of Medicare and cannot be any higher. We think that we can comply with this provision with some minor changes to our business processes and how we craft statute and make sure that we're still gaining all the flexibility and able to promote the values of Vermont and make sure that we're funding the things we want to fund in Vermont's Medicaid program and still comply. We're working on what exactly we need to do to come into compliance with this, but we're optimistic that there are things we can do that still promote our values by complying with this provision. It's really just something to flag because we're going to be coming back to the state legislature in the next couple of months, really, to talk about things that we think need to happen or not happen when statute is being developed to make sure that we don't fall into some of the pitfalls of state directed data.

[Sen. Ann Cummings (Chair)]: And

[Ashley Bergener (Director of Medicaid Policy, AHS)]: the last one is related to cost sharing, patient cost sharing for the Medicaid program effective October 2028. The new adult group or the expansion population under the Affordable Care Act will be subject to cost sharing on all Medicaid services except for services explicitly exempted. This carves out individuals under 100% of the federal poverty level, so it's just going to be for people at 100% of the federal poverty to 138% of federal poverty eligible under that new adult group, and states will have flexibility to decide what those co payment amounts are. But we have a lot of questions about this particular provision, and we don't have answers from our federal partners yet, so we're waiting on regulatory guidance from them on how states are supposed to administer something like this, why explicit services can be carved out. We have a lot of questions that we're just so waiting We know that the Centers for Medicare and

[Julie Bordo (President & CEO, PCH Mutual Risk Retention Group)]: Medicaid Services are focused

[Ashley Bergener (Director of Medicaid Policy, AHS)]: on other priorities right now, so we don't anticipate getting answers to those questions on this provision anytime soon because the date is so far off. But again, just wanted to flag because it will have an impact in Vermont. Would this be include some preventative screenings? It's likely that preventative screenings will be excluded. Okay. But, right now, we only have co payments on a very limited set of services, dental, hospitalization, and pharmacy. So, we'd be adding co pays to everything. Yeah.

[Sen. Ann Cummings (Chair)]: Which would discourage people. I mean, where is the federal poverty levels of 15,000 something for an individual? That's in the ballpark. A 100%. You don't have a lot of spare cap at So that you might put off the regular manual mammogram that you've got if they don't open.

[Ashley Bergener (Director of Medicaid Policy, AHS)]: And there are some exceptions that will be written in, and we do know that. We just don't know exactly what they are gonna be or how we're expected to administer them.

[Sen. Ann Cummings (Chair)]: Okay. Thank you. There's a lot. Thank you, Ann Cummings. Thanks for the presentation. I feel like one of

[Ashley Bergener (Director of Medicaid Policy, AHS)]: the things that's happening is that we're seeing so many devastating cuts, and at the same time, it's being kind of obfuscated and confused by the 195,000,000 rural health grant that we're getting. Are you finding that people are conflating or confusing this and they think that that rural health grant is going to fix these problems. My understanding is it won't. A separate bucket of money that is not at all going to solve this problem. You're right. Is totally different. Mostly people have pointed out to me that it's different and made sure that we understand that it's different, which we definitely do. I'm hearing from constituents. Yeah, well that may be, yeah. It is confusing, and the Rural Health Transformation grant is an opportunity that also grew out of this legislation. It's one that I think we wanna take advantage of because it's an opportunity to do things we might not have otherwise been able to do, but it does not impact some of the other things that we're talking about. So, they are entirely separate. Yes, that is we view it as an opportunity to take advantage of, but yes, you're right.

[Sen. Ann Cummings (Chair)]: There are other problems with us all.

[Ashley Bergener (Director of Medicaid Policy, AHS)]: Thank you. Thank you. I have a question before we're allowed to ask questions now back on your the provider tasks. The numbers that you gave, I think, I was looking back at our presentation from The Economist on Friday, and I think the numbers you gave for the impact are higher than what he was reporting. And and maybe it's because you're accumulate like, you're doing accumulative, but is is the 18,000,000 the final year of that, or is that the first year? It's 18,000,000 a year. 18,000,000 a year. Yeah. It doesn't look like what Are you referring to Nolan's presentation? No. I'm referring to Tom Covet's presentation. I'm just looking at it right now. I mean, he what in what year does it start? It starts November 27. Yeah. I mean, his his numbers are much more modest than that, at least based on this one chart that I'm looking at health care revenue. So we'll take a look at that. We have drawn these numbers, and I know Nolan Lanewell and joint fiscal office has kind of a slightly different presentation, but the numbers are consistent with our numbers. So Yeah. And it may be just the way that they're I mean but I would really like to know, like, what the real Yeah. So if, like, you and Nolan and Tom could just check the numbers and see what the Wait. What? Do you have this presentation? I mean, this is online. Well, yeah, we'll take

[Sen. Ann Cummings (Chair)]: a look. Two. Yeah. Thank you. So,

[Ashley Bergener (Director of Medicaid Policy, AHS)]: I'm going to pass it over to Addison to talk about eligibility.

[Sen. Ann Cummings (Chair)]: Okay.

[Addison “Addy” [last name unknown], Deputy Commissioner, Department of Vermont Health Access]: Thank you. So yeah, as mentioned, I oversee eligibility and enrollment in your healthcare programs, both Medicaid and the qualified health plan marketplace. So we're the entry point for people to get and maintain healthcare coverage. And this eligibility process is one of the other kind of major levers that was used in the budget reconciliation legislation that we're discussing today. So a lot of the near term work is with us and our teams here at DIBA. We began the work right when the bill passed, including some small pieces that we had to adjust during open enrollment this past fall. And right now, we're focused on three major provisions that require implementation over the course of 2026 for effective dates in late twenty twenty six and 01/01/2027. And then there's a fourth work scheme I'll mention briefly for 2028. The first change, we can go to the next slide, are changes regarding healthcare eligibility based on immigration status. So these changes apply both across the Medicaid program. They're not specific eligibility groups within the program. And those changes for Medicaid are effective 10/01/2026. The same changes apply to the marketplace. So premium assistance to get on a qualified health plan and those go into effect 01/01/2027. And what this does essentially is that it blocks eligibility for certain non citizens, including asylees and refugees who currently can get on those programs. Our early estimates are that a few 100 members will be directly impacted by this change. It's difficult to identify this population because currently people don't have to provide this level of detail on their immigration status when applying for healthcare. But this is a big area of focus to both identify the population and then work to outreach them as we implement this change. The second major provision is about those Medicaid redeterminations or renewals. That's that kind of annual process where we check to see if someone remains eligible. This is applying not across the Medicaid program, but specifically the Medicaid expansion population. That's the group of non disabled adults that are eligible for Medicaid based on their income up to 138% of the federal poverty limit. We refer to this expansion group as the new adult population. So this will be a change that's effective 01/01/2027, and it increases the redetermination frequency from what it is now, which is annually, to every six months. So it kind of doubles the engagement with the system and the paperwork people will have to maintain in order to maintain their coverage. Right now we have about 55,000 new adults who will be subject to this increased redetermination cadence. The third major provision is what we call community engagement or work requirements for Medicaid. This applies to that same population, the expansion or new adult population, and is also effective 01/01/2027. So this is a brand new requirement that asks members to demonstrate eighty hours of work per month. It can be work, community service or education as a condition of maintaining their Medicaid. There are a number of exceptions and accepted populations within the statute like pregnant individuals, medically frail, those with children 14. So taking those kinds of exceptions into account and looking at our population, we think this change, this need to demonstrate additional standards around work requirements will impact about 30,000 members in our system. So that's the kind of Medicaid story. There's a fourth provision that we are not yet working on. This is going to be a lot of our work once we get past this year, but there's a really significant change coming for the marketplace that we'll have to implement in 2027 for that open enrollment period for 2028 plan year. And this is basically eliminating our ability to do automatic renewals for the Marketplace and requiring that people come back and validate all of their eligibility factors before they can re enroll and get premium assistance. It's a really fundamental change to that whole process. And with this one, we're hoping to get guidance from CMS that either clarifies or kind of softens the statutory requirement, because right now it's really a bit overwhelming in terms of what it will take to make this change. Again, it's another year or so out in terms of our work, and they do plan to issue regulations later this year. So then in summary, I just wanted to say, you know, it's a big project that we have before us, of these different provisions. We can advance to the next slide, Ashley. And our overall kind of guiding principle with this work is trying to maintain coverage. We want to minimize the risk of, you know, people dropping off, even though this does reflect a lot of really stringent new standards around paperwork and verification and other pieces. So we're hoping to use some of the lessons that we've learned in recent years when we restarted Medicaid renewals after the public health emergency about ways to outreach people, stay in touch with them, leverage automatic renewal processes and data sources to help people so they don't have to provide that paperwork. But it's going to be a big challenge and we're grateful in advance for your support as we undertake it. We

[Sen. Ann Cummings (Chair)]: do have

[Addison “Addy” [last name unknown], Deputy Commissioner, Department of Vermont Health Access]: one more slide, but it's just a visual depiction of the kind of the project over the next year. So I'm happy to take questions on any of the above.

[Sen. Ann Cummings (Chair)]: Okay. Questions?

[Unidentified Committee Member (male)]: Okay, just to get back. Regarding this provider tax, my understanding is we collect the provider tax from our hospitals and then that provider tax is redistributed back out to the hospitals in some formula. Is that wrong?

[Unidentified Committee Member]: That is what most other states do with the That is why this provision exists. It's because most other states do have what they call a hold promise, where they tax the providers, they match it, and then they make sure that the providers get all that money back. In Vermont, this is a particularly difficult provision because we don't have that hold harmless provision. The provider tax revenue goes straight into the general fund, which is just a giant, as you know, a giant pool of general fund money. Some of it surely goes to Medicaid, but it's not a one for one. There's no way to really match the dollars. Not like how long the electrons. Okay.

[Unidentified Committee Member (male)]: So, we were wholehearted as this would being no big deal because

[Unidentified Committee Member]: It would be a big deal for the hospitals. It was would, not be a hole in our fund the same way it is for us. Okay.

[Unidentified Committee Member (male)]: Got it. Thank you.

[Sen. Ann Cummings (Chair)]: Yeah. There'll be $86,000,000 less than the general fund, which will either have to come out of Medicaid, the reimbursement, our share, or some other program unless we can find about 10 more captive insurance industries to bring it.

[Unidentified Committee Member (male)]: I've got a control. Later compensation.

[Unidentified Committee Member]: I thought the federal law prohibited that kind of, like, tax the hospital's promise. They're gonna get it all back. Right. They allow it up to 6%. So, there's a 6% whole harmless threshold, which is what most states are at now, and they're reducing that from 6% to 3.5%. So, they're still going to allow a 3.5% whole harmless, but they're significantly reducing it.

[Sen. Ann Cummings (Chair)]: Oh, I was under the impression that you couldn't promise any of

[Unidentified Committee Member]: it back. Could just use for Medicaid, but you couldn't promise that that specific hospital got that exact amount. I'm not aware exactly of all the mechanics in other states. I think different states do it differently, the idea is that it's a way to The rationale behind this provision is that states are using provider taxes to bring in more federal dollars and then reusing the Medicaid program. Right. No. I get that. I understand that. And I think arguably that's what we're doing. But think that but I thought that it was the provision was you couldn't say, okay, you know, Smith Hospital, we're gonna tax you and you're you're gonna pay a $100,000 in taxes and then we're gonna wink wink, you're going to get $100,000 back in Medicaid reimbursements. Know exactly what's that. It's in the race. So, it's considered an enhanced Medicaid payment is how they couch it in federal regulation. And so, you can have an enhanced Medicaid payment up to 6% held harmless. So, it wouldn't be Smith Hospital gets all the money that they paid back, but the enhanced payment would be it would, in an aggregate way, add up to the amount that hospitals pay. Right. So if Jones Hospital has more Medicaid patients, then Jones Hospital might be getting some of the revenue that Smith Hospital paid because they have a wealthier client base than how to repay people on Medicaid.

[Unidentified Committee Member (male)]: I don't know. I'm a baller. I know. But

[Unidentified Committee Member]: I I just I thought it was there was a prohibition on, you know, a one to one, but maybe I I just misunderstood it all. So Well, I think we should clarify that outside of this room. Just that yeah. But but it it I think that what's important is that in Vermont,

[Julie Bordo (President & CEO, PCH Mutual Risk Retention Group)]: we are putting my name to the general

[Unidentified Committee Member]: Yeah. Yeah. Yeah. For our purposes, that's really the only thing on the table that has impact on us is that

[Sen. Ann Cummings (Chair)]: we are going to lose general fund of everything. And we have at least two institutions that do not accept Medicaid. They are taxed and they get nothing back because they don't take Medicaid payments and they have they didn't to complain.

[Unidentified Committee Member (male)]: Sure.

[Sen. Ann Cummings (Chair)]: But Yeah. But I I

[Unidentified Committee Member]: know what senator Hardy is referring to. I I I some of that in my head too, but I I just so

[Julie Bordo (President & CEO, PCH Mutual Risk Retention Group)]: I just wanna we'll we'll sort out if

[Unidentified Committee Member]: that Okay. Yeah. That would be great.

[Sen. Ann Cummings (Chair)]: Yeah. I think there was a time when the feds hadn't caught on to what was going on. They did. Mhmm. And rather than just saying you can't do this anymore, they put things around it. But we did put it into the general fund.

[Unidentified Committee Member (male)]: The provider tax isn't a trust tax, right? No. Okay. Make it easy just like

[Sen. Ann Cummings (Chair)]: Well, yeah. Questions. You know, if you don't feel bad enough for the rest of the night. Okay. Yeah.

[Unidentified Committee Member (male)]: I got one if I missed it. Sorry. How does this all interplay with the federal dollars, the rural health care monies?

[Ian Davis (President, Vermont Captive Insurance Association)]: Did somebody ask that?

[Sen. Ann Cummings (Chair)]: They did.

[Unidentified Committee Member (male)]: Oh, good. Good. Excellent.

[Julie Bordo (President & CEO, PCH Mutual Risk Retention Group)]: I I can follow-up after.

[Unidentified Committee Member]: I'm happy to answer that.

[Brittany Evans (Captive Insurance Economic Development Director, State of Vermont)]: Yeah. Go ahead.

[Unidentified Committee Member]: It's really separate. So Okay. So the bill this bill did create the rural health care fund, but it is really all about essentially one time investments in rural health care, and it has no impact on premiums or co pays or any of the insurance related pieces that we might find important. So it's a separate opportunity, but it's more about time investments.

[Sen. Ann Cummings (Chair)]: You can buy computers, but you can't pay the salary for someone to run them. Oh, cool. Great. Ambulance, but you can't pay for the. Pretty much. Yeah. Yeah. Okay. Other questions?

[Unidentified Committee Member]: Okay. Thank you. Thank you very much. Thanks for having us in. Mhmm.

[Sen. Ann Cummings (Chair)]: You. Keep watching. I think some of the worst is not gonna hit us for years.

[Unidentified Committee Member]: Yes. Some of this is us letting you know what is coming. And then on the state directed payments, it's more that certainly wanna make sure we don't create more state directed payments this year. Yeah. Just to get prohibited. So yeah.

[Sen. Ann Cummings (Chair)]: The committee doesn't do that.

[Unidentified Committee Member]: Yeah. I wouldn't have to

[Sen. Ann Cummings (Chair)]: do that. Marches down the hall. Do have enough.

[Unidentified Committee Member]: We buy it everywhere. It sounds like a lot of this goes into effect starting January, so you have a lot of work, as you said, to get this all going in the next And a lot of it is informing patients about what they're going to have to do. And do you have a budget request to ask for navigators or people who are out in the community helping folks?

[Addison “Addy” [last name unknown], Deputy Commissioner, Department of Vermont Health Access]: Yeah. We'll definitely be talking about that in the context of the budget with an ask. There also is some grant money separate, totally separate from Rural Health Transformation, but specific to the eligibility implementation that we've gotten from the feds that can be used both for the IT and the system changes as well as the really necessary outreach member noticing and various community supports that we will need to implement this.

[Unidentified Committee Member]: Okay. Good. I'm glad that you're coming to ask for something to help with that. And the healthcare eligible or the QHP renewals, how do they have to renew all of the get all of the verification before they even go to to to sign up for Medicaid? And how does that work?

[Addison “Addy” [last name unknown], Deputy Commissioner, Department of Vermont Health Access]: That's the one that we really don't know that much yet because we haven't gotten any regulations from the federal government, but that's specific to the qualified health plan marketplace. So the idea is, yes, people would have to validate all of their eligibility from premium assistance before they can get it. Whereas now just kind of automatically renew people into coverage during open enrollment.

[Unidentified Committee Member]: Got it. So there would be a sort of verification? Well, you don't know yet.

[Addison “Addy” [last name unknown], Deputy Commissioner, Department of Vermont Health Access]: If it's Enrollment verification is what they're calling it. Yeah. So some kind of separate box that you log into, validate everything, maybe follow-up with paperwork before we can give you the assistance and the coverage.

[Unidentified Committee Member]: Got it. Okay.

[Sen. Ann Cummings (Chair)]: Thanks. Okay. Other questions? Thank you. You. You.

[Brittany Evans (Captive Insurance Economic Development Director, State of Vermont)]: Hang in there.

[Sen. Ann Cummings (Chair)]: Thank you very much.

[Addison “Addy” [last name unknown], Deputy Commissioner, Department of Vermont Health Access]: This is a great team. I think

[Unidentified Committee Member]: I said earlier, I'm new to state government and there are some incredibly smart

[Julie Bordo (President & CEO, PCH Mutual Risk Retention Group)]: and forgettable working on

[Unidentified Committee Member]: behalf of the Moncter. So, have three or four every day. Please do.

[Brittany Evans (Captive Insurance Economic Development Director, State of Vermont)]: Hi, everyone. Good

[Sen. Ann Cummings (Chair)]: afternoon. Good afternoon. Mike

[Mike Fisher (Chief Health Care Advocate)]: Fisher, healthcare advocate. It's kind of

[Sen. Ann Cummings (Chair)]: low seat. You've been great.

[Unidentified Committee Member]: I

[Mike Fisher (Chief Health Care Advocate)]: decided to just, I did a kind of prepared remarks, given who was coming first, And just to give you a, just a little perspective of what the world looks like from the healthcare advocacy perspective, given everything that you were just told that's coming at us and everything that's happened to us already. So I'll just say this past open enrollment period was really hard. We just bitten really hard on Vermonters, and it was really hard it was hard on on the state government, hard on the healthcare advocate's office, it was hard on our shifts, who were set up to help Medicare recipients. There was a great deal of stress going into it and through it, I think some really bad outcomes. I am very confident, you know, we didn't get, we haven't yet gotten a presentation from Eva about sort of where did people go in the in the QHPs? How many do we think became uninsured? Last, the QHP, we don't really know where they went in.

[Sen. Ann Cummings (Chair)]: We're waiting for those numbers.

[Mike Fisher (Chief Health Care Advocate)]: We're waiting for those, and they're still crunching up. But generally, we know, I mean, I can't walk through the building without somebody saying, I left my insurance, or saying, I'm pay I paid on the bond, and I don't know how I can keep doing it. Mean, I mean, like literally today, somebody said, I can't keep doing it. I'm I'm I'm gonna go without insurance starting next month. So I I you know, the combination of the loss of the, part c market and the loss of the enhanced tax credits was a double whammy on offices like ours. Lots of calls from seniors who needed a great deal of time and assistance in helping them know what to do.

[Sen. Ann Cummings (Chair)]: Part C, Sorry, Medicare Advantage? Medicare, that's what I figured it was.

[Mike Fisher (Chief Health Care Advocate)]: Everything Medicare has to

[Sen. Ann Cummings (Chair)]: have at least two names so that it

[Mike Fisher (Chief Health Care Advocate)]: I can know, be the alphabet. Yes. And there are certainly some people in each of those pools who have no affordable options. I can't recommend that they get coverage. And, know, despite, I want to recognize that you did, the legislature did some incredibly good movement in increasing the program that we have for low income people on Medicare, Medicaid like program that wraps around it, substantial improvement there going up effectively to these two different levels, you know, 202% of the federal poverty level. And so that was the only silver lining of the year because that also went into effect for the first time just January. And so we are now, we've been helping people get into it and we have quite a bit of work to do outreach to make sure our machinists know about it. But there are people for whom coverage, there are people in the Medicare marketplace for whom coverage is likely forty, thirty five, 40% of their income to pay their Medicare premiums. Before, I'll share it, and remember, everyone talks about Medicare, pretend to think of Medicare as this great savior, no out of pocket max, no lifetime out of pocket max.

[Sen. Ann Cummings (Chair)]: It was set up in a different time. You had a heart attack, You went to the hospital, and you died within two weeks. It was pharmaceuticals were aspirin. I mean, the the world of health care has just changed so dramatically since Medicare went was the debate topic in 1963 in high school.

[Mike Fisher (Chief Health Care Advocate)]: And then the combination of

[Sen. Ann Cummings (Chair)]: Socialism.

[Mike Fisher (Chief Health Care Advocate)]: Oh my goodness. We got a we now have the 400% of poverty cliff again. And, you know, just to you know, we we try to avoid cliffs because we don't wanna drive economic decisions based on eligibility. And we have a doozy of a cliff today where you fall over that 400% of positive cliff family of four, all four people eligible. You know, we're talking $25,000 of lost tax credits. And, you know, when you have a dynamic of you guys know this in tax laws. When you have a dynamic of somebody earning just a couple dollars over, you know, you know, an arbitrary limit, and they lose those kinds of subsidies, it necessarily drives what people do in their lives. So that is the other sort of major dynamic that's playing out. So all of that, you know, and I wanna repeat, I wanna sort of emphasize in my office office the intersection between immigration status and healthcare policy is a big deal. So, you know, we are certainly hearing from many Vermonters who are trying to figure out how the change in waves affects them there. And but as we look forward to what's coming at us, It's really an all hands on deck, like, dynamic. And I appreciated hearing Addy talk or the administration talk about wanting to ramp up the efforts to to help Vermonters through the combination of the biennial reenrollment and the, you know, work requirement. But and and I very much agree. I think that's one place where we're gonna the health care advocates can put a lot of of effort into. If we're gonna avoid losing those populations in coverage, We're gonna have to do some real work and some real innovative partnership with community organizations to help people just manage the manage the made. So I feel like I've, blah, blah, talking for a little while. And so if you guys have questions about

[Unidentified Committee Member]: I do. I have one question that is just regarding the immigration issue. Can you just give us immigration 101 vis a vis healthcare in Vermont right now and what it's going to be after this change so we can see the full picture I can't. In brevity? I can't.

[Mike Fisher (Chief Health Care Advocate)]: I have members of my team I have members of my team that would love to. You know, the thing that is tricky about talking generally about immigration status is that there are of them, And so the law is particularly complicated even down to which country you're from. Mhmm. You've got a lot of status you have and how it plays out in Medicaid policy and sort of the timeline of when the changes are happening. How does it

[Unidentified Committee Member]: start having done any or been able to do with anyone else any kind of a calculation which show based on all of these permutations and combinations, what's going to be the effect from today to a year from now, to a

[Mike Fisher (Chief Health Care Advocate)]: year from then based on changes that you know about right now? Particular to the immigration question? Yeah. So for that question, we're pretty highly dependent on Medicaid information, Medicaid data about immigration. Mhmm. And I think to be generous with them, they have some challenges in their data around that topic. And that's both that's a bad thing and a good thing, maybe, at times. But I think that if you had Addy back here and you were saying how many people, you know, she would give you I think she did. A couple 100 people, I think she had. But that, in my experience, that number has changed some is that Yeah. That was more than nice. I think I think that that they asked the immigration the immigration status question when it applies directly to the application. And so there are plenty of times where they do ask that question and there are plenty of times when they don't because if you go there, you have issues to sort of based on their immigration status, or it wasn't thought to. Thank

[Unidentified Committee Member]: you. A couple years ago, we created a parallel program, parallel to Medicaid. Immigrant Health Insurance Plan or a for children. For children and pregnant women. Right, yes. Just, is that impacted and what's the status of that?

[Mike Fisher (Chief Health Care Advocate)]: That is not impacted. That is not. It is a state run program, state dollars only, and the legislature did a particularly good job of making sure that the data associated with that. Yeah, thank you.

[Julie Bordo (President & CEO, PCH Mutual Risk Retention Group)]: We worked hard on that. Thank you.

[Mike Fisher (Chief Health Care Advocate)]: I remember And that has proven to be very important to this. That

[Sen. Ann Cummings (Chair)]: was like four years ago. Four years ago. It's still called it, I think. Yeah.

[Unidentified Committee Member]: You were on the committee. Yeah. You and I were on the committee. Yeah. We worked hard to make sure that the data was secure and that it was a separate parallel.

[Mike Fisher (Chief Health Care Advocate)]: Yeah, and so I'll just say another sentence or two about data, though I think, I think we don't really know what it means, but people should know that there is a court case going through the courts that has to do with Homeland Security's access to Medicaid data.

[Sen. Ann Cummings (Chair)]: And the HIPAA?

[Mike Fisher (Chief Health Care Advocate)]: This is not healthcare data. This is demographic data. And so No. So we all have quite a lot to learn about exactly how that might impact providers. We have, in the past, been, you know, said very matter of factly that Medicaid data can only be used for Medicaid purposes. And I think we now can't say that. And, but I'll say again that I had programs not part of that.

[Julie Bordo (President & CEO, PCH Mutual Risk Retention Group)]: I think we've said

[Unidentified Committee Member]: the same about snap data.

[Mike Fisher (Chief Health Care Advocate)]: I think

[Julie Bordo (President & CEO, PCH Mutual Risk Retention Group)]: it's That turned out to not be the case.

[Mike Fisher (Chief Health Care Advocate)]: Very similar than that.

[Sen. Ann Cummings (Chair)]: So you don't end up with the program because that was my vibe. Yeah.

[Mike Fisher (Chief Health Care Advocate)]: I I didn't feel I feel confident at this moment or my belief is that Medicaid has not shared any data that would help identify an individual. Okay. So that's a good.

[Sen. Ann Cummings (Chair)]: Any ethical questions? Thank you.

[Mike Fisher (Chief Health Care Advocate)]: Thank you. And you guys what what did the captain sort of take all the

[Sen. Ann Cummings (Chair)]: Well, no. The captains, you know, told them it was the best it was gonna feel, and Yeah. You guys have brought us down to earth. The thug. Yeah.

[Unidentified Committee Member (male)]: This Friday. Yeah.

[Sen. Ann Cummings (Chair)]: Do the reports. Yes. And they are online. So we can click on the reports. They

[Unidentified Committee Member]: are online. Is report list online? No.

[Sen. Ann Cummings (Chair)]: But I can

[Unidentified Committee Member]: Just because it's easy. It'd be helpful to be able to click on the report we can see it. Was one All of the the reports. Well, it's hard to just look at our list and decide whether we want the report because it could be Right. Nothing, or it could be a valuable report if we don't see the content of it.

[Sen. Ann Cummings (Chair)]: And it's, I mean, first part is the private activity bond advisory committee report. That gets reported to the e board. I don't, I've never read it. It's here. I don't feel but I think the information should be there. I assume it is, so if it ever comes up, we could get it, but I don't need somebody setting it out. And maybe we could do footnotes when we send this in that says, you know, information should be available upon request. Oh, we can say, dad, that's very healthy. Does anybody need the private activity bond advisory committee report? But it said it expired in 2017, so I don't understand.

[Unidentified Committee Member (male)]: How do I read that?

[Sen. Ann Cummings (Chair)]: Well, I guess it means do we leave it expired, or do we want it retained? It's kept.

[Unidentified Committee Member]: I mean So I say what the latest report was? Because I look over here, it says, offended in 2012.

[Unidentified Committee Member (male)]: I don't even know what the dude is.

[Unidentified Committee Member]: Yeah. I mean, this is I think it would be helpful to go through this with our legislative council because that that's they want some of these

[Sen. Ann Cummings (Chair)]: cleaned well, that's about 8. We've got till Friday. They're all being discontinued.

[Unidentified Committee Member]: That's not true. Right. There's somebody a lot

[Sen. Ann Cummings (Chair)]: of these have to be We can always go through and say, oh, well, Chris is here.

[Unidentified Committee Member (male)]: Alright. That's good.

[Sen. Ann Cummings (Chair)]: Tucker sent this out. Maybe we could ask him to see if Tucker could join us.

[Brittany Evans (Captive Insurance Economic Development Director, State of Vermont)]: Well, I mean, when

[Unidentified Committee Member]: we did this before Yeah. When I chaired the Hops and these went out, what I recommended to all the chairs was that they have their their legislative council attorneys in their area walk through the reports with them to say, this is what this report is. This is this is why it was created. Do you still want it?

[Sen. Ann Cummings (Chair)]: I have no idea.

[Unidentified Committee Member]: Because some of them are completely useless, and some of them sound useless, might be not useless if you know what I mean.

[Sen. Ann Cummings (Chair)]: But as long as the information there, if I wanna know what got done in Vermont Enterprise Fund, I can call and say I've got it. And this is

[Unidentified Committee Member]: actually not even a report. If you look at the statute titled 32 BSA nine ninety four B3, It is on December 1 of each year shall make recommendations to the E on the allocation including any amounts reserved for contingency allocations of the state's private activity bond ceiling for the And that gets

[Sen. Ann Cummings (Chair)]: done to the e board. Right. It's just a recommendation, it's not a report. Yes. And why are we saying and it's the same recommendation every year.

[Unidentified Committee Member]: And it's one of the treasurer's it's a recommendation from the treasurer. I would say we would still don't you still want that? I mean, it doesn't require that

[Sen. Ann Cummings (Chair)]: you I think, why don't receive Tucker can join us and tell us what this means? Does this mean we don't get it? Or does it mean the doesn't get it?

[Unidentified Committee Member]: Yeah. It doesn't even I don't even see in here where the finance committee gets it.

[Sen. Ann Cummings (Chair)]: Propriation, ways and yes. S finance at the bottom. Well, more than five thread. Doesn't doesn't say that in statutes. Not that

[Unidentified Committee Member]: I'm missing it somewhere. I'm looking at that statute. This is just the treasure making recommendation of the e words.

[Sen. Ann Cummings (Chair)]: Then treasurer should keep making. But it says it goes to me, somewhere, something is coming to us. I've never seen it.

[Unidentified Committee Member]: In fact, what all of these things seem to say, if I'm interpreting it correctly, at least

[Unidentified Committee Member (male)]: in most of them, is their activity regarding a particular or a particular department

[Sen. Ann Cummings (Chair)]: or

[Unidentified Committee Member]: action on a particular subject, It says, you're doing a report. I can't tell here whether these are annual reports or not, although I see dates in which last report and I see dates in which the program has started. If nothing else, I would think that every program that's a continuing program ought to have some sort of report of statistics as to what they've done and when to accomplish or fail to accomplish during the preceding year.

[Sen. Ann Cummings (Chair)]: I would assume that if it says it expires in 2019, that some committee somewhere said it should continue.

[Unidentified Committee Member]: This form that I'm looking at, frankly, does not give me enough information to tell me whether I want it or not. I don't even know what it is in most cases as I read this title.

[Sen. Ann Cummings (Chair)]: Okay, so maybe what's tougher is this is out of House job ops, not Senate.

[Unidentified Committee Member]: Yeah, and it's possible that this report, just using the first one as an example, was a one time thing that was supposed to come to finance. It expired in 2017. It's never come to us, but the treasurer still makes annual recommendation, and there is no actual report. I wonder if they just it was could have been a session law thing.

[Sen. Ann Cummings (Chair)]: Yeah. So that's what we need to find out. So maybe we'll see Chuck. He's busy this afternoon. It looks like the quickest we've

[Unidentified Committee Member]: been getting would be Friday afternoon. Well, let's And he might say that Kirby or Rick or one of the other attorneys Yes.

[Sen. Ann Cummings (Chair)]: Just tell them we are unclear about what these reports are. I think it says they've expired.

[Unidentified Committee Member]: Are they still being done?

[Sen. Ann Cummings (Chair)]: Are they still still being being

[Unidentified Committee Member]: could you also just, maybe you already did, Charlotte, but post it so that then it's easier

[Sen. Ann Cummings (Chair)]: to click on. Under today's date.

[Unidentified Committee Member]: Perfect. Thank you, Janet.

[Sen. Ann Cummings (Chair)]: Okay. And if we do nothing, they're all gonna go away. And then if we want them, you can put them back in. Well, we can check them all. They

[Julie Bordo (President & CEO, PCH Mutual Risk Retention Group)]: don't have

[Unidentified Committee Member]: to go to on a bill somewhere to get rid of them. What they're trying to do is do a bill, and then it will come through the committee.

[Sen. Ann Cummings (Chair)]: And then we can we'll have more time to add.

[Unidentified Committee Member]: They're just trying to figure out where to put in the bill. So let's

[Sen. Ann Cummings (Chair)]: not we can cease to worry about that till we hear from senate gov ops. In the meantime, though, think we should have a chance to come in and explain what these are. I mean, we can go look on and see what the report is, but it's not clear if they expired in '17. And does everybody have to say no before they are report out or just

[Unidentified Committee Member (male)]: That's fine.

[Ian Davis (President, Vermont Captive Insurance Association)]: No, I

[Unidentified Committee Member (male)]: was gonna say it's never just us on here, so maybe we let everybody else pick it that

[Sen. Ann Cummings (Chair)]: long. We don't seem to have a really strong opinion about getting any fees.

[Unidentified Committee Member]: No.

[Unidentified Committee Member (male)]: But I certainly don't want

[Unidentified Committee Member]: unnecessary work done

[Sen. Ann Cummings (Chair)]: If by you go in and find something you absolutely think you need to have, check that one out. We haven't started in Senate Health and Welfare. We have 13 pages.

[Unidentified Committee Member]: Well, we've gone over them quickly, but that was the extent of it.

[Sen. Ann Cummings (Chair)]: We haven't made Yeah. No. We have to make the trees. Oh, and I have a feeling we aren't going to by Friday. Okay. So, Chris Sure. Come on up. We got feeling really good with captive insurance, and then the two house care bills have totally depressed us. So we need you to kind of back up with them. Lift us up a little bit.

[Unidentified Committee Member (male)]: Well, madam chair, are you

[Ian Davis (President, Vermont Captive Insurance Association)]: sure the Canadians need a break before I start?

[Sen. Ann Cummings (Chair)]: You wanna take about a I'm flexible. So just You wanna take about a ten minute break? Sure. Right.