Vermont Legislature SmartTranscripts:

[Senator Virginia "Ginny" Lyons, Chair]: Okay, so we are live. Again, this is Senate Health and Welfare, and we're coming back with Legis Council to look at twenty twenty five acts. Jen, why don't you introduce yourself and the topic? Alright, Jen Carvey from the Office of Legislative Council. Yes, brought a review for you of twenty twenty five healthcare related acts.

[Jennifer Carbee, Office of Legislative Counsel]: I think you looked at the more human services focused ones with Katie last week. So this is the other half of that. So bills that went through this committee and were enacted into law. So I will share, should have this on your website as well, I think. Should I always run into this instead? So, can you take that or block tonight? Next, it's okay. Alright, so twenty twenty five healthcare bills that passed out of this committee, and One that didn't officially, which is this first one, but it's relevant. Was permanently unmerging the individual and small group health insurance markets. This actually was just in the finance committee. I think it didn't go officially here, But it's certainly relevant to this committee's work. So after passage of the Affordable Care Act and creation of the Health Benefit Exchange, we had a merged individual and small group health insurance market, which meant that their premiums were all based on the same risk pool. There were some efforts over the last few years to temporarily unmerge them in order to maximize federal funds that were available to people who qualified for assistance. And this currently unmerged those markets so we stopped having to do a one or two year unmerging. So now there's separate community rating for the individual health insurance market, people who buy not through an insurer on the commercial insured market, and the small group market. Thanks. And as we get more into insurance in here, and Senator Ann Cummings' committee of the great guy for sure will try to get an understanding what that all means. I know. May regret I know. Doing stuff. So it it's trying to keep the rates and the subsidies, the individual market frequently or people who have chronic illnesses. Yeah. They're expensive.

[Senator Martine Larocque Gulick, Vice Chair]: Yeah.

[Jennifer Carbee, Office of Legislative Counsel]: Small group is your small employers. They tend to be a little less expensive, but the subsidies but now the subsidies are gone. They can't But as associations are back in maybe. Not yet. Not yet. We're gonna have a long discussion I about know we're moving pieces, but just looking at what we did last year, what you did last year, those of you who were here, was you permanently unmerged those markets. And that was Act two, so that was very early, apparently early in session. Act three, also fairly early, was making some minor tweaks to a 2024 act, Act one eleven, that dealt with claim edit standards and prior authorization requirements. So in this case, were, in that act, Act 111, there were a bunch of parameters around what health insurers could do to edit claims that providers submitted for payment. And so there were So we set up a bunch of provisions that said what the insurer could or couldn't do to kind of modify what was sent to them. And then a question came up about out of state providers, and so there was an interest in recognizing that we really can't necessarily control, or it may be more difficult for the health insurers to affect the claim edit standards that are applied to out of state providers. So it exempts claims for services delivered outside of Vermont from the required claim edit standards that health insurers have to follow, unless the insurer and the out of state provider agree that certain standards will apply. A little bit more specific to this state, is the act created an exemption from prior authorization requirements for most services ordered by a primary care provider, but it used a definition of primary care to determine who's a primary care provider that wasn't especially workable in practice. So this modified that definition to say that a primary care provider is a provider who is contracted and enrolled with a health plan as a primary care provider. So they have specific criteria, health insurance plans do for who's a primary care provider. If the provider fits that definition, then they are to be exempt from the prior authorization requirements from that insurer for many, but not all, services. Next we have Act Six, which is the Office of the Healthcare Advocate. I think you've heard from Mike Fisher before, so you know who he is and what he does. The Act expanded the scope of that office's duties. It had been more narrowly focused historically on health insurance, but in practice and in reality, they've been doing a lot of work for a number of years on affordability and access to care for all Vermonters, and so this amended the statute to kind of reflect that expanded scope. It gave them some additional ability. They have a role in a lot of Green Mountain Care Boards, regulatory processes. So this expanded the healthcare advocates' ability to ask questions in health insurance rate filings and rate review processes. Before it was that they could suggest questions, the board could take or leave. As far as passing ons, this allows them to have more of a role in asking questions as long as they're relevant. The act also requires the Intermountain Care Board to make the entire record of a health insurance rate review available to the public after redacting confidential information. It expanded the roles of the healthcare advocate and kind of the long term care corollary, the long term care ombudsman's office when they intervene in a certificate of need application. There's specific criteria for when they can intervene. And then it requires, the act requires state agencies to actively seek input from the healthcare advocate's office when they develop policies that affect access and affordability of healthcare. And it allows the healthcare advocate's office to access confidential or proprietary information when appropriate, as long as they don't further disclose that information. That was Act six. Act nine, Katie might have gone over this one with you because it was her bill. It's the only one in my presentation that wasn't in We my could. Yeah, we did talk about this one. Great, then I'll just skip over that one. Just jump right in. The one that's not in here because it didn't go in this committee, I'll I started to put it in, or keep it in, but I'll just mention it, is Act 11, reorganized and updated the entire chapter on health insurance in Title VIII. That also went through the Finance Committee. There was a lot of technical stuff in there, but some more substantive stuff there. But there was a lot of aligning definitions and terminology throughout the chapter. I mention it mainly because there may be in some materials that you get presented references to the former numbering, so we'll just need to be mindful of any of that. Hopefully not in any of my bills, because I think I updated everything in statutes. But there could be places that people are referring to statutes that no longer describe the subject matter, they just figure out what's intended. Oh, this is from one act that's house healthcare, that's my asterisk here, but this is Medicaid rates to community based service providers. And this act requires the Secretary of Human Services to calculate the payment rates for providers of community based services in the Medicaid program that are reasonable and adequate to achieve the required outcomes for the populations that they serve. And it requires the secretary to establish a methodology for calculating the rates that includes a schedule for doing kind of in-depth Medicaid rate studies on particular provider types that sets a predictable timeline for redetermining the base rates and that develops a process for calculating annual inflationary rate adjustments. And then importantly, as a takeaway, it then directs the secretary to recalculate the payment rates, do the math, at least annually, and report the rates, what the rates should be, to be reasonable and adequate to achieve the required outcomes, and what it would cost to fund them annually as part of the agency's budget presentation. So it doesn't guarantee that the providers will get those rates, but it has that information available to the legislature about what age estimates the appropriate rates should be and how much more it would cost to adjust a mitigation increase to achieve those rates. And this is largely because every year you get requests from various provider groups saying we need our Medicaid rates increased by x percent and then there may be a decision to raise them, if at all, by some other percent. And so this will provide you with more information on which to make decisions. It doesn't volume the legislature to any one decision. Maybe what community based services are? Very broad. So it includes the designated and specialized service agencies, but it also includes, I think a lot around home health and adult days and services that are provided less at home than in a community based setting, but not in institutional settings. So not a nursing home, not a residential care home, but something. So it could be a mental health provider going out to schools? I don't believe they are in the definition. We'd have to look at the definition. We came up with a very specific, but very broad definition that includes enhanced residential care services, lots of provider types. Okay. We can certainly look at any of these. Ag15 increased the monetary thresholds for a certificate of need. Did I finish that one? Oh no, did not finish that one. Directed the secretary establish, also to establish a process for providers to request stabilization assistance from the Agency of Human Services if they're at imminent risk of closure. This is kind of a non nursing home extraordinary financial relief kind of process, and initially that was the language that was used in the bill when it was in human services upstairs and the agency said that's really a specific process for nursing homes. But we, you know, would like to, you know, we're on board with establishing a process to look at provider stabilization if somebody's about to close, but that should be its own process. And then it requires the agency to provide an implementation update by tomorrow. I don't know that this one has come in yet. I don't remember where whether I've seen that report. I was just updating some reports and I don't think that was one of them, it was one of them, but I don't, know, from when we came in before. But I will give an updated list to Const later. And we'll see some of this in the budget process. You'll definitely see some of this in the budget process. Act 15, the increase for the monetary thresholds for when a certificate of need is required. I don't know if you've talked about certificates of need in here yet. No, I have not. No, we have not. But we will have to do that when DF, PeerBand PeerBoard, is everything. There is a requirement, and a fairly long standing requirement that when a healthcare facility, including a hospital, wants to build a new facility, do a major expansion of facilities, buy land, start a new service that has a cost over a certain threshold, that they first have to request and obtain a certificate of need for the Green Medicare Board. And that is kind of what they're looking at is really is this, is there a need for this project service facility in this state? Is there a need in that area that it's in? Trying sort of balance access with not having too many resources or services that might drive up utilization at cost. So there are monetary thresholds for when a certificate of need is required for many types of these projects, and they had been different thresholds for healthcare facilities other than hospitals and hospitals. So one thing it did was align the triggers for hospitals with those for other healthcare facilities and fairly significantly increase the trigger. So there will be fewer projects that need to get a certificate of need, but the bigger ones still would. And then it added some new general exclusions from the certificate of being process, and you'll see one or two others in other acts. But in this particular act, there was a new CON exclusion for fully depreciated medical equipment. So if they wanna replace medical equipment that has been fully depreciated, a facility does not need a certificate of need for that. It exempts ground ambulance services and emergency medical equipment and supplies. And it exempts new services or construction projects for facilities that are owned or operated by the state or funded by a grant or contract from the state. And the rationale for this one, as it was discussed, is if a facility or a provider is working with, say, the agency of human services, the agency has determined that this project makes sense and has awarded a grant for it or a contract for it, then it doesn't make sense to have these people go through a separate process, have the Agreement on Care Board also weigh in on whether this needs to happen. So this just requires notice to be given to the Agreement on Care Board, but it doesn't require a COF. And there was also a lot of talk about that slowing down, the COF environment slowing down projects that had been, or services that had been determined necessary. Next we have the licensure of freestanding birth centers. So this, the act required a free to licensure requirements for freestanding birth centers. This is a birth center that's not affiliated with or part of a hospital, but it would literally be a freestanding facility in the community. It's talked about as sort of a middle ground between a home birth and a hospital birth. So it'd staffed by trained and licensed providers, but standing on its own in a more home like setting. So it created a licensure requirement to allow those centers to operate, directed the health department to adopt the rules for birth centers, including what's required to operate one, what services can they provide, so they can't provide things like a cesarean section that would need to go to a hospital. And it also requires the rules to include requirements for written practice guidelines and policies that address things like transferring a patient to a hospital if they need a higher level of care, and collaboration with other providers to make sure that the patient's getting all the services they need. This is another exemption. Birth centers would be exempt from the COM requirements if they even if they met the financial thresholds,

[Senator Martine Larocque Gulick, Vice Chair]: which are,

[Jennifer Carbee, Office of Legislative Counsel]: as I said, are much higher than they used to be. It requires health insurance plans that cover maternity services to cover those services at a birth center, and it requires the agency of human services to seek federal approval for Medicaid coverage of services provided at a birth center. Next we have Act 20, which made some changes to the Legally Protective Healthcare Act and statutes that were first enacted in 2023. In 2023, we had two acts, Act 14 and Act fifteen, fifteen, that dealt with what is termed establishing legally protected healthcare services. That's reproductive care and gender affirming care, and providing and receiving those services. So there were two acts that year. One was a more judiciary focused and one was a more healthcare provider focused. The healthcare and provider focused one went through this committee, and so did these updates. So the first one is created reciprocity with other states that protect access to these services. So if a provider who delivers reproductive or gender affirming care in another state that is protected by that state, but a third state is unhappy with the provider or providing services perhaps to a resident of that third state and that provider comes to Vermont, Vermont will similarly not participate in extradition orders and investigations relating to that provider if what they had done in the state where they did it was lawful in the state where they did it. It also creates some privacy protections for healthcare providers, so it exempts records held by the Office of Professional Regulation and the Board of Medical Practice, exempts those records from the Public Records Act if they contain personal contact information for the applicant or licensee. If the applicant or licensee is designated a particular address as their public address, then that can be made public, but the rest of it would not be available through the Public Records Act. It amended the unprofessional conduct laws for healthcare professions to add as unprofessional conduct advertising that is misleading or has a tendency to mislead and someone letting their name or license be used if they are not actively overseeing the services being provided in their name. It allows a healthcare provider to prescribe medication to terminate a pregnancy based on an adaptive questionnaire that lets the provider ask follow-up questions if needed. Otherwise, that is not permissible. It expands the scope of health related conduct that violates the Consumer Protection Act. Act 15 had been very narrowly focused on limited service pregnancy centers, and there were some legal concerns raised about that, so it expands the scope to apply to any health related conduct that is deceptive or misleading. It adds federal investigations and proceedings to non cooperation provisions that were in the judiciary version of the 2023 Act. So this is saying state employees are not to use time or resources to aid in out of state investigations and proceedings into legally protected healthcare. This adds federal investigations as well, and that started to become pursued in a similar path. It modified some limits on disclosure of protected health information related to legally protected healthcare activity to add, in part, those relating to federal matters in addition to out of state matters. And it allows prescribers and pharmacists to have their meetings removed from the physical prescription container and packaging of medications for reproductive and gender affirming healthcare services to the extent permitted under federal law. Act 21 was a proposal from the treasurer's office that is medical debt relief and removing medical debt from credit reports. It appropriated $1,000,000 to the treasurer's office to contract with a non profit entity to acquire and repay certain medical debts of Vermonters. There's eligibility criteria saying the debtor has to be a Vermont resident and they have to either have income at or below 400% of the federal poverty level, or owe medical debt at a 5% or more of household income, and their patient account still has an outstanding balance, even after the provider has done their routine efforts, to collect the meds too. The rationale for a million dollars is that this is effectively debt that the hospitals had written off. So it is worth significantly less than it originally was. It was pennies on the dollar. So to pay off that devalued debt, a million dollars I think was projected to cover approximately $100,000,000 worth of medical debt. So you may want get an update from transferr's office on how that is going Good idea. Yeah. It added a definition of behavioral health to title one of the statutes for limited purposes. This wasn't super relevant, but it did come up in the context of the type of medical debt that was important to a house member. The act allowed nonprofits to request, so it's a nonprofit entity that would be doing this debt repayment, medical debt repayment.

[Senator Martine Larocque Gulick, Vice Chair]: Want to ask a question that is not necessarily right to what you are talking about, but it makes me think about this. Many hospitals were operating in the red, so where does the money come from that keeps them sustainable?

[Jennifer Carbee, Office of Legislative Counsel]: That's a good question that we will have to answer. It's, I mean, generally, it's from taking a payment for services that Yeah, they right.

[Senator Martine Larocque Gulick, Vice Chair]: But if they're operating in the red, that means they're not bringing in enough

[Jennifer Carbee, Office of Legislative Counsel]: That's a that's

[Senator Martine Larocque Gulick, Vice Chair]: a shame.

[Jennifer Carbee, Office of Legislative Counsel]: Shouldn't bring them bring them on. Questions. Yep.

[Senator Martine Larocque Gulick, Vice Chair]: I just

[Jennifer Carbee, Office of Legislative Counsel]: It's all about transformation.

[Senator Martine Larocque Gulick, Vice Chair]: Stay alive. I mean, what is it if that happens here and here? What are they where's the money coming from that pays their staff that keeps the lights on? You know?

[Jennifer Carbee, Office of Legislative Counsel]: Yeah. So I'll tell you. On one case, the state helped them out. We had a couple million dollars. What was it, 5,000,000? What did we pay? Springfield. Brownboro, Springfield. Can save this question, put a big star next to it, and when the Care Board comes in, you're gonna Yes, very appropriate question and it is part of the balancing act that the Green Care Board does with setting health insurance rates, which affects the rates that they pay to providers, and setting hospital budgets, and the amount of revenue that hospitals are allowed to get, and the prices they're allowed to charge, and how that gets translated into the amounts paid by the payers. So yes, is sort of a tricky balancing act. This piece of it may give them, this act may give them a small amount of debt they thought they thought it was gone forever. Yes. It's gone to like a repayment and debt agency collection agency, and there is actually an agency that they get you 10¢ on the dollar. So for a million dollars, this agency will buy down $10,000,000 worth of Yeah, I think we heard $100,000,000 Was it 100 It is $100,000,000 All right. So it's done by a separate entity. Right. It's a nonprofit organization whose sole purpose is doing this. So I'm sorry. You want? So Yep. Never mind, I'll tell you. Alright. There's some additional stuff about credit reports that allows these entities to pull a consumer's credit report without their permission in order to determine if they're eligible to have this medical debt paid off. And it prohibits reporting about medical debt information or keeping, or credit reporting agencies keeping medical debt information in a consumer's file. And it prohibits large healthcare facilities medical debt reporters collectors from reporting medical debt. So basically trying to keep medical debt out of people's credit reports. And 49 allowed the Green Mountain Care Board, allows the Green Mountain Care Board, so this was some fairly substantial new authority to the Green Mountain Care Board, allows them to reduce a domestic health insurer, that's Blue Cross Blue Shield of Vermont, so reduce a domestic health insurer's reimbursement rates to one or more Vermont hospitals if the insurer faces an acute and immediate threat of insolvency, which is what happened with Blue Cross. There's limits. The board can only reduce rates to hospitals that meet certain criteria around fiscal health, and only to the extent necessary to address the threat of insurers' insolvency. It directs the board to make some changes in setting a new hospital budget to account for any significant deviations in hospital revenue during the prior fiscal year from what the Green Mountain Care Board had approved. It allows the board to adjust hospitals' commercial health insurance reimbursement rates mid year to ensure hospitals stay within their approved budget. So that could be a piece of what you're talking about too, is if something's going very poorly for a hospital, the board now has the authority to adjust the insurance reimbursement rates in mid year. And it allows the board to appoint an independent hospital observer to go in and learn things about the hospital and report back to the board under certain circumstances having to do with material misrepresentation in budget submissions from the hospital or a material deviation from an approved budget. This is short term authority that'll be revealed unless you extend it June 23, or before twenty third. Should I ask a question about that? Yeah. Is that for, was that just for UVMMC or was that for any hospital? The hospital observer or is any hospital? Any hospital. Okay. Till 2030? Yes, so through 2020. Okay. Section Act 50 created a voluntary certification process for community based perinatal doulas in the Office of Professional Regulation. It's voluntary, a doula does not have to be certified in order to continue to provide the services that they have been providing. And this is like physical, emotional, educational support to a pregnant individual before, during, well, during and after pregnancy, labor, and delivery. So, doulas can continue to provide those services without being certified, but if they want to be paid by Medicaid for providing doula services, then they need to get this certification. And the act requires DIVA to reimburse the certified providers for providing services to Medicaid beneficiaries. In pregnancy, labor and delivery, and postpartum, it expresses some legislative intent about the adequacy of the reimbursement rates and it directs DEMA to seek a federal state plan amendment by July to allow Vermont Medicaid to cover DEMA services. I'd like to get a update on this, yes. Yes, I think there bills out there that extend that date. Act 55 deals with 340B drugs. These are drugs priced as part of a federal program. And it restricts certain actions by drug manufacturers relating to 340B contract pharmacies, 340B drugs, and patients of 340B covered entities. These are hospitals and some other types of providers. It also requires hospitals to report information about their 340B program participation to the Green Men Care Board annually by January 31 through January of, well, the last year will be 2030, it expires in 2031, and it directs the board to post those reports on its website. And then something you will probably hear talked about a lot if you haven't already, is the act of set a cap on the amounts that hospitals can charge insurers for prescription drugs administered in an outpatient setting. So this is one of the first caps that has been put in place, a cap at 120% of the average sales price as of 04/01/2025. So this was, at that time, a date recently passed, which meant it was a known number. So if a hospital charged 120% or more, then their cap was at 120% if they charged less than 120% of the average sales price on that date, The cap was whatever their actual percentage of average sales price was on that date. And there's some parameters around that. The hospital can ask the board to increase other reimbursement rates if those caps are having a significantly negative impact on access, quality, or rural health sustainability. The price caps, as they are, are in place unless or until the board sets a different reference based price that applies to those outpatient administered drugs. And the price caps do not apply to independent critical access hospitals that are not affiliated with another hospital or hospital network. So it only applies to a portion of Vermont hospitals. Act 62, I think, shows the last one. Gonna suggest. This is the last one before you get to Act 68. Oh, it is? Okay. So let's just do it. It eliminated said three months care board. What? I was gonna say, but 68 is like 68 is one I already did the other day. Ah. This last one Twenty Okay. I was gonna say. Yep. So this eliminates the board's duties related to that. So these are changes affecting the duties of Green and Care Board. It eliminates the board's duties related to health information technology and vital that it's really become more of an AHS and diva issue. It eliminates, as I think we talked briefly about, back when I was doing, Katie and I were doing a list of reports, and that the board can build back the regulated entities for a portion of regulating them, the act from last year eliminated the 8% allocation for accountable care organizations, ACOs, because the main accountable care organization in New Vermont wrapped up its business in 2005, One Care Vermont. It also modified ACO certification and budget review processes, recognizing that right now we really have mainly Medicare only ACOs that are quite small in their scope. And it set fees for certification and budget reviews. It specifies this a little in the weeds, Green Mountain Care Board regulation of hospital budgets is not a contested case under the Vermont Administrative Procedures Act, and specifies that aggrieved parties can appeal to, it's really the Supreme Court, through board's existing appeal statute. Was largely settling a difference of opinions. It modified the scope of requirements around meetings of an ACO's governing body to apply only to ACOs contracting with Medicaid, and it eliminated a sort of related Pre Med Care Board advisory rate case review that made some sense in the context of the all care model, that is not happening anymore, so it eliminated that review. And that's it, then we get into Act 68 all of the Act 68 provisions we went through the other day. Here again are Nolan's fiscal notes to the extended of life. Alright, you for that. That's a lot. Wow. Been through huge amounts. You guys have been busy. We were busy.

[Senator Virginia "Ginny" Lyons, Chair]: Right. And we're gonna be busy again. Don't hold your breath. Okay. So that's it for today.

[Jennifer Carbee, Office of Legislative Counsel]: We'll go off live and we'll start in