Vermont Legislature SmartTranscripts:

[Sen. Virginia "Ginny" Lyons (Chair)]: Yeah, live. Alright, good morning. It's Friday, February 27, and this is Sinai Health and Welfare. Gonna begin walking through a bill, an act relating to biomarker coverage by health, testing by health insurance. Jen, why don't you go? We'll do not not too low, not too high. Okay.

[Sen. John Benson (Member)]: Probably not too bad, right?

[Sen. Martine Larocque Gulick (Vice Chair)]: Right, it's, yeah, they're go higher.

[Jennifer Carbee (Office of Legislative Counsel)]: Good morning, Jen Carvey from the Office of Legislative Council. We are looking at S-one 154, sponsored by Senator Gulick and others. F-one 154 is an act relating to health insurance coverage for biomarker testing, and this would add a new section to the insurance statutes. It actually would add identical sections, or almost identical sections, to health insurance and Medicaid checkers. It's a six page bill, it's mostly the same language twice. It starts out with a number of definitions. It might be helpful to look at recent definitions of biomarker and biomarker testing. Biomarker is a characteristic that is objectively measured and evaluated as an indicator of normal biological processes, pathogenic processes, or pharmacologic responses to a specific therapeutic intervention, including known gene drug interactions for medications being considered for use or already being administered. And biomarkers include things like gene mutations, characteristics of genes, and protein progression. Biomarker testing is analysis of a patient's blood, tissue blood, or other biospecimens through the presence of a biomarker, and then it gives some examples of what is included in biomarker testing, lots of different types of tests, including things like genome sequencing. It talks about consensus statements. It's a term that gets used in the bill for describing evidence based or agreed upon approaches. Health insurance plan is our broad definition of health insurer. And then nationally recognized clinical practice guidelines. And you can sort of get assessed in that terminology. So this would require health insurance plans to provide coverage for the services of biomarker testing for purposes of diagnosis, treatment, appropriate management, and ongoing monitoring of a patient's disease or condition when the test is supported by medical and scientific evidence, including, as you may, some of these are labeled indications for a test that has been approved or cleared by the US Food and Drug Administration, FDA, indicated tests for an FDA approved drug, warnings and precautions on FDA approved drug labels, CMS national coverage determinations, or Medicare administrative contract or local coverage determinations, or nationally recognized clinical practice guidelines and consensus statements. That's why those terms are in the definition. And then it requires that the coverage be provided in a manner that limits disruptions in care, including the need for multiple biopsies or biospecimen samples. Section two does the same thing, but in the Medicaid statutes, so it has the same definitions, and then requires the agency of human services to provide Medicaid coverage for biomarker testing. Same language there. Section three directs the agency of human services to request approval from the Centers for Medicare and Medicaid Services to amend our Medicaid state plan if needed to provide the coverage. And then this bill was introduced last year, so the effective dates are a year behind where they would be if you were acting on this bill now. The insurance coverage would take effect on January 1 and roll out over the course of the next year as plans are issued, offered, or renewed, but in no event later than the following January 1, so just imagine these for January 2027 and 2028. Section two, the Medicaid coverage, would take effect on the later of, and again, move this out of year, 01/01/2027, or upon approval of our state plan amendment, if needed, and then the state plan amendment and effective date sections take effect upon passage. One piece I will flag for this committee that I have done in the finance committee as well, is that new health insurance mandates for things that are not covered in our plans and qualified health plans in the exchange, incur a state cost. The state's required to defray pay any additional premium for those plans that is attributable to a new mandate that was enacted after 2012, since the requirements in the Affordable Care Act. Why we have not looked at a lot of new benefit mandates since then, but just something to be aware of, that there would be a state fiscal impact. And I don't know what that would cost. I have no idea.

[Sen. Virginia "Ginny" Lyons (Chair)]: So, know, what do they cost? I have what they got.

[Jennifer Carbee (Office of Legislative Counsel)]: Yeah. You read all what these I do not

[Sen. Virginia "Ginny" Lyons (Chair)]: know what these Okay. I don't

[Jennifer Carbee (Office of Legislative Counsel)]: know what the coverage is under our current financial plan.

[Sen. Virginia "Ginny" Lyons (Chair)]: Right, so that's one question. And the one question is how many biomarkers are there that would be included here and how much will it cost to provide coverage for all of those? And I know that the Alzheimer's Association is very interested in this with a new biomarker for Alzheimer's disease and I'm thinking if we can ask the question how many biomarkers and how much does it cost or we could also narrow, golly Ned, sorry. We could narrow the question and say how much would it, what about the Alzheimer's biomarker, what is the laboratory diagnosis for that? And then look at the cost for that since it is the Alzheimer's group that brought the pill to us in the first place, starting with that. And I know there are biomarkers all over the place and that biomarkers are being used for special infusions for, you know, treating disease. This could be

[Sen. John Benson (Member)]: a big one. Could I just step back since you've said this, you've been in the works, just and somebody provide a little bit of background on what we're trying to accomplish here, what what is this subject so that we get the context as we're looking

[Sen. Virginia "Ginny" Lyons (Chair)]: at this. Senator, that's exactly what we would do with some witness testimony, and we'll have folks come in who can tell us the evolution of this bill, why it's here, what problem is it solving, and then the immediate questions that we've had about how much will it cost us, that's always the first thing, and how difficult is it to do. I need do something before we go.

[Mike [last name unknown], American Cancer Society Cancer Action Network (Government Relations)]: Does Medicare pick up any of

[Sen. Virginia "Ginny" Lyons (Chair)]: these costs? We don't know these.

[Sen. John Benson (Member)]: Medicaid will, according to what we do, if you open it up.

[Sen. Virginia "Ginny" Lyons (Chair)]: We ask,

[Jennifer Carbee (Office of Legislative Counsel)]: that's right. I mean the bill would require Medicaid to cover it and require Medicaid to get a state plan amendment, federal approval for coverage.

[Sen. John Benson (Member)]: Right, and also the private insurance companies. Right, the ones that we regulate. Correct, so the only one that wouldn't potentially would be Medicare.

[Jennifer Carbee (Office of Legislative Counsel)]: Medicare and self funded.

[Sen. John Benson (Member)]: And self funded, okay.

[Jennifer Carbee (Office of Legislative Counsel)]: So we are preempted from regulating it. So

[Sen. Virginia "Ginny" Lyons (Chair)]: it would basically be the ones on the exchange that the Obamacare exchanged and subsidies just went away for The enhanced subsidies. Yeah. There are some. The enhanced subsidies went away, but those prices just took a major out for you. And if we do this, the state of Vermont has a problem with the cost. Right. The increased premium. So all of it?

[Jennifer Carbee (Office of Legislative Counsel)]: All of the increased premium, if you pass a new mandate under federal law, yes, the state is responsible for picking up the cost of any increased premium that is attributable to the union.

[Sen. Virginia "Ginny" Lyons (Chair)]: And another thing I just wouldn't go on with the they wouldn't go on with

[Jennifer Carbee (Office of Legislative Counsel)]: the premiums for the plans in the exchange.

[Sen. Virginia "Ginny" Lyons (Chair)]: The state would have a lot of that state.

[Sen. Martine Larocque Gulick (Vice Chair)]: But another potential roadblock is their schools to want to amend state plan activity. That's I

[Jennifer Carbee (Office of Legislative Counsel)]: think there's right. I think there is some some concern about the ability of the state to to receive approval for amendments to the state plan. But I don't know what would we wanna hear from you about what is required.

[Sen. Virginia "Ginny" Lyons (Chair)]: It's probably you didn't cover hearing.

[Sen. John Benson (Member)]: Oh, really?

[Beth St. James (Office of Legislative Counsel)]: Well, and then you

[Jennifer Carbee (Office of Legislative Counsel)]: phased it in initially for the large group and then Yes. The yes. Change the benchmark plan.

[Sen. Martine Larocque Gulick (Vice Chair)]: And we're still working on dual looks and, yeah, it's just a lot of this.

[Sen. Virginia "Ginny" Lyons (Chair)]: So, I guess we had asked to look at and finance at it and we can, I guess we could look at it, continue to look at it, we should have folks in who represent the Alzheimer's Association? We should have to understand the background and the information, what the problem is we're trying to solve here. And then

[Jennifer Carbee (Office of Legislative Counsel)]: we can bring

[Sen. Virginia "Ginny" Lyons (Chair)]: biomarker if there's no cure. Pardon me? I'm just saying, I wanna know if there's an Alzheimer's biomarker if there's no cure? Well, there might be some new medications associated with this because once you have a biomarker you can develop an antibody type response to it. Yes, so that's the disease. That, I'll let others talk about it. But that's right up our alley there. So what we'll do, if we have Nader coming in to talk with us about 157, We've seen the bill. We may come back to it later in the day today. And I know that you folks are here from Alzheimer's. Cancer. Cancer. Society. Yeah. Okay. Sorry. Okay, so we'll, and what will be helpful is for you to give Calista your names and we'll get you on the list. And then we'll see where we get to with this. If we have a chance before the end of the morning, when I say later in the day, I mean it has to be before 11:30 in this room, because that's when we're, I'm long, and we're gone for a whole week, which is our happiness news. So we'll we'll set it aside for now, but now you kinda get the gist of what's here.

[Sen. Richard "Dick" Sears Jr. (Chair, Senate Judiciary Committee)]: And

[Sen. Virginia "Ginny" Lyons (Chair)]: it will have to have finance.

[Sen. John Benson (Member)]: And Yep. And appropriations of it. Yes. If you're gonna be using gel,

[Sen. Virginia "Ginny" Lyons (Chair)]: you just have to go through the whole game. I mean, it's first. I was like Good. Great. So I think we're normal together.

[Mike [last name unknown], American Cancer Society Cancer Action Network (Government Relations)]: Good morning. Hey.

[Sen. Virginia "Ginny" Lyons (Chair)]: So, thank you for highlighting that language yesterday because we're not the judiciary committee, and I didn't even recognize it to ask you to look for it. Oh, no worries. We don't know what we don't know. So you have a proposal for

[Sen. Martine Larocque Gulick (Vice Chair)]: us. Yes.

[Sen. Richard "Dick" Sears Jr. (Chair, Senate Judiciary Committee)]: Printed some copies of the books here. Sure. For the record, chair fiduciary, and proposing this hopefully very technical short amendment that would address the minor issue that I raised on the floor yesterday. It changes the language of No offense. That admits a crime to is charged with a criminal offense, and that just brings it in line with Yeah. How it's worded in almost all the other statutes that Okay. Involve a similar topic. The the phrase commits crime, I I get what you're getting at, but, you know, somebody who commits a crime, you you could argue, please say that somebody's just been convicted, and that's something that happens two or three years down the road. Uh-huh. Whereas somebody who's charged with a crime, they're getting a citation from a police officer. They've been arraigned most likely, and that's so it just brings it in line with language elsewhere. Very simple. Yes.

[Sen. Virginia "Ginny" Lyons (Chair)]: I think this is better than saying a frame.

[Sen. Richard "Dick" Sears Jr. (Chair, Senate Judiciary Committee)]: Than saying what?

[Sen. Virginia "Ginny" Lyons (Chair)]: You were gonna say Oh, arranged. Yes.

[Mike [last name unknown], American Cancer Society Cancer Action Network (Government Relations)]: Yeah.

[Sen. Martine Larocque Gulick (Vice Chair)]: Just wanna say thank you, doctor. This is great. Yeah. Yeah. Thank you. We are considering striking the language, but we don't wanna strike it. It should be inherent, so this is threading a good needle for us, so thank you. Yeah, thank you for entertaining it.

[Sen. Virginia "Ginny" Lyons (Chair)]: Senator Benson, did you want to comment? You're the reporter.

[Sen. John Benson (Member)]: No, I think this is fine. Okay. I'll just speak for the committee that we accept the proposed change. Yeah. Great. I agree. That's great. It is

[Sen. Virginia "Ginny" Lyons (Chair)]: still discretion. Well, you should do a straw we'll do a straw.

[Beth St. James (Office of Legislative Counsel)]: No. I'm

[Sen. Virginia "Ginny" Lyons (Chair)]: This says they can be removed. They don't have

[Sen. Martine Larocque Gulick (Vice Chair)]: to

[Sen. Virginia "Ginny" Lyons (Chair)]: be clogged because you can get a citation for Jane. Well, that's what we were talking about on the board yesterday. Even depression. Yeah.

[Mike [last name unknown], American Cancer Society Cancer Action Network (Government Relations)]: Right.

[Sen. Virginia "Ginny" Lyons (Chair)]: Whether or not that compares your speedy probably wouldn't get you thrown out. Right. Right. Unless it was in the drive by me. I got

[Sen. John Benson (Member)]: through the building or something like that.

[Sen. Virginia "Ginny" Lyons (Chair)]: Anyway, we're good with this. And did you give this to the secretary?

[Sen. Richard "Dick" Sears Jr. (Chair, Senate Judiciary Committee)]: Yes. They have a copy of it, and just procedurally wise, they'll ask if there's any amendments. I'll present this and then the committee presents that it is or is accepted in place.

[Sen. John Benson (Member)]: That's good. Thank you. Thank

[Sen. Virginia "Ginny" Lyons (Chair)]: you very much. Appreciate it.

[Sen. John Benson (Member)]: Yes. Thanks,

[Sen. Virginia "Ginny" Lyons (Chair)]: And we're looking at your bill

[Sen. Richard "Dick" Sears Jr. (Chair, Senate Judiciary Committee)]: Oh, one ninety three?

[Sen. Virginia "Ginny" Lyons (Chair)]: Yeah. We're looking at it the the day we get back.

[Sen. Richard "Dick" Sears Jr. (Chair, Senate Judiciary Committee)]: Fantastic. If you are able also to hear from WellPath, that would be great. Oh, okay. We've been trying to hear from them without competency restoration, and I think that falls mostly in your area.

[Sen. Virginia "Ginny" Lyons (Chair)]: Yeah. Because we we have, you know, connected with them in the joint justice oversight. So we'll have Calista get Does your assistant have contact information for Wilcox?

[Sen. Richard "Dick" Sears Jr. (Chair, Senate Judiciary Committee)]: We've been trying to get contact information. I don't know We tried getting contact information from DOC a week ago and hadn't heard anything. DMH was in yesterday and said that they would get us contact sorry. Information. Okay. And it was Daphne who was committee assistant yesterday.

[Sen. Virginia "Ginny" Lyons (Chair)]: Good. Thanks. You'll do that.

[Mike [last name unknown], American Cancer Society Cancer Action Network (Government Relations)]: Thank you.

[Sen. Virginia "Ginny" Lyons (Chair)]: And we can always contact

[Sen. Martine Larocque Gulick (Vice Chair)]: the commissioner of medical. And she's gonna be

[Sen. Virginia "Ginny" Lyons (Chair)]: in here when we look at this. Very good. Okay. Cool.

[Mike [last name unknown], American Cancer Society Cancer Action Network (Government Relations)]: Thank you. Have a

[Sen. Virginia "Ginny" Lyons (Chair)]: good one. Yep. Alright. Good. Good solution. It always feels uncomfortable when you're on the floor and someone points out something that is a legitimate concern, but it's a good concern to be identified

[Mike [last name unknown], American Cancer Society Cancer Action Network (Government Relations)]: and Always

[Sen. Virginia "Ginny" Lyons (Chair)]: make your children sing that house. Twice. Right. Right. Jen, why don't we come back up and talk briefly about 154 of well, let's not be that let's there are people in the room who would like to comment on 01:54, and I'm happy to have that happen. Just like this.

[Mike [last name unknown], American Cancer Society Cancer Action Network (Government Relations)]: Let me do Yes,

[Sen. Virginia "Ginny" Lyons (Chair)]: please. Go on up. Sure. You have something to have going on.

[Mike [last name unknown], American Cancer Society Cancer Action Network (Government Relations)]: So for the record, Mike, American Cancer Society, my government relations So, don't have anything written today because I wasn't That's what I'm saying. So, we've been working on this legislation that's passed in 22 other states already. And it runs the gamut from everything that you've heard this morning through the walkthrough for commercial and state sponsored, to some states have just done Medicaid, some states have just done commercial, and as I said, some states have done the combination. We have the percentage of June with the full plate, and we would leave a clue to make decision as to whether or not you can get your full coverage. But I will say that, so biomarker testing, and this legislation has been designed that this is not for everybody. This is not, you can go to your doctor and demand a full panel of biomarker testing for anything. There are guidelines, I already walked you through a bit, so there are standards. You do not believe that this is necessary care for everyone. However, for those patients with cancer that would benefit, there's a reason why they have access to the training. However, this testing. This testing is used to determine the best course of care, basically. Once a diagnosis is already managed, it can also be used to determine whether or not the treatment is actually working. And it can be used post care to ensure that there's not a reoccurrence. That's not to say that every single patient needs all of those steps, but biomarker testing is multi pass in cancer care. Know you'll hear that. It's much different our friends in the Alzheimer's space. But there are also applications for rheumatoid arthritis. There are for Parkinson's disease. There's a whole host of chronic diseases where biomarker testing has applications. And it's a great way to determine the best course of treatment for our patients, but it's also a great way not to waste resources. And that's what we've seen in other states, that this is used not only to the benefit of patients, but we've had Medicaid directors who have been very enthusiastic. In fact, cover New Hampshire as well. New Hampshire is only doing Medicaid this year. They have endorsed, the state Medicaid program has endorsed this, even though it will cost them money, a little money upfront. But they see it as a way to actually save resources, because they be covering unnecessary medications, surgeries. We have a volunteer that was diagnosed with none of The doctor said, Well, good news for you is that there's a novel biomarker for this specific type of cancer. We can test for it and see if you're a candidate for a new treatment. Or if not, would have to go through a very invasive expansion surgery. She had a biomarker test, came back to a doctor candidate for the new therapy, pharmaceutical therapy. She avoided the surgery. Unfortunately, several months later, she got a permanent note for $9,000 because her carrier didn't cover it. It was out of network. She's still trying to get that resolved. But on average, now I know all your eyes probably just bugged out me over the $9,000 that was just for one. On average, the cost to the carrier and to Medicaid, they range from $46 to 200 It's under $300 on average for these tests. 90,000 in the extreme examples. But it goes to show that you have a constituent that may be getting a surprise bill in the mail because they had access to a test that they thought might be covered, and in the end, they wasn't. As I said, we've seen this in United across the country where this is actually saving resources to the overall healthcare system. And that's not necessarily what we focus on at the cancer society. We're more concerned about the patient getting the best course of treatment and having the best outcomes. So it's really a win win, because you're seeing that for patients. When there's medically utilized. Like I said, this is not a blanket, we want every single person in the state of Vermont getting a biomarker. It just wouldn't waste, that would waste resources also. And again, I apologize if I don't have my, will

[Sen. Virginia "Ginny" Lyons (Chair)]: No, Michael, we'll

[Mike [last name unknown], American Cancer Society Cancer Action Network (Government Relations)]: There's a lot to cover.

[Sen. Virginia "Ginny" Lyons (Chair)]: No, we'll invite you back in. I just wanted to get the Ground Floor for this. Sure. This is fine.

[Mike [last name unknown], American Cancer Society Cancer Action Network (Government Relations)]: This is, as said, 22 states have already done it, so this would not be groundbreaking So, for

[Sen. Virginia "Ginny" Lyons (Chair)]: here's what I'm gonna ask, you know, there are questions.

[Mike [last name unknown], American Cancer Society Cancer Action Network (Government Relations)]: I know, I'd love to have Jenny be able make sure to pump

[Sen. Virginia "Ginny" Lyons (Chair)]: We'll do that. Let's have you come up for a couple of minutes, if don't mind. Yes. Not long because parents are loose or let you

[Mike [last name unknown], American Cancer Society Cancer Action Network (Government Relations)]: I know. Jenny's people get herself talking. I don't know how.

[Jenny Fargan (Alzheimer’s Association, Vermont Chapter)]: Thank you for being Carla, Thank you so much. My name is Jenny Fargan. I am the Alzheimer's Association here in Vermont. And if appropriate, do have a long pager that I could provide to you all that kind of gives an overview for you, little bit more information about biomarker testing and all of that. Know, Mike covered some really great information regarding what biomarker testing is and the utility for that in diagnosing, care planning, treating, of that for Alzheimer's specifically. I know, Senator, you mentioned that there are treatments coming out and we have these blood based biomarker testing that is coming out helping with diagnosis. For Alzheimer's specifically, we do have two types of treatments, Afrotzuma and Leukembi that do the very best work in slowing the progression of the disease in the early stages. It is vital that if somebody is able to and it's appropriate for them to access that type of treatment, that they get that as quickly as possible. So having access to these biomarker tests ensure that they get a diagnosis earlier, and again, don't waste that time, those resources that Mike spoke to. You can see the data that we have says that it can have projected cost savings of $63,000 per person. So that's $30,000 in savings for Medicare, 20,000 in Medicaid, and $13,000 in other savings per person. So it does have a cost savings directly in terms of improving care and access to care for everyone, but for Alzheimer's specifically, it really does enhance the amount of time someone has and time that an individual who's facing this horrific disease has to come up with the decisions about how they're going to live their life, give them time to do the things that they want to do, and also delays the reality of them necessarily potentially going to a long term care facility, which is covered, as you know, a lot by Medicaid. There are huge ripple effects along with the strain on our workforce, healthcare workforce for diagnosing doctors and nurses and all the testing that goes on to that, as well as the long term care facilities and the strain on our workforce there. So we certainly see this as a huge benefit. Understand it has this upward cost, but the ripple effects of cost savings and the quality of life for people, as well as the fact that for Alzheimer's, for cancer, for so many diseases that this bill would be helping, the science is moving so quickly. Specifically for Alzheimer's, is incredible. We are an incredibly exciting time and breakthroughs are happening so, so quickly. We want to ensure that responders have access to the best treatment, the best care, and the most amount of times possible when facing this horrific disease to choose how they want to live their lives. Certainly, would love the opportunity to come back, testify, bring some of our amazing advocates who are care partners and whoever they face the challenges of these Disney that I

[Mike [last name unknown], American Cancer Society Cancer Action Network (Government Relations)]: don't think share their

[Sen. John Benson (Member)]: stories with.

[Sen. Virginia "Ginny" Lyons (Chair)]: We'll try to do that. Our time is significantly limited when But we do get it might make sense for us to get started on the bill at the end of the week when we come back, and then it'll it will automatically go to finance should we decide to Yeah. Yeah. Well, thank you so much. Thank you.

[Sen. John Benson (Member)]: Thank you.

[Sen. Virginia "Ginny" Lyons (Chair)]: Alright. Thank you all.

[Sen. Martine Larocque Gulick (Vice Chair)]: I know. Good.

[Sen. Virginia "Ginny" Lyons (Chair)]: Thank you, Sarah. Yeah. Well, it's an important evolution in laboratory medicine.

[Mike [last name unknown], American Cancer Society Cancer Action Network (Government Relations)]: It's really important to look at.

[Sen. Virginia "Ginny" Lyons (Chair)]: Okay, so, Jen, is there anything else that we need to know about S-one 54? No, I'm of it above, if you, okay,

[Jennifer Carbee (Office of Legislative Counsel)]: your witnesses know a lot more about the subject matter.

[Sen. Virginia "Ginny" Lyons (Chair)]: So we have Beth St. James coming in at ten, but maybe you could come up. I know we did have one hundred forty two on here. So Beth, why don't we just look at that bill again together even though it's not on the agenda. Okay. We're not gonna need this anymore, senator Veron. No. But thank you very much for being here.

[Mike [last name unknown], American Cancer Society Cancer Action Network (Government Relations)]: Really appreciate your time. Enjoy the week off.

[Sen. Virginia "Ginny" Lyons (Chair)]: We will. And I hope you'll enjoy being away from us this morning. Never.

[Mike [last name unknown], American Cancer Society Cancer Action Network (Government Relations)]: This is my favorite time of the year.

[Jenny Fargan (Alzheimer’s Association, Vermont Chapter)]: Thank you so much, John.

[Sen. Virginia "Ginny" Lyons (Chair)]: Yep, thank you. Thank you. 42 is the Interventional Medical Director. Thank you, I forget what the I stands for.

[Jennifer Carbee (Office of Legislative Counsel)]: International. Again, Jen Carvey, Office of Legislative Counsel. Yes, I think at one point you were thinking of maybe having some discussion, input or markup on Yes, the 140 we were. Because I know you've heard a lot of testimony. We may as

[Sen. Virginia "Ginny" Lyons (Chair)]: well do that. Let's do that.

[Jennifer Carbee (Office of Legislative Counsel)]: Great. And I have have sources watching the hospital for research when I get summoned, I vote. Fair

[Sen. Virginia "Ginny" Lyons (Chair)]: enough. So I will put that. I

[Jennifer Carbee (Office of Legislative Counsel)]: think

[Sen. Virginia "Ginny" Lyons (Chair)]: they're part of support on this bill. It's just a matter of what the board can do or what time frame we could put on. Right.

[Jennifer Carbee (Office of Legislative Counsel)]: And I don't know if you're waiting for something back from the board, maybe it doesn't make sense for

[Sen. Virginia "Ginny" Lyons (Chair)]: us to Well, no. I think let's go through it so we can understand some of the concerns that the board had the other day. They were concerned about administrative oversight and then how to analyze some of these things. We also heard feedback that other states are doing it and there might be ways that the board can minimize their administrative There's contracting up maybe to a place like New York. They could do that. That's also it's also a cost, but we wait to hear from the board. If we don't hear from them, we're gonna have to make our own decisions on this. Okay.

[Jennifer Carbee (Office of Legislative Counsel)]: So this is S-one 142, an act relating to a pathway to licensure for internationally trained physicians and medical graduates. And so, as you may recall, and we've walked through this, and then you've

[Sen. Virginia "Ginny" Lyons (Chair)]: heard from a lot of

[Jennifer Carbee (Office of Legislative Counsel)]: people since then, so we'll remind you what is in here. It starts out by amending an existing provision in the Board of Medical Practice statutes around qualifications for medical licensure and allowing the board to issue a license to an internationally trained physician or medical graduate who has successfully completed the pathway to licensure that the rest of the bill sets up. Section two is adding this sub chapter, the Board of Medical Practice Statutes, creating a pathway to licensure for internationally trained physicians and medical graduates.

[Sen. Martine Larocque Gulick (Vice Chair)]: They're taught with

[Jennifer Carbee (Office of Legislative Counsel)]: definitions of healthcare facility, internationally trained physician and medical graduate and participating healthcare facility. Then it creates the provisional license to practice with supervision. You recall, there's two years where the person is doing, has a provisional license, they're practicing the supervision from a participating healthcare facility. After two years of that, they can get a limited license to practice, and after two years of that, they can apply for full licensure. So the provisional license can be provided to someone who submits evidence acceptable to the board, showing that they meet certain criteria, that they have received a degree of doctor of medicine or equivalent from a legally chartered medical school recognized by a couple of different entities, or that a plot appears on an official list of medical schools recognized by the Medical Board of California, that they are licensed, have been licensed, or otherwise authorized to practice medicine outside of The United States, and have practiced medicine for at least three years unless the board approves an alternative standard. They provide sufficient evidence to the board that the applicant has demonstrated capacity to practice medicine, completed a three year post graduate program in their country of training, and practiced as a medical professional performing the duties of a physician outside The US for at least three of the last five years. I know this was a provision that several people have commented on, so maybe one for you to think about whether that is an appropriate time period or whether you wanna do something different in that space. And they've not been having practice. Yeah, so let's just talk about that a little bit.

[Sen. Martine Larocque Gulick (Vice Chair)]: Was there testimony that that's too restrictive?

[Jennifer Carbee (Office of Legislative Counsel)]: So I think there's a couple of things. They had to practice for at least three years, practice for at least three of the last five years, and not been out of practice for more than five years. I think there was some thought that that was sort of internally inconsistent. I'm not sure I followed that. It is. But I'm not sure if I followed Well, they have

[Sen. Virginia "Ginny" Lyons (Chair)]: to be in practice three of the last five years. Right. But they would have to practice within five years. Those are two different organisms. I mean, so it's like saying you don't have- Right, I'm

[Jennifer Carbee (Office of Legislative Counsel)]: not sure you've, yes, I'm not sure is, I'm not sure two is necessary if you have sacred. That's true. But I think you also heard that that may not be realistic for somebody who has been in, you know, who

[Sen. Virginia "Ginny" Lyons (Chair)]: may have been in The United States

[Jennifer Carbee (Office of Legislative Counsel)]: performing not to the full extent of their training because they didn't have the opportunity. Which is

[Sen. Martine Larocque Gulick (Vice Chair)]: the problem we're trying to solve.

[Jennifer Carbee (Office of Legislative Counsel)]: Right. Rewording it, maybe. I think you just need to think about what you are looking to, what might be gained from this concept and how you might wanna frame that in a different way that would be useful to someone who has been in this country operating and working. In medical environment. Right, in the medical But not allowed to practice.

[Sen. Virginia "Ginny" Lyons (Chair)]: Right, but they're doing something related to medicine if you don't wanna have the custodian. I don't know.

[Jennifer Carbee (Office of Legislative Counsel)]: I if you may decide that based on all of the education and training and experience that they had before coming to this country, you know, regardless of what employment opportunities they have found since they came to the country, that you want to make that pathway available. That data gets policy question. You may be looking at it transitional. The phlebotomist that has all the training

[Sen. Virginia "Ginny" Lyons (Chair)]: Hasn't practiced because we haven't allowed them to practice. That's kind of a transitional group. But say from x date forward, you have to have done this. I suppose you might be up in a, you know, a refugee camp somewhere for a number of years, but it sounds like there's a group of physicians that are here now that have not been able to practice for three of the last five years because we haven't allowed them to do that. Okay, let's try that and so maybe Yeah. Yeah, and I'm just wanting to follow-up.

[Jennifer Carbee (Office of Legislative Counsel)]: Well, I know we have an existing provision of law around internationally trained physicians. Just want to look at my table to see where that is.

[Sen. John Benson (Member)]: I'm trying to think that that that's where maybe the board and whoever's gonna bet these individuals would have the wherewithal or the ability to look into that and say yes, they're okay. Yeah. Which is where I heard the board say They don't have, they don't have to do that.

[Sen. Virginia "Ginny" Lyons (Chair)]: Correct. Yep. So that's I will make me their only employee. They don't support medical. Mean, David Hurley. David Hurley. Yeah. Yeah. Okay. Oh my god. Yeah. Yeah.

[Sen. Martine Larocque Gulick (Vice Chair)]: And it'd good to see what other states are doing to

[Sen. Virginia "Ginny" Lyons (Chair)]: the public. Well, but on yeah, no. And they on the other hand, they do a lot of work with our provisional licenses within the telehealth world. They're doing they've added on a lot of that without complication. That that's No. But I'm sure

[Jennifer Carbee (Office of Legislative Counsel)]: you know, last week, did another state. Right. It is. Yes.

[Sen. Virginia "Ginny" Lyons (Chair)]: It is. But they have to reach out, and they have to say, they're still currently licensed in The United States. The compacts that we had for physician, we had a physician assistant call.

[Sen. Martine Larocque Gulick (Vice Chair)]: Yeah. Well, was my other question. She said contracting with New York, and I thought I heard compact. Is it compact or contract?

[Jennifer Carbee (Office of Legislative Counsel)]: I think it's

[Sen. Martine Larocque Gulick (Vice Chair)]: contract. Oh, okay. Contract.

[Sen. Virginia "Ginny" Lyons (Chair)]: And it could be any, it could be another state. Doesn't have to be a New York state that hasn't been That makes it more difficult, Rob. I mean, if I'm gonna move to New York or California to get licensed, why am I gonna move back? Especially if I'm older and have a family, and

[Sen. Martine Larocque Gulick (Vice Chair)]: there's a cost. Don't think they were suggesting a move.

[Sen. John Benson (Member)]: I agree. I thought it was just using their process that you would go through the vetting process with New York, what it would be for an individual who was going to practice here in So Vermont

[Sen. Virginia "Ginny" Lyons (Chair)]: it would just be sending a paper packet over?

[Sen. John Benson (Member)]: Yeah, or interviews or whatever New York's required so hard to be Someone

[Sen. Virginia "Ginny" Lyons (Chair)]: knows the community college at Tanzania is accredited. Right. Connecticut doesn't exist. I think

[Sen. John Benson (Member)]: they got the language even from New York. Did they say that they were

[Sen. Virginia "Ginny" Lyons (Chair)]: That's a question for the folks who did it come from New York? Did Diana Gulick? I don't know. I don't recall it. No. No. Didn't. Didn't know.

[Jennifer Carbee (Office of Legislative Counsel)]: Think it was more organic. Because I was involved in the. So, just wanted to pull up as well that under the existing statutes and the powers and duties of the Board of Medical Practice, one of their Powers and duties? Chapter number four, two, three, to

[Sen. Virginia "Ginny" Lyons (Chair)]: adopt,

[Jennifer Carbee (Office of Legislative Counsel)]: adopt rules that prescribe a process for the board to assess the equivalence of an applicant's professional credentials earned outside The United States as compared to state licensing requirements for professions within the board's jurisdiction. Then there's some other language about somebody, there is somebody who can do three years out in The US or Canada of additional training if they have received their medical education outside of those countries. But I'm not sure if the extent to which there may be existing processes. They

[Sen. Virginia "Ginny" Lyons (Chair)]: may have rules in place. I don't remember seeing any of the rules. I don't think they've begun them, basically. Right, I don't

[Jennifer Carbee (Office of Legislative Counsel)]: recall if there are, but I just think it may be useful to understand from them.

[Sen. Virginia "Ginny" Lyons (Chair)]: So maybe what we're asking by, sorry, go ahead. No, go ahead. Maybe what we're asking is for an update on the rules that may include

[Jennifer Carbee (Office of Legislative Counsel)]: these things. And I can look at the rules as well and That see what's in would be great. But I'm just not aware, I think there may already be some processes at the board for evaluating our nation to be trained. And I suspect, although, that didn't seem to be necessarily until somebody's self.

[Sen. Virginia "Ginny" Lyons (Chair)]: I suspect that there are connections with some countries and not with others. And they don't have the system in place for folks from Afghanistan or from Yeah, they don't know anything about that. Don't. Couple. But they could. Canada is next year.

[Jennifer Carbee (Office of Legislative Counsel)]: Canada is a different category.

[Sen. Virginia "Ginny" Lyons (Chair)]: I think they, there's But not the bulls. But there are certainly a number of western nations that have physicians in this country and They in this have to have gone through some process. Can we, Jen, can we task you with looking at them?

[Jennifer Carbee (Office of Legislative Counsel)]: No, looking at them a little bit. Okay.

[Sen. John Benson (Member)]: She always is.

[Sen. Virginia "Ginny" Lyons (Chair)]: We may as well sort it out. Right.

[Jennifer Carbee (Office of Legislative Counsel)]: I mean, yeah, there is, this is gonna be a very inexact way of looking at this,

[Sen. Virginia "Ginny" Lyons (Chair)]: yes, I think maybe it

[Jennifer Carbee (Office of Legislative Counsel)]: would be helpful to hear from them how they currently, they have a fifth pathway, they have, well, they're rules. Have some, their rules do speak to board approved medical schools outside of The United States or Canada, but there may be some existing requirements that are more burdensome than what is being contemplated in the bill, like residential training in The US or Canada. Okay.

[Sen. Virginia "Ginny" Lyons (Chair)]: We need to leave. But we'll have to ask the board to come back and next week. We'll have to find it. The next week. Yes. I asked. No, no, no. But, oh, we'll talk. I will just say this. If they are reluctant to come in or their schedule is full, we're gonna have to make our own decisions on this because they already have some direction in their rules and this seems like a reasonable request that we've had from folks over. And didn't they say the bill went three to five? I mean, it wasn't a huge number. Were I was gonna Estabating.

[Sen. Martine Larocque Gulick (Vice Chair)]: Say that too because there was a little bit of a conflict between this statement about added administrative burden being very difficult and it was only gonna apply to something

[Jennifer Carbee (Office of Legislative Counsel)]: like

[Sen. Martine Larocque Gulick (Vice Chair)]: I thought

[Jennifer Carbee (Office of Legislative Counsel)]: he said, ten, fifteen, And

[Sen. Virginia "Ginny" Lyons (Chair)]: he could do it individually. Right. Telephone, he could have, anyway, so, yeah, I don't think it's

[Jennifer Carbee (Office of Legislative Counsel)]: Anyway, we can go back to the bill. So,

[Sen. Virginia "Ginny" Lyons (Chair)]: going back to the bill. So, if maybe the one maybe decision point is maybe we have them elaborate more on the rules so that they're more inclusive.

[Jennifer Carbee (Office of Legislative Counsel)]: Yeah, or understand what they have in place now or opportunities for internationally trained. Okay, then the applicant has to have a valid certificate issued by the Educational Commission for Foreign Medical Graduates or another credential evaluation service approved by the board, except the board can waive that If the applicant is unable to get the required documentation, like Missile Country, their job is not cooperative. They must have achieved a passing score on both steps one and two of The US medical licensing exam. Before applying, they have to have entered into an agreement for employment with a participating healthcare facility, and these are the facilities that would have a program in place to develop, assess, and evaluate their clinical and non clinical skills, familiarity with standards appropriate for medical practice in Vermont, and they don't meet any disqualifying criteria that's set

[Sen. Martine Larocque Gulick (Vice Chair)]: out in here. Sorry, Can

[Sen. Virginia "Ginny" Lyons (Chair)]: you go back up to the top there where you were talking about, okay, so as balance review and

[Sen. Martine Larocque Gulick (Vice Chair)]: then participating healthcare facility, do we have a sense of who would be participating?

[Jennifer Carbee (Office of Legislative Counsel)]: So that was the, one of the defined terms here is a hospital FQHC or community health center approved by the board that has capacity to provide an assessment and evaluation program. Four of these terms.

[Sen. Martine Larocque Gulick (Vice Chair)]: So do we know who does have the capacity to do that study? Do we

[Jennifer Carbee (Office of Legislative Counsel)]: have any sense of that? I don't recall if you've heard. I feel like you've heard from somebody from at least one of the FQHCs. Yeah. You know, said that they

[Sen. Virginia "Ginny" Lyons (Chair)]: would be interested in Yes. One in Island Pond yesterday, we heard Josh was talking about, would welcome his competition.

[Jennifer Carbee (Office of Legislative Counsel)]: But you could certainly hear from the Hospital Association Medical Center the FHCS

[Sen. Martine Larocque Gulick (Vice Chair)]: if you have not. I mean, it's just really helpful to know who is excited to join in the process, you know.

[Sen. Virginia "Ginny" Lyons (Chair)]: Yes. Very. So, the other thing is, I'm looking at number five here and I'm wondering if that goes first because it's prior to submitting an application.

[Jennifer Carbee (Office of Legislative Counsel)]: Oh. Yeah, I mean, think you could put them in any order. Think that somebody may need to have the appropriate credentials from another country and have achieved a passing score before they can have that employment So the provisional license is good for two years, after which the individual can apply for a limited license to practice. The provisional license is only good for practicing at the participating healthcare facility where they have an employment agreement, so it's just a, you know, it's a sponsored and supervised arrangement. Although it does allow the provisionally licensed physician to change employers during their provisional licensure period with the approval of the board, as long as they have a total of two years of supervised practice before they become eligible for the Linden license. The board can extend the required period of provisional licensure for up to one year if there is a change in the site of employment. If there's been some lack of continuity, I think, in the training, then the board could add on up to an additional year. And then here's the ineligibility. Person is ineligible to receive a provisional license if they previously had their license to practice medicine suspended, revoked, limited conditioned, or otherwise restricted because of unprofessional conduct, or they've been convicted of a crime, or they otherwise demonstrated a lack of confidence or lack of moral Convicted of a convicted of crimes. You've got the

[Sen. Martine Larocque Gulick (Vice Chair)]: I have to have much fish here.

[Sen. Virginia "Ginny" Lyons (Chair)]: That's pretty clear. Right. Yes. No. That one does indeed. Right,

[Jennifer Carbee (Office of Legislative Counsel)]: and that was the piece that Senator Xi was saying could be two years later, if that's okay for your purposes here, it doesn't really work for your recovery of residence purposes. So the participating healthcare facilities, there's certain criteria for them. They have to agree to provide the mentoring, evaluation, assessment, and support for the licensed, by one or more fully licensed physicians to the provisionally licensed physician using an evaluation and assessment system developed under protocols approved by the board. Question here. Yes. I'm just going through because we heard that this was gonna be a huge task.

[Sen. Virginia "Ginny" Lyons (Chair)]: Is this rather than, should this be done on your tools? They develop an evaluation assessment system.

[Jennifer Carbee (Office of Legislative Counsel)]: So the protocols, the evaluation and assessment system is developed under protocols approved by the board. So maybe protocols that the facility is developing, and the board is approving the protocols.

[Sen. John Benson (Member)]: Yeah. So, I'll get to that. Number two, if we're already struggling with physicians, and they're already overburdened.

[Sen. Martine Larocque Gulick (Vice Chair)]: You mean with lack of physicians?

[Sen. John Benson (Member)]: Yeah. Okay. Are they gonna want to take on additional responsibilities, guess, how much is Ann? Is there any liability associated to that, or is it associated to the facility? Are you going to get local physicians wanting to take on this additional responsibility? I don't know why.

[Sen. Virginia "Ginny" Lyons (Chair)]: That would be under the umbrella of the hospital or the That's why it's an organization. And then I'm not sure what personal liability would be attributed to

[Mike [last name unknown], American Cancer Society Cancer Action Network (Government Relations)]: Because they'll be working under

[Sen. John Benson (Member)]: their license.

[Sen. Virginia "Ginny" Lyons (Chair)]: Yeah. Yep.

[Jennifer Carbee (Office of Legislative Counsel)]: Right, I mean, I think to the extent that the, it becomes a supervision requirement, I think, on the individual physician who's providing the oversight, probably similar to how they would do it with an internal resident.

[Sen. John Benson (Member)]: Oh, okay.

[Jennifer Carbee (Office of Legislative Counsel)]: Yeah. Where they, some of the responsibility for supervising and ensuring the person who is doing the work has the requisite knowledge and ability does come back to the individual.

[Sen. John Benson (Member)]: What I could see is a hospital agrees to do this. The condition is that physician works there for two years, but they are also under some kind of obligation to stay with that hospital for for so many years. They could

[Sen. Virginia "Ginny" Lyons (Chair)]: do that.

[Sen. Martine Larocque Gulick (Vice Chair)]: Nothing would do

[Sen. John Benson (Member)]: that. That's what I could see the hospital doing.

[Sen. Becca White (Windsor District)]: Alright, and that could be part

[Jennifer Carbee (Office of Legislative Counsel)]: of their participation requirement with in the order to participate in our program, you have to agree to provide your support. Yeah.

[Sen. Martine Larocque Gulick (Vice Chair)]: The people is good to use their burden in the long run. Seems like they're welcome.

[Sen. Virginia "Ginny" Lyons (Chair)]: The short term.

[Sen. John Benson (Member)]: No, I agree. Just half people are people.

[Jennifer Carbee (Office of Legislative Counsel)]: So number two requires the participating facility to ensure that the mentoring, evaluation, assessment and support of the provisionally licensed physician is provided by one or more fully licensed physicians who are physically located in Vermont and that the provisionally licensed physician only provides services to patients who are physically located in Vermont. Must carry, here we go, carry medical malpractice insurance covering the provisionally licensed physician for the duration of that physician's employment by that facility and not retaliate against or discipline the physician for making the complaint or pursuing enforcement of an employment related claim. So then within ninety days before completion of the two year period of provisional licensure, the individual's eligible to apply for a two year limited license. We go from a provisional license to a limited license, practice medicine in Vermont. The limited license cannot be renewed more than once. And after two years of practice under a limited license, the physician is eligible to apply for a full unrestricted license to practice in the state. So that would just be the regular medical practice decision licensure.

[Sen. Martine Larocque Gulick (Vice Chair)]: Is the limited Sorry, judge. Is that your

[Beth St. James (Office of Legislative Counsel)]: No.

[Jennifer Carbee (Office of Legislative Counsel)]: I'm actually I was just letting you know they're passing over the bill.

[Sen. Virginia "Ginny" Lyons (Chair)]: I was waiting for the house. That's good for you and bad for Beth, but we'll just tell them. Don't worry, we'll get

[Jennifer Carbee (Office of Legislative Counsel)]: it earlier. Is limited license a term

[Sen. Martine Larocque Gulick (Vice Chair)]: of art in the world of medicine?

[Jennifer Carbee (Office of Legislative Counsel)]: It's something we have created right here. I mean, I don't know if it's used in other context, this is what we are calling Provisional. The second set. So there's the provisional license for two years, and then the limited license for two years, and then the full license. So no, I don't believe it's something we have, at least under

[Sen. Virginia "Ginny" Lyons (Chair)]: the Board of Medical Practice. Just going backwards.

[Sen. John Benson (Member)]: Oh, sorry.

[Mike [last name unknown], American Cancer Society Cancer Action Network (Government Relations)]: But it

[Jennifer Carbee (Office of Legislative Counsel)]: is a license that is limited.

[Sen. Martine Larocque Gulick (Vice Chair)]: And will those licenses, will it just be drawn up by the facility?

[Jennifer Carbee (Office of Legislative Counsel)]: So it'll be an internal? No, it is through the Board of Medical Practice.

[Sen. Virginia "Ginny" Lyons (Chair)]: Okay.

[Jennifer Carbee (Office of Legislative Counsel)]: Yeah, which said I limited the language. Oh,

[Sen. John Benson (Member)]: I was just thinking back of our issue of when we read back in the bill and the board saying it didn't have the capability, could we have in the bill that the board could actually contract to help those services? Well, can think about that when we get there. You know, it's just an option.

[Sen. Virginia "Ginny" Lyons (Chair)]: I mean, but then they'll have to have money to do that. That's true. So, I know, I'm not interested in putting only in Yeah. I think let's let's hold that thought. It might be something that the next group that looks at this bill might consider if the board is more forthcoming. What's the next group? House.

[Sen. Martine Larocque Gulick (Vice Chair)]: Besides, who did you refer? Okay,

[Jennifer Carbee (Office of Legislative Counsel)]: so after two years under a limited license, the physician can apply for a full, unrestricted license to practice. The limited license to practice can only be issued by the board to an applicant who meets certain criteria. They must be on track to successfully complete the participating facilities assessment and evaluation program. They must have an offer of full time employment from a healthcare facility or an offer of continued employment from the facility that they are working with. And the facility is located in Vermont and accepts patients covered by Medicaid or Medicare or both. They must have achieved a passing score on step three of The US medical licensing exam. So steps one and two are required for the provisional license, step three for the limited license. And then the board will issue a limited license to begin immediately upon the provisionally licensed physician's completion of the participating facilities assessment and evaluation program, and the end of the provisional license, so there's no gap in licensure and the board can rescind or refuse a limited license to practice if the applicant does not successfully complete the participating facility program. If the board refuses to issue a provisional or limited license, then the board has to provide specific reasonings for the refusal, and the refusal is a final order of the board that can be appealed. According to appeal provisions in court medical practice statutes. It directs the Board of Medical Practice in consultation with partner organizations as needed to collect information needed to evaluate the implementation and success of this Android licensure program, and a lot of different information to be collected there about who's applying, where are they coming from, how many provisional and limited licenses were granted, how many were refused, if they were reviewed, why, who successfully completes the program, were there complaints received, where did people work in their country of origin, and where did they work when they started the process here, and then where do they go after they have a full and unrestricted license? What practice settings, specialties do they choose? And that information would be reported annually on a report on April 1 to this committee and other committees of jurisdiction. Directs the Board of Medical Practice to adopt rules necessary to implement this pathway to licensure. Evidence. Including which country's licensure is acceptable to the board, and what criteria do the participating healthcare facilities need to use to assess and evaluate physicians' familiarity with Vermont Medical Practice.

[Sen. Virginia "Ginny" Lyons (Chair)]: Should we say country, or should we put in their medical school as well?

[Jennifer Carbee (Office of Legislative Counsel)]: It says which country's licensure or other authorization to practice medicine is acceptable to Ford? Mean you could have the board specify which countries, you're asking which country's medical schools?

[Sen. Virginia "Ginny" Lyons (Chair)]: Well, would, yeah, because they, in the international language that's currently in statute, it references medical schools.

[Jennifer Carbee (Office of Legislative Counsel)]: I think it does, but that's leading up to then the licensure and where they get their initial licensure.

[Sen. Virginia "Ginny" Lyons (Chair)]: We can certainly add it. Well, somewhere, is it in the information they need to provide to the board? But if the board's gonna approve a country, that's different from approving a medical school within the country. So there might be one that's very acceptable and has similar basic didactic information and clinical stuff that would allow for practice, and then there might be some that don't achieve that. Okay. And certainly have some consideration.

[Jennifer Carbee (Office of Legislative Counsel)]: So that's it. And then there were effective dates. This is another bill that was introduced last year, so effective dates would need to be updated. Okay,

[Sen. Virginia "Ginny" Lyons (Chair)]: have we put the rule making stuff and the language in the section of law that deals with international medical companies?

[Jennifer Carbee (Office of Legislative Counsel)]: No, is there different They're totally different. There are different existing provisions. That's where I think it would be helpful to you to hear from the board about what they currently do regarding internationally trained positions and how they might see that fitting with what you're proposing.

[Sen. Virginia "Ginny" Lyons (Chair)]: So then the question I have is we've got effective dates, we don't have dates certain by which this is implemented. Well, provisions

[Jennifer Carbee (Office of Legislative Counsel)]: of the bill

[Sen. Virginia "Ginny" Lyons (Chair)]: would take effect,

[Jennifer Carbee (Office of Legislative Counsel)]: I mean, the pathway would be, so this was introduced last year, so it gave a little over a year before the provisions, the pathway would be law. So that is sort of my understanding, and we could be more specific about it, that was

[Sen. Virginia "Ginny" Lyons (Chair)]: my I am concerned that implementation, rule making of course takes time.

[Jennifer Carbee (Office of Legislative Counsel)]: Right, well that's why I gave them over a year. Yep. And

[Sen. Virginia "Ginny" Lyons (Chair)]: once the rules are in place, I'd like to have it implemented. And So have rules in

[Sen. John Benson (Member)]: you wanna do the rules first, get the rules all Right, set

[Sen. Virginia "Ginny" Lyons (Chair)]: and that's how

[Jennifer Carbee (Office of Legislative Counsel)]: it would work. Mean, that's why there's the rule delay. Making takes effect on passage, rule making provisions take effect on passage, and the pathway program takes effect a year plus out from passage.

[Sen. Virginia "Ginny" Lyons (Chair)]: And we say that? That's what the effective date's The effective date says '26.

[Jennifer Carbee (Office of Legislative Counsel)]: Right, because the bill was introduced last

[Sen. Virginia "Ginny" Lyons (Chair)]: The rule making takes effect on passage.

[Jennifer Carbee (Office of Legislative Counsel)]: Right, so you would need to move the date

[Sen. Virginia "Ginny" Lyons (Chair)]: out because

[Jennifer Carbee (Office of Legislative Counsel)]: the bill But was introduced in '20

[Sen. Virginia "Ginny" Lyons (Chair)]: then, I wanna know that they're communicating the results of their work to the medical community and that this can be implemented. It's right post case. Post taste. Alacrity, we haven't done that enough.

[Jennifer Carbee (Office of Legislative Counsel)]: So I'm not sure I'm post tolerant. I mean, the pathway, pathway becomes effective on a date certain. Yes. So I'm not sure what more, the rules will already be in place. Okay, well,

[Sen. Virginia "Ginny" Lyons (Chair)]: do we wanna put any, this is a question and then we'll leave it on the table till we come back to it, but do we want to have them, a communication go out? I know they're gonna have a public hearing with rule making and all of that, but that notification goes out to hospitals and clinics that this is now in place.

[Sen. Martine Larocque Gulick (Vice Chair)]: Yeah, but more clarity the better, right?

[Sen. Virginia "Ginny" Lyons (Chair)]: You think they might drive their people?

[Sen. Martine Larocque Gulick (Vice Chair)]: Okay, but that's

[Jennifer Carbee (Office of Legislative Counsel)]: all I mean, will note that the language in here is all about saying the board may issue a provisional license, that's because you never require them to issue if they don't find that somebody has successfully met

[Sen. Virginia "Ginny" Lyons (Chair)]: the qualifications. I just wanna make sure that the notice goes out, that now there's a system in place, a pathway system in place for provisional limited ampullized system, clinical implementation date. Did they have to Yeah. You have

[Sen. John Benson (Member)]: to notify the 14 hospitals. And

[Sen. Virginia "Ginny" Lyons (Chair)]: the clinics, yeah.

[Mike [last name unknown], American Cancer Society Cancer Action Network (Government Relations)]: I hope

[Sen. Virginia "Ginny" Lyons (Chair)]: to reach any unsure return. Finding good parties, Bob. We're finding some it's my son's problem.

[Sen. Martine Larocque Gulick (Vice Chair)]: I'm gonna drop her off the cuff. Right right right

[Sen. John Benson (Member)]: next to it. Yeah.

[Sen. Virginia "Ginny" Lyons (Chair)]: Okay. So my husband in. Are you leaving then? She's out. Yeah. See you later. Sorry about what I'm talking about. Okay. And we'll put this up on the agendas. I think we already have that one. We can go back to you. Okay.

[Jennifer Carbee (Office of Legislative Counsel)]: And so, I'm gonna hear from the board about what their suggestions are and what their process is.

[Sen. Virginia "Ginny" Lyons (Chair)]: We'll ask them again. They've indicated they have said what they're that they've had their final say, but we'll ask them again. Thank

[Jennifer Carbee (Office of Legislative Counsel)]: you. Yes.

[Sen. Virginia "Ginny" Lyons (Chair)]: Yes. Okay.

[Sen. Martine Larocque Gulick (Vice Chair)]: Thank you. Okay.

[Sen. Virginia "Ginny" Lyons (Chair)]: Thank you. I'll say it. Friday. Alright. Come on up, Beth. Thank you for being here.

[Mike [last name unknown], American Cancer Society Cancer Action Network (Government Relations)]: It's really good to meet you

[Sen. John Benson (Member)]: up today. I don't know why.

[Sen. Virginia "Ginny" Lyons (Chair)]: Wait. Does It's today. I'm trying to Senator White, did you wanna give a quick intro to your bill, please? I would. You're out of order on the list. It's Oh. Here we are. And is Alexis She's So, on should we have her go before we go through the bill or after? I just want you to give a quick background and then we can

[Sen. Martine Larocque Gulick (Vice Chair)]: have her go after that.

[Sen. Becca White (Windsor District)]: Well, thank you, madam chair,

[Sen. Virginia "Ginny" Lyons (Chair)]: and thank you, committee. I

[Sen. Becca White (Windsor District)]: have a bill for you today. I really do. This is a great bill, and the only concern I have is I was surprised that it ended up in this committee rather than in education. So I hope that you give it your that due any committee would, and if you were to refer it, I would not be offended. So S-two 33 is a bill that I worked on with a very determined and considerate constituent named Alexis Palmer, who is on Zoom hopefully after we get a walkthrough of the bill. Alexis reached out to me and her state representative in Ludlow because she was seeing a real gap in support for families and then children who are dealing with the complex special needs system that we've created within our education system. She works closely with that community, and this was an attempt, in a two year pilot form to try to give support to the most vulnerable families who are trying to make sure that their children have the needed supports in the classroom. And that is in the form of, like, IEPs. I know Sandra Gulick is well versed in this conversation, but the stories that she provided to me made me want to draft this bill. And you see that the full senate delegation from Windsor is on it because it is a unique problem, I think, in our area as well. Beth St. James can walk through what it specifically does, but essentially the idea is to support families through the IEP process and give them an advocate in that space that isn't fully associated with the school and is not like someone there paying themselves in an attempt to support them and reduce the inequity that you see when a student who may have a lot of resources in their family, their family might understand the IEP process, versus a student who might come from a background where their family isn't gonna be working with a lawyer. Their family isn't gonna be working with the school in the same way, and they might wanna have someone who can say, hey, here's a support that you might not know about. And Alexis has been very active in this community, and she has worked tremendously and has on her website provided, I believe, a white paper on the topic, and testimonies from families, and folks in the parent childhood network that would benefit from this. So it is $250,000. That's the ask for this short pilot program, and it would create a program that would, I believe, hire three, perhaps. I'm not sure how many grants we ultimately landed on, but we wanted to give you a small amount

[Jennifer Carbee (Office of Legislative Counsel)]: to deal with. I can't remember how much.

[Sen. Becca White (Windsor District)]: It's a two year pilot where the grants would go towards the advocacy program, so I think you could break it out. I don't remember where Alexis and I landed on what the cost per each of these claims could be, but I leave that to you. And I've had good success in this committee with my APRN bill for three page bills, so I'm hoping we can see that again. I'll leave You never

[Jennifer Carbee (Office of Legislative Counsel)]: know. I

[Sen. Becca White (Windsor District)]: So I'll leave it to Beth.

[Sen. Virginia "Ginny" Lyons (Chair)]: No, thank you. And to answer your first question, why did it come here? Deal with special needs kids And all the this is a DCF, AHS issue, and it is related to Medicaid reimbursement. It's also related to support services that are outside of school. So it does fit nicely here. Good. And it would be, I think, also important to have at least a fly guy, and I'll ask Beth St. James for her input on how the education committee feels. My name is March.

[Sen. Becca White (Windsor District)]: And I don't work with Beth very

[Sen. John Benson (Member)]: much,

[Sen. Becca White (Windsor District)]: so it was nice to-

[Sen. Virginia "Ginny" Lyons (Chair)]: And Alexis, we will get to you as soon as we've gone through the bill, so thank you for being here. Thank

[Beth St. James (Office of Legislative Counsel)]: you. Good morning Beth St. James Office of Legislative Counsel. I think this is my first time in your committee, certainly this session. Can't remember if I was even here last session, so maybe this biennium. Oh.

[Sen. Becca White (Windsor District)]: So, Well,

[Sen. Virginia "Ginny" Lyons (Chair)]: you and I have talked, so I

[Sen. Martine Larocque Gulick (Vice Chair)]: Oh, yeah. No.

[Sen. Virginia "Ginny" Lyons (Chair)]: So, oh, yes. We did a good job on that, Phil, and they haven't taken it up yet.

[Beth St. James (Office of Legislative Counsel)]: I am nonpartisan. I know.

[Sen. Virginia "Ginny" Lyons (Chair)]: Well done. I just want to compliment you on the academic freedom bill that I introduced into education. You did such a good job. I appreciate that. Thank you very much.

[Beth St. James (Office of Legislative Counsel)]: Would you like me to share my screen for the walkthrough? Yep. Okay. Perfect. Okay. So, we're gonna walk through S-two 33 as introduced, an act relating to establishing a special education family advocacy pilot program. Sponsor did a great job of summarizing the bill. So I will also try to summarize and not go line by line. Piece of session law for you all because it's a pilot program. First subsection, subsection A, I'm on page one, line 14, would be a $250,000 appropriation from the general fund to AHS for the two year pilot program. The pilot program will aim to, so these are the goals of the pilot program, ensure that families of K-twelve students have access to knowledgeable, neutral advocates to guide them through the IEP process, including access to in person support during IEP meetings. Strengthen collaboration between schools and parents, and help prevent costly disputes and due process hearings by addressing issues early. AHS is required to seek applicants from school districts, parent child centers, and other interested nonprofit organizations. Successful applicants are required to submit an application to the agency describing how the applicant, if awarded a grant, will do the following: train advocates to provide direct support for parents of children with disabilities in K-twelve through the IEP process, provide trainings for parents to prepare and empower them to advocate on their own during the IEP process, and collaborate with school districts with the goal of supporting all involved parties to work together in the best interests of students. On or before 11/15/2027, AHS is required to submit a written report to the education committees and the Human Services Committee and Health and Welfare Committee in the Senate evaluating the pilot program and any recommended future actions. In drafting a report required pursuant to the subsection, AHS is required to seek the input of the agency of education in evaluating the need for and effectiveness of the pilot program and include the agency of education's response as part of the report. And then this act would take effect on 07/01/2026.

[Sen. Virginia "Ginny" Lyons (Chair)]: Go ahead. So what I'm seeing here, and then we'll listen to Alexis because it seems like she may have the broader vision on this, but what I'm seeing here is that the agency will have $250,000 They'll send an RFP out. They'll get a reply back from various parts around the state to accomplish this goal, to provide support services for the development of IEPs and then any questions related to issues around that. There doesn't seem to be a period of time within which the organization or the individual stays connected with That's true. The There's no indication of that. There aren't conditions for the type of organization, there is a little bit about who can apply and the credentials that that individual would have, or the organization would have. So there is some work that I think we would have to do in here to flesh it out a little bit. And then there's the question of $250,000 and I'm wondering, we'll have to hear from the agency DCF about this, but I'm wondering how and if this fits in with the Rural Health Transformation Grant process because it does link very much with the health and welfare of children who have significant disabilities. So those are my questions. Just thinking about it upfront and I know that we'll all have other questions. There are a lot of issues with this. For example, when you apply for this RFPs, will you already have made connection with the school? Do you have that connection built in? Have you made a connection with the parents and the children? So there's a lot. It looks short but it's good. I mean it's an interesting, it's a good idea. Let's go ahead, Martine, Senator Gulick. Thank

[Sen. Martine Larocque Gulick (Vice Chair)]: you, Madam Chair. We might not have time to do this now. Thank you for helping us through this bill, but I am gonna, I'm just curious about what the current responsibilities are in terms of the ID-thirty process, what's in statute, what's in rule, what is federally mandated. Like, there's just a lot, I know there's a lot when it comes to special education. So we don't, again, we

[Sen. John Benson (Member)]: don't have to do it

[Sen. Martine Larocque Gulick (Vice Chair)]: now and I am gonna be curious to see what's

[Sen. Virginia "Ginny" Lyons (Chair)]: to be there. Right, that's why I was asking about credentialing and connections and all the rest. Yeah. There's a lot there. And I know when I met I met recently with our special ed folks and they're working out a lot now. Other questions, senator Benson, senator Morley. Okay. So, let's hear from Alexis. If you have time to stick around I do. Do

[Beth St. James (Office of Legislative Counsel)]: you want me to stay in the seat?

[Sen. Virginia "Ginny" Lyons (Chair)]: Sure, you can stay wherever you want. Alexis, well, I'm so comfortable. We are going to introduce ourselves for you so you know who we are, and then you can introduce yourself for the record and give us your telephone. John Morley, Orleans District.

[Sen. John Benson (Member)]: John Benson from the Orange District.

[Sen. Virginia "Ginny" Lyons (Chair)]: Oh, Ginny Lyons, Southern Mid Southeast.

[Sen. Martine Larocque Gulick (Vice Chair)]: Hi, Alexis, I'm Senator Martine Larocque Gulick. I live in Burlington and represent Chittenden Central.

[Sen. Virginia "Ginny" Lyons (Chair)]: And Senator Cummings had to step out for personal reasons and so she'll catch up at a later time. But thank you for being here. So introduce yourself for the record and then we'll, we have your testimony, just guide us through, so we can understand exactly what it is that you're asking for. And you've heard some of our comments, so maybe you can help elaborate a little bit.

[Alexis Palmer (Constituent/Witness)]: Sure. I am Alexis Palmer. I am a resident of Ludlow, Vermont. Thank you very much for having me today. I really appreciate it. So as Senator White had mentioned, I work very closely with this community. Hold a bachelor's of science in applied psychology with a concentration in education advocacy. I've worked as an elementary school paraeducator. I've worked as a youth employment specialist with Hire Ability Vermont. And I currently am an early intervention developmental educator working with families kind of in their first experiences of the special education process. But I think more importantly, I myself am a special needs mother to a four year old son who has an autism diagnosis level three. He's nonverbal. He's a complex child. Through kind of entering that as a parent, not just a professional, that's really where this gap opened up for me. In my community, I have gained this reputation as somebody who knows a lot about this since I had the privilege of going back to school when my son started presenting with his disability, was very privileged to study specifically how to advocate for him, and parents don't always have that privilege. So in my community, I gained this reputation. And now I've got parents coming to me all the time asking for help. I have had the honor of even running a few parent education opportunities, kind of IEPs one zero one class three times now. And historically, about half of the participants are actually educators looking for more information as well. But ultimately, I'm asked also, how much do I owe you for this service? Or why don't you charge for this service? And morally, I can't. Disability doesn't discriminate. It doesn't care about your race, gender, socioeconomic status. And I just don't feel that parents shouldn't be able to access help just because they can't pay for it. Hence, this pilot program. My my hope is that in this pilot program is to create the opportunity for the state of Vermont to collect data to better create a formalized structure that families can access and educators as well. Sorry, I'm nervous. And I don't really know what to say.

[Sen. Martine Larocque Gulick (Vice Chair)]: Take your time.

[Sen. Virginia "Ginny" Lyons (Chair)]: Don't be nervous. We're we're all friendly in here.

[Alexis Palmer (Constituent/Witness)]: This is just this is something that I'm so passionate about and we

[Sen. Virginia "Ginny" Lyons (Chair)]: So,

[Alexis Palmer (Constituent/Witness)]: the goal of this pilot program is to really not create adversarial dynamics. It's to strengthen that collaboration between schools and families to help families better understand the process, answer those questions, because educators are often working within strained confinement as it is and don't have the time to bridge that gap themselves despite the best of intentions and want. So yeah, that's kind of my quick little lowdown, but I'm happy to address any specific questions.

[Sen. Virginia "Ginny" Lyons (Chair)]: So I have a question for you. Hearing actually something different from what I'm sensing in the bill, and that is you're asking for the development of a program rather than the actual implementation.

[Alexis Palmer (Constituent/Witness)]: Well, so the pilot program would essentially get something rolling. So every state has a different kind of system. There are some states that have a program like this through the vocational rehabilitation. Some states have it through a designated agency like a nonprofit. Vermont is one of those states that doesn't really have a formalized structure. And so my thought behind the pilot program was to ensure that we could create something that would be best suitable for specifically for Vermont families.

[Sen. Virginia "Ginny" Lyons (Chair)]: Okay, so the bill that we have before us would establish a program, test out the program, and then come back with final recommendations to implement a full blown program. So that might be more than we can accomplish in the time that we have with this bill, but I'm thinking we might be able to add some language either in a short bill to this bill, or we might be able to recommend some language in the budget that would allow for the agency to bring us a model for Vermont. So just I'm asking you a little bit to be patient with this. I know where you sit and I know the stress you're feeling to have something happen, but this is a law. It is a law in this bill. It is a good thought. I know I've heard from parents of children with disabilities about support needs in schools and outside of schools. We got it. Right, questions for Alexis? Okay, good, thank you. So Beth, I'm gonna ask you to back up and the committee to have a little conversation. I know we've just looked at the bill for the first time, but you're hearing the extent of what's here. It's a big deal. Mhmm. A very big deal. And it might it would, as written, have to go back to education so they can look at it with all the considerations that senator Gulick brought up about the IEP and the involvement of the school and then how the RFP is written between any two agencies? Committee.

[Sen. John Benson (Member)]: Well, I guess I'd like to understand a little bit better on what agencies are really involved in these programs so that, you know, you're trying to do a coordination and understanding what they provide, and I'm not sure just which agencies have jurisdiction over or what parts.

[Sen. Virginia "Ginny" Lyons (Chair)]: I think that's what we're going to try to sort out for the support system and let Beth respond because from my perspective I'm seeing both agencies having a specific role and if we were to move some of the support systems to five zero one C3 organizations out in the community, it would be AHS. If it would stay in the school, it would be AOE. Wanna help respond a little bit after that.

[Beth St. James (Office of Legislative Counsel)]: Yes, first I will say, start by saying, I am your education policy attorney, so my knowledge base is really just around the education piece of this, so I'd be happy to work with Katie to the extent that we need some input on AHS's involvement in the kind of special education world. But from an education perspective, the individualized education program process, that's what IEP stands for, is a federal requirement. And the agency of education it would be the state entity involved there, not AHS. Right. AHS may be involved in providing wraparound services to some of these students, but as far as the federal special education law, that is really something that is in AOE's wheelhouse.

[Sen. Virginia "Ginny" Lyons (Chair)]: How come we

[Sen. John Benson (Member)]: I I don't know if the funding's gonna stay in there,

[Mike [last name unknown], American Cancer Society Cancer Action Network (Government Relations)]: but if you're gonna be developing a, you know,

[Sen. John Benson (Member)]: a model going at least over the next year or less. I'm a little surprised that one two fifty goes comes from AHS versus AOE.

[Beth St. James (Office of Legislative Counsel)]: The policy choice. Mhmm. If if you decide to take this bill up, if you have questions about the IEP process, there are many folks other than me in the field who are better able to speak to that. But I the IEP is a team process. Parents have a a legal right to be at the table. Schools have a legal right to be at the table. And and the law is very prescriptive of who has a legal right to be at the table, ultimately, the decisions are made by the school district, by the local education agency. And so, even though someone may have a legal right to be at the table, they may not be the decision maker, which can naturally lead to adversarial situation. And so, I think something that is an interesting policy piece for you all to debate is, given that the agency of education is kind of like the state entity for those decision making processes around special education services? Are they the right ones to be holding the pilot program, the grants, the whatever, for the advocates who may be not

[Sen. Becca White (Windsor District)]: on the

[Beth St. James (Office of Legislative Counsel)]: same page as them. That's a big call. That's a big philosophical question. Though. May

[Alexis Palmer (Constituent/Witness)]: I may I also just add one thing? I'm so sorry. Go ahead. Within IEP meetings, parents do have the right to have an advocate present. Nationally speaking, advocates don't necessarily have a certification process,

[Jennifer Carbee (Office of Legislative Counsel)]: like

[Alexis Palmer (Constituent/Witness)]: a formalized certification process. There are classes and certifications available, but ultimately the presence within an IEP meeting of an advocate is in support of the family representative who is that decision maker in partnership with the school. I just wanted to, sorry, I remember you asked about kind of credentials and those kinds of things.

[Sen. Martine Larocque Gulick (Vice Chair)]: Okay. Thank you, Madam Chair. I should probably know the answer to this. But having been on a school board, and I've dealt with this situation. So I understand it. One thing I'm not clear on is if there is a disagreement between, because a lot of times, at least in my experience, this has to do with sending, potentially sending a student out of state. We get into those extraordinary special ed costs and it becomes very complicated. And

[Beth St. James (Office of Legislative Counsel)]: I am wondering, does the AOE have a responsibility or role to ever play the arbiter in these disagreements? There is an escalation process, and I may not be the best student. I certainly can't I'm certainly not familiar enough with it to just speak off the cuff about it today, but there is a formalized process in law, a dispute resolution process. I'd be happy to do my homework on that, or you may want someone from the agency of education who deals with that. I can just tell you by looking at the agency of education's organizational chart, they have attorneys that are specifically dedicated to IDEA, our federal special education law disputes and inquiries, not just disputes. So yes, the agency does have a role in that. Was there another, I'm sorry.

[Sen. Martine Larocque Gulick (Vice Chair)]: No, that was That was it. So, that's helpful, and would find out, I'm really curious as to how that plays out. Yeah. So, yeah, we could take that.

[Sen. Virginia "Ginny" Lyons (Chair)]: Other questions? Typically. So, I guess you heard my comments about the complexity that this brings out in the bill. So let's do this. It is important and I know it's important. I know from my own past experience it is important. Certainly Senator Gulick has been very much involved in the school stuff Let's think this through a little bit and see if there's something we can do to advance the concept, the idea, at least. There may not be money with it and that actually be to your advantage, I think, at this point. So let's do that. We'll leave it here on the table. We'll come back to it. We do have a little bit of time at the end of the week when we get back and we'll try and connect with Beth and Katie about this and we'll all just, we can talk about it at some point during our meetings. Great. And Alexis, thank you very much for being available. We all we may call on you again. So

[Alexis Palmer (Constituent/Witness)]: I appreciate it, and I would be more than happy to come back and and have another conversation with you guys.

[Sen. Virginia "Ginny" Lyons (Chair)]: Thank you. Terrific and good luck. Good luck with your child. It's a difficult situation and we can very much understand and appreciate what you're going through as much as we can.

[Alexis Palmer (Constituent/Witness)]: You so much.

[Sen. Virginia "Ginny" Lyons (Chair)]: All right, good. So we are

[Sen. Martine Larocque Gulick (Vice Chair)]: don't know, actually that much garbage.

[Sen. Virginia "Ginny" Lyons (Chair)]: So here's what I would like to say.

[Jennifer Carbee (Office of Legislative Counsel)]: Looks like we

[Sen. Virginia "Ginny" Lyons (Chair)]: have a little time to wrap our committee up. But I will say this, we have 189, I think we've gotten to some resolution on that, on multi senior language. We have 190, we'll be senior language, and we'll hear the last bits of testimony when we get back. 197, similarly.

[Sen. Richard "Dick" Sears Jr. (Chair, Senate Judiciary Committee)]: I keep looking at the board.

[Sen. Virginia "Ginny" Lyons (Chair)]: Oh, okay. Print space pricing is $1.90, and I have to say, you know, that one ninety and one ninety seven connect so closely. So what we do with one is gonna link in with the other.

[Sen. John Benson (Member)]: Are you gonna make one ninety seven part

[Mike [last name unknown], American Cancer Society Cancer Action Network (Government Relations)]: of that 90?

[Sen. Virginia "Ginny" Lyons (Chair)]: No, we're not gonna do that because they're two different organisms, they're different groups interested in different things that could happen. So 197 primary care. We have a little bit of finish up testimony on that on the Tuesday that we get back. Hopefully we'll have time when the floor doesn't knock us off of the agenda. We'll also work with Katie on S26 and try to get to some language there. She's got a new draft that we can look at based on the conversation with Rosie Krueger. And 193 is the forensic facility that judiciary has looked at and they want us to take a look at it. So we'll have Katie and Eric Fitzpatrick in on that. That's all on Tuesday if we can do it. I'm saving time through the week that we can get to some of the things we have finished. So then we'll also finish up on 189. We'll look at S-two 39, the child abuse and the library reporting. 190, the Green Mountain Care Board Hospital Outsourcing and Reference Based Pricing.

[Sen. Becca White (Windsor District)]: 97

[Sen. Virginia "Ginny" Lyons (Chair)]: care, 142 we have plugged in for Thursday and we'll finish that off. Then we're going to do some markup on S64 probably on Wednesday or Thursday and then we'll have possible votes for all of those bills. That's what

[Mike [last name unknown], American Cancer Society Cancer Action Network (Government Relations)]: we're looking at. Do you think we'll be busy?

[Sen. Martine Larocque Gulick (Vice Chair)]: We'll be well vaccinated. We will have a crap of coffee.

[Sen. Virginia "Ginny" Lyons (Chair)]: You've done a lot of work on each of these bills. We're making huge progress. Yes. We really have, and it's great to see. I want to thank Martine actually for reaching out to the recovery partners and the residences and asking about the proposed amendment that we're going to see on the floor and they are fine with it. So you can also share that in your test appointment.

[Sen. John Benson (Member)]: You did yesterday on the you know that that was there was my state. So

[Sen. Virginia "Ginny" Lyons (Chair)]: we are now is there anything else? I just wanna say take some time next week for yourselves and then take some time to look at

[Mike [last name unknown], American Cancer Society Cancer Action Network (Government Relations)]: the fall of hell. Catch up on work back home.

[Sen. Virginia "Ginny" Lyons (Chair)]: Yeah. We take your knives out with you. And and, Talista, thank you. We're getting to closure on a lot of stuff. We can't do it without you. Appreciate it.

[Sen. Martine Larocque Gulick (Vice Chair)]: Just a

[Jenny Fargan (Alzheimer’s Association, Vermont Chapter)]: reminder, 08:30 on Wednesday and Thursday that we can come back. That's brutal. Guys. Wait.

[Sen. Virginia "Ginny" Lyons (Chair)]: So and here's how it will go. If we can accomplish things, you know, one day, then we can go back to nine on the next day. So we'll just see how it goes. I I thought by adding a little extra time, we'll have some break time.

[Sen. Martine Larocque Gulick (Vice Chair)]: No. Yeah. We'll do it.

[Sen. Virginia "Ginny" Lyons (Chair)]: 08:30 could be doable in practice. I