Vermont Legislature SmartTranscripts:

[Senator Virginia "Ginny" Lyons (Chair)]: We haven't made any changes to the bill. I brought up a number of discussion points yesterday with respect to numbers of procedures that are included in the bill and there wasn't, I don't think anyone else on the committee was interested in making changes at that time except for one. No. I think I it's just comfort level, and I think I feel more comfortable with the basic. Starting with the basic. But yeah. Yeah. A step. You let your steps approach. There was one that the that we had in testimony for the direct Direct. The ank the first correction for glaucoma. That one. Same. I mean, so we're at the end of the day, we're at the end of crossover. Yeah. So if there are suggestions for a change, I need to have them right now. For gensanity. Senator Gulick, do you have any suggestions for change in S-sixty four?

[Senator Martine Larocque Gulick (Vice Chair)]: Not at this time, nope, thank you.

[Emily Brown (Green Mountain Care Board)]: Okay.

[Senator Virginia "Ginny" Lyons (Chair)]: It won't be me, and it won't be senator Cummings most more likely that to put forward a motion, but I think it's probably time for a motion if that is what committee desires. I'll put forward a motion that we move forward with s 64. So you can say Only the right words. The right words.

[Committee Clerk (name not stated)]: Okay, so a motion.

[Jen Herbert (Office of Legislative Counsel)]: Motion is to pass S-sixty four or favorably. S-sixty four and then paste.

[Committee Clerk (name not stated)]: As mentioned. Okay. Senator Benson? Yes. Senator Cummings?

[Senator Ann Cummings (Member)]: No. Senator Gulick?

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

[Committee Clerk (name not stated)]: Senator Morley? Yes. Senator Lyons. No. Three two zero.

[Senator Virginia "Ginny" Lyons (Chair)]: Who wants to report it? We expect a full description of each I'm not lying to you. And so and I don't excuse myself from speaking on the floor. Ordinarily, you know, we don't do that to anybody as chair. I will speak to the building. Wonderful. I'm assuming they can proceed back. I'm gonna try to get the refund. Okay. We know, sir, that your lines came up from the ambulance to do a phonetic. Yeah. Yeah. And then

[Committee Clerk (name not stated)]: That is true.

[Senator Virginia "Ginny" Lyons (Chair)]: Well, I certainly hope that should the bill go forward, that it will accomplish the goals that we've heard it will accomplish, and that is to provide coverage in rural parts of the state and to ensure that we have adequate care for people need that need that service. Okay. I knew you should have briefed the book. Right. Yes. So let's move on to, Janet, which one is the easiest for you?

[Jen Herbert (Office of Legislative Counsel)]: So I don't think I've introduced myself on the record today. Jen Herbert, office of Ledge Site Town. I think the one with the fewest changes is S197.

[Senator Virginia "Ginny" Lyons (Chair)]: Well, then let's look at that. Literally, what I that's what I thought. Reading from yesterday. Yeah. Okay.

[Jen Herbert (Office of Legislative Counsel)]: Did I send you that one? We don't see it posted. Four ninety seven years ago. Yes. I have it. Okay. It's it's not posted. Sure.

[Senator Virginia "Ginny" Lyons (Chair)]: Then I can pull it

[Jen Herbert (Office of Legislative Counsel)]: up from my, you know, from my dad or.

[Senator Virginia "Ginny" Lyons (Chair)]: So it's just

[Jen Herbert (Office of Legislative Counsel)]: Minor change right after day.

[Senator Virginia "Ginny" Lyons (Chair)]: Patient.

[Committee Clerk (name not stated)]: Right.

[Jen Herbert (Office of Legislative Counsel)]: Right, so S197 is an act relating to establishing a primary care payment reform program, at least as introduced, and

[Senator Virginia "Ginny" Lyons (Chair)]: that name is proposed for change later in

[Jen Herbert (Office of Legislative Counsel)]: the bill. We walked through this yesterday. At that time, there was some language that the medical society had proposed in the exhibit that had not, I think the NHS folks had taken it back to consider, but hadn't responded, so I've incorporated it into this draft and it's there. We're happy with it, they think they can have the answer. We're happy with it. Great. So the one change in this version, I believe, is simply in section, there's now section seven, the report, AHS report on transitioning care to community settings, and there are specific entities named to be consulted with in preparing that report. There were a request that the care pass along to me from by state primary care association to be specifically named in that list, and

[Senator Virginia "Ginny" Lyons (Chair)]: so on. Yeah, I think they're pretty key, that they are a primary care provider in their state. Makes a little sense. That is it.

[Jen Herbert (Office of Legislative Counsel)]: That's the only change. Okay, then.

[Senator Virginia "Ginny" Lyons (Chair)]: Any questions for Jen on the, or anyone else on the draft that we have on this? Good. So it really is a primary care based on our Blueprint program, which has received a lot of attention outside of our state and continues to do that. And we've heard from our insurers and others their support for the work that we're doing. I'm very excited about this bill. I hope that you can support it. So I'd accept the motion unless there are other questions. I'll move approval S197 draft number 3.1, dated threetwelvetwenty six. Okay. Well, bill goes someplace else. Oh, well, does this bill go somewhere else? Oh,

[Joint Fiscal Office analyst (name not stated)]: I talked to the clerk.

[Senator Virginia "Ginny" Lyons (Chair)]: Okay. No, it's not. The secretary. Yeah. Sorry, secretary. So, okay. It's a secret only on YouTube. Guess. Bill has introduced, I

[Jen Herbert (Office of Legislative Counsel)]: would say he has introduced me, and think it might have had

[Joint Fiscal Office analyst (name not stated)]: I haven't looked over, I haven't looked over the last three years.

[Jen Herbert (Office of Legislative Counsel)]: Yeah, so latest version doesn't, but I think the bill was introduced May because it was establishing primary care funding and reform program,

[Senator Virginia "Ginny" Lyons (Chair)]: But we'll have to see if Secretary can see. So the motion is to vote favorably on draft 3.1 of

[Committee Clerk (name not stated)]: S-one 190

[Jen Herbert (Office of Legislative Counsel)]: it's a strike

[Senator Virginia "Ginny" Lyons (Chair)]: all

[Jen Herbert (Office of Legislative Counsel)]: the And it goes on to the, and it's recommended to the full set. Discussion.

[Senator Virginia "Ginny" Lyons (Chair)]: Good? We are good. Thank you. Okay. So, Clerks?

[Committee Clerk (name not stated)]: All right. Senator Benson? Yes. Senator Cummins? Yes. Senator Gulick?

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

[Committee Clerk (name not stated)]: Senator Morley? Yes. Senator Lyons? Yes. Five zero zero.

[Senator Virginia "Ginny" Lyons (Chair)]: We're a bee. Yeah. I'll inform him. And so, no one, I don't know. Secretary probably sent it somewhere because they had the word fund in it. Don't say anything again. F U N? F

[Jen Herbert (Office of Legislative Counsel)]: U N.

[Joint Fiscal Office analyst (name not stated)]: For the record, whole nine will adjourn this call. There are no appropriations, we're not creating any special funds, there are no fees. The only thing you have in there is change to Blue Creek payments. Although I wouldn't be surprised if it is set to appropriation, but I've talked with AHS, and there's no appropriation needed. So I wouldn't look over the bill and scoot it up, but I

[Senator Virginia "Ginny" Lyons (Chair)]: Uh-oh, sent out the stairs. Somebody phoned? Yeah. Uh-oh, this is

[Jen Herbert (Office of Legislative Counsel)]: a helpful book. Also don't have the one. It sounded bad.

[Senator Virginia "Ginny" Lyons (Chair)]: States are bad. We're just Anyway, sorry. I they're okay.

[Joint Fiscal Office analyst (name not stated)]: Yeah. And so I'm looking over this weekend to determine whether a fiscal note will even be needed or if it goes to the appropes, maybe I'll have to do a fiscal note to say the appropriation to you. I have to look over the bill.

[Senator Virginia "Ginny" Lyons (Chair)]: No problem. I understand exactly where we all are right now. Thank

[Jen Herbert (Office of Legislative Counsel)]: you. My expectation is there is no actual fiscal note, but that the use of the words payments and funds may have been sent to Traders of the appropriation.

[Senator Virginia "Ginny" Lyons (Chair)]: I'd love to Thank take you. That's a good bill, and I look forward to it going forward. Alright. Let's move on to one that I need. Okay? That also draft 3.1? I don't have the stairs, but it strikes. Oh, oh. Somebody's hurt? Yeah. But she's not getting care, so. She's not what? The police are there, but she has not requested over the place.

[Jen Herbert (Office of Legislative Counsel)]: S-one 190 is an act relating to the Green Mountain Parabolic Reference Based Pricing and the name changes again at the end to reflect the study.

[Senator Virginia "Ginny" Lyons (Chair)]: So, I'm trying to read you to myself, or I may change it, so I don't think there There is was a section that appeared to be redundant or not needed.

[Blue Cross Blue Shield of Vermont representative (name unclear)]: So,

[Jen Herbert (Office of Legislative Counsel)]: I think there was, are you talking about what I was just informed about? Yes, that one. Right, so when we get there I can flag it. I don't think it's redundant, but I think if there's a suggestion that it come out, Okay,

[Senator Virginia "Ginny" Lyons (Chair)]: we can decide whether to take it out now at the end of the day or whether they can, we can let that Right, I

[Jen Herbert (Office of Legislative Counsel)]: mean, sorry. From a drafting standpoint, very easy, so if you want to

[Senator Virginia "Ginny" Lyons (Chair)]: take it out. Oh, okay. It's just 3.1.

[Jen Herbert (Office of Legislative Counsel)]: This is 3.1. We're in reference based pricing is where we start, and if you remember a conversation yesterday, was discussion between the Green Mountain Care Board and the hospitals about how the hospitals present information around their current prices and the benchmarking to Medicare rates. So based on the results of that conversation, I've done a couple of things. First, I've just moved, so if you remember that issue came up in the context of both the provider contracts, where the hospitals and health insurers are supposed to start expressing rates as a percentage of Medicare, and then also down here, when making public the charges for items and services also required by federal law, the hospital would provide that information as a percentage of Medicare rate. So I've taken it out of its standalone subdivision e here, but just moved it up here and made this one C one and two. So I have no substantive change to the part about making public the charges showing as percentage Medicare, just moving it because I've made these two provisions subdivisions C one and two and Ann and a three that says for purposes of subdivisions one and two, that's why it made sense to put them together, a hospital may express rates as a percentage of your Medicare based on the actual reimbursement amounts the hospital receives from Medicare for items provided services delivered to Medicare beneficiaries until such time as the Green Mountain Care Board adopts a rule establishing the methodology for determining Medicare rates for use as a benchmark in establishing reference based prices under this larger reference based pricing subsection. So basically, an opioles can use the info they know based on what money actually come into them from Medicare until the board has established the across the board Medicare benchmarking that the hospitals then would be able to use. And I unlike some provisions where I talk about the applicability, so certain caps that we put in would be in place until the Green Medicare Board is actually applying their new rule. This one I based on adoption of the rule because it's a methodology. Once the whole rule making process has been completed and the rule is actually adopted, that should be, seems like it should be sufficient notice to

[Senator Virginia "Ginny" Lyons (Chair)]: the hospital so they're ready to use the new method. I also assume hospitals have some voice in the discussion about the rules.

[Jen Herbert (Office of Legislative Counsel)]: Right, there's the public process for rule making. Exactly. So hopefully this works for people at least for now we can keep it. Now,

[Senator Virginia "Ginny" Lyons (Chair)]: I see it. With that it comes back. Okay. Can

[Jen Herbert (Office of Legislative Counsel)]: I ask, could you define machine readable files? I cannot.

[Senator Virginia "Ginny" Lyons (Chair)]: Somebody's gonna ask that question at some point. Looking at Devin. When we did Sure,

[Devon Green (Vermont Association of Hospitals and Health Systems)]: Devin Green from Bob, it's basically, like it can just be an Excel spreadsheet, right? And you put it into an under

[Senator Virginia "Ginny" Lyons (Chair)]: share file sort of scenario.

[Devon Green (Vermont Association of Hospitals and Health Systems)]: Think And that's probably searchable. And I could print it out.

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

[Jen Herbert (Office of Legislative Counsel)]: would have to go in, but I am assuming that that language is used in this federal Yes. And so that's why it's just using that as kind of a tie in. Okay. Alright. And then, so as I said, I just moved the language in subdivision in capital E here up to become part of subdivision. Just a language change here for clarity. In the section two language on the reimbursement cap for the 250% of the Medicare adjusted base rate for qualified health benefit plans. It was pointed out to me that it could be confusing to say an individual enrolled in a qualified health benefit plan because that could suggest it was only the individual market. I think arguably it's hard to have us, you know, you don't deliver services to small businesses enrolled in a plan, but I think it's clear and maybe fair to say enrollee and that is a term that gets used in the chapter. Just change individual enrolled to enrollee.

[Devon Green (Vermont Association of Hospitals and Health Systems)]: I have a raised that read from us on one thing in here is the Medicare definition. We would like to see it match the above Medicare definition. Is not? Not for section two.

[Jen Herbert (Office of Legislative Counsel)]: Oh, you wanna see it as far as the actual amounts piece?

[Devon Green (Vermont Association of Hospitals and Health Systems)]: No. Because section two has the old Medicare definition as part of the 250%. You go I know. I went okay. Stop it. Yeah. Right there, A1.

[Senator Virginia "Ginny" Lyons (Chair)]: Medicare adjusted base rate? Right.

[Devon Green (Vermont Association of Hospitals and Health Systems)]: That's the old definition.

[Jen Herbert (Office of Legislative Counsel)]: Yes, but I wasn't aware that there was talk about changing, you mean to change it to them that's possible, was actually received in for Medicare. So I wasn't aware that was part of the conversation yesterday. I thought it was specific to the information that had to be provided included in the provider contracts and the public lists. I'm happy to change it if that's the direction the committee wants to go, but

[Emily Brown (Green Mountain Care Board)]: I wasn't aware that was.

[Senator Virginia "Ginny" Lyons (Chair)]: I didn't remember her talking about charging Right, you know. But does this leave us with two different definitions? No, there's no definition.

[Jen Herbert (Office of Legislative Counsel)]: The language here doesn't use the Medicare does a base rate term or define it, so it just says, show them as Medicare and

[Senator Virginia "Ginny" Lyons (Chair)]: So if they show them as, they talk about loaded rates for different hospitals, but they didn't find that out. What is the concern that you have?

[Devon Green (Vermont Association of Hospitals and Health Systems)]: The concern is operationalizing it. Again, like our critical access hospitals can't convert to the PPS to get to this in this timeframe. Like, we will be unable to do that. It's the same issue as the reported case. Okay.

[Emily Brown (Green Mountain Care Board)]: I'm really proud the work. I also, because this is an insurer based on the insurer's plan, right, would be in, I think it would be interesting to hear on the insurer side if they would be able to do it based on this definition. I hear Devon's concern, but because this is a plan based change and not asking the hospitals to make the cancellation, again, I understand there will have to be a way to check it with the hospitals, but I'm also wondering if because this is the QHP plans and not asking hospitals to do it, if there is a way the insurers can do

[Senator Virginia "Ginny" Lyons (Chair)]: it that doesn't put the burden on hospitals. What's the answer?

[Blue Cross Blue Shield of Vermont representative (name unclear)]: Bernie harness, Blue Cross and Blue Shield, yes.

[Senator Virginia "Ginny" Lyons (Chair)]: Yeah, so the insurers will have some responsibility for helping out. Yeah. Okay, so we don't have to go into this. You will have a higher court. Okay.

[Jen Herbert (Office of Legislative Counsel)]: Section three.

[Senator Virginia "Ginny" Lyons (Chair)]: Not changes since

[Jen Herbert (Office of Legislative Counsel)]: yesterday. Here's a new section based on interest in understanding the impact on VIHI and state employee plans. This would direct the Green Mountain Care Board in consultation with Departments of Financial Regulation and Human Resources and BIHI to analyze commercial health insurance plans for inpatient and outpatient hospital items provided and services delivered to active and retired members and their dependents enrolled in the state employee's health benefit plan and in the health plans offered to teachers and other school employees through BIHI to determine the opportunities available through the use of reference based pricing and the projected impact on Vermont's hospitals. It requires BIHI Department of Human Resources and the administrator of the state employee's health benefit plan to provide the board access to the claims data necessary to perform the analysis. By 01/15/2027, the board would provide to this committee, in house healthcare, the board's findings and any recommendations with respect to scope, timing, financial impacts, and other considerations in implementing reference based pricing for items provided and services delivered to enrollees in the state employees plan and the health benefit plans offered by The United States. That sound like what people had in mind? Yeah. So the other

[Senator Virginia "Ginny" Lyons (Chair)]: Got it. Okay, it's all there. Sounds good. Great. Yep.

[Jen Herbert (Office of Legislative Counsel)]: And then the only other change I have from the draft we looked at yesterday, other than changing section numbers again, is reducing the appropriation for the study committee. Think after further discussions with the chair from $200,000 to $50,000 Enjoying fiscal. Because

[Senator Virginia "Ginny" Lyons (Chair)]: of the short term nature of Alright, yeah.

[Jen Herbert (Office of Legislative Counsel)]: And that is it. Oh, but I did forget to mention the piece that was Right, supposed to that come one. So as I understand it, we're back in section two, the cap on reimbursements for that two fifty percent of Medicare for qualified health plans, and my understanding that the board and the hospitals would like to remove the language in subsection E that says the purpose of this section is to reduce costs in a hospital, which will not increase the amounts charged to other commercial plans or private payers in an effort to offset reduced revenue, unless the board authorizes the decrease.

[Senator Virginia "Ginny" Lyons (Chair)]: The reason that you're suggesting removing this?

[Emily Brown (Green Mountain Care Board)]: Yep, Emily Brown, Green Mountain Care Board. The reason we're suggesting removing this is because we have budget guidance that effectively already does this. Currently our budget guidance is a negative 1% for commercial rate and how we've historically done it is as long as the hospitals are within that negative 1%, then they're satisfying our budget guidance. We thought this was duplicative because it added an extra requirement on top of what our hospital budget guidance is already asking the hospitals to do. So underneath that negative 1%, in addition to the 250% of the reference based price for QHP, the hospitals are going to need to have to meet that negative 1%. And so, we felt like this was putting too much of a burden on hospitals to be able to meet that negative one. It could effectively put them far below what our budget guidance would have been requiring hospitals to target.

[Senator Virginia "Ginny" Lyons (Chair)]: So your budget guidance changes over time. This really describes the purpose of this section. So within the context of this bill what we're trying to do overall is to reduce health care costs. Correct. So it's not so much that we're not directing anybody to do anything here, we're just saying that the purpose of what we're doing is to make sure that health care costs are held at a lower, lower, and so I don't know why we take it out. When I hear what you're saying because it's budget guidance, It's just an overarching kind of purpose.

[Jen Herbert (Office of Legislative Counsel)]: So if I can clarify a little bit, think maybe and then the parties. Think, Madam Chair is correct as far as the first sentence. The purpose of the section is to reduce healthcare costs. I think it's the rest of it that is creating concern because it is kind of tying the hands of the hospital with a part of how they would be setting their budgets. And so the board is saying, if they are moving things around within the parameters and the guidance. Perfect. Is that correct? Understood. So take it all out. So I don't think there's a reason to leave the first sentence or something.

[Senator Virginia "Ginny" Lyons (Chair)]: Make it all up. Mean, as long as everybody else on the table will agree to me. Not too much. It's just a subsection. And there's only one answer. And I need to make a clean copy.

[Jen Herbert (Office of Legislative Counsel)]: Alright. So I'm just gonna if it's okay with community, I'm just gonna take it out and not show you a new version that has that with lines through it.

[Senator Virginia "Ginny" Lyons (Chair)]: No. That's fine. I'll just make that needle. Still be as a stripe or it will be something else besides 3.1. I'm just making three point It's not that big a Got it. Alright.

[Jen Herbert (Office of Legislative Counsel)]: Do you wanna do something else? No.

[Committee Clerk (name not stated)]: 3.2 is what you said. Yeah.

[Senator Virginia "Ginny" Lyons (Chair)]: Is there anything else in here that's I understand the initial comment about the Medicare definition. Hospitals and companies, I mean, insurance companies have their help with that.

[Blue Cross Blue Shield of Vermont representative (name unclear)]: Should, madam chair, the Harris Blue Cross Blue Shield of Vermont. There's a chance with the timeline that the VA's recommended, the insurers could support this timeline, but it may cost money that could lead to increased premium. So I would just bring that to the committee then.

[Senator Virginia "Ginny" Lyons (Chair)]: So this is a good time to bring it to the committee since we're gonna vote, but what we'll do is as the bill moves forward that will be a conversation. Understood. I know things always pop up at the last minute. I'm not complaining about that. I understand how that works for everybody. Some things come for us. And it cost time, money. Yeah. It's paperwork, which isn't on paper anymore. It's not my reading. Alright. So, Jen, we've struck that section. We've struck that subsection. Yep. Subsection b. Yep. Subsection b. And now we have a bill. We have a strike off bill. Alright. Discussion on this bill? Thanks. Okay, so I would entertain a motion on S-one 190 draft 3.2. Send to the full setting? Send it to the full setting. Well, if it gets

[Jen Herbert (Office of Legislative Counsel)]: there, it's gonna have

[Senator Virginia "Ginny" Lyons (Chair)]: to go to the Yep. Yep. It's gonna go to appropriations. Okay. Exactly. You can ask about it. You're gonna go this week. We've got a motion on the table. Okay. Mr. Clerk. Clerk.

[Committee Clerk (name not stated)]: Benson. Yes. Senator Cummings. Yes. Senator Gulick.

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

[Senator John Morley III (Member)]: Senator Morley, BS. Hopefully it'll change later on. Senator Lyons?

[Senator Virginia "Ginny" Lyons (Chair)]: Yes. Now I'll take this one more so.

[Committee Clerk (name not stated)]: 500.

[Senator Virginia "Ginny" Lyons (Chair)]: Alright, so that's great. Thank you for that. So, Jen, let's, we've got two other bills we wanted to look at. One is 142 and the other 154. Yes. You got it.

[Jen Herbert (Office of Legislative Counsel)]: Just a second. I'm sending I'm the ones you have finished to the list so you

[Senator Virginia "Ginny" Lyons (Chair)]: can post the final versions. Which one? Other one? 142. Is that the one? Is that could be Either one is fine. Okay.

[Committee Clerk (name not stated)]: This one

[Senator Virginia "Ginny" Lyons (Chair)]: is the internationally trained physician and the Department of Health has asked for some time to evaluate what goes on in other states and what they might do through the Board of Medical Practice, how they might facilitate this. So if we can have any blank, I did send some language in from them, that suggestion. So I thought, we had talked about this bill, just looking at what they say and decide, yes or no.

[Jen Herbert (Office of Legislative Counsel)]: Yes, so here's what I have done based on your conversation. S-one 142 and hyperlinked pathway for licensure for internationally trained physicians and medical graduates. So, it keeps the whole pathway process set up in the bill as introduced. So, it's not a strike all. It just strikes out the effective date section, puts in a new section and then some different effective dates. So section four, I call it Alternative Pathway Licensure for Internationally Trained Physicians and Medical Graduates with a report. This would require that by January 15, the Department of Health, in collaboration with the Board of Medical Practice, would provide to this committee and the government operations committees and your host counterparts a report detailing a pathway to licensure for internationally trained physicians and medical graduates as an alternative to the pathway established in section two of this Act. The report would include the following information. A summary of other states' processes for licensing internationally trained physicians and medical graduates to practice medicine, and available data on the outcomes of the processes and related programs. A description of the external resources needed to evaluate the education experience and examinations of internationally trained physicians and medical graduates, and the availability of these resources, a proposal for licensing internationally trained physicians and medical graduates to practice medicine in Vermont, including potential qualifications and supervision requirements for licensure, a summary of any additional resources and statutory authority needed, and a plan and timeline for implementing the licensing program, and any additional information the department deems relevant for a robust consideration of the issues related to licensing internationally trained physicians and medical graduates to practice in Vermont. In preparing the report, the department would be required to consult with other states that have implemented licensing programs for internationally trained physicians and medical graduates, the Vermont Chapter of the NAACP, third party credentialing services, the Vermont Medical Society, around Association of Hospitals and Health Systems, and other advocacy organizations, researchers, and other entities whose expertise is relevant to developing a report. Section five, the new effective dates, would move out the effective date for the tax rate licensure established in S-one hundred forty two as introduced to 2028. It would have the rule making take effect, so the authorization for rule making take effect 07/01/2027, and then with that report coming back to you in January 2027. So you can decide if you wanna change what would otherwise be set in motion beginning in July 2027 with the rulemaking, and begin on 07/01/2028, or if you want to do any of the changes and allow that to go into effect.

[Senator Virginia "Ginny" Lyons (Chair)]: The section I think that would separate the both sides of the fence here. Right. Wanna take it back, John. Yeah, she's good.

[Jen Herbert (Office of Legislative Counsel)]: That's it. Again, it doesn't undo what is in the bill, and it doesn't make any changes to what is in the bill other than delaying the effective date and the maintenance report from the department filed on alternatives.

[Senator Virginia "Ginny" Lyons (Chair)]: And we were gonna change the date anyway. Yes. Yeah, so. Good, can't remember

[Committee Clerk (name not stated)]: talking with the Department of Health on this.

[Jen Herbert (Office of Legislative Counsel)]: You talked to the Board of Medical Practice, the Board

[Senator Virginia "Ginny" Lyons (Chair)]: of Medical Practice, which within, and so the suggestion that came from the Department of Health was rather than put the Board of Medical Practice in this, put Department of Health, and they have been working on this since their second go around with test findings.

[Jen Herbert (Office of Legislative Counsel)]: And I think to be clear, think the Department of Health, and they can speak for themselves, but would prefer you just did the report and you didn't do the rest. Right. You didn't set something in motion to be unless

[Senator Virginia "Ginny" Lyons (Chair)]: you wanna do it. So this

[Jen Herbert (Office of Legislative Counsel)]: is the committee. I don't want to speak representative throughout this. This is giving the board or that department the report, the study and the report they asked to do, but it is also setting something else in motion, unless you, later, unless you come back as much as you when you hear the report, and Change it. Make changes of things. Yeah. Let's think about that. I told you that each is fine.

[Senator Virginia "Ginny" Lyons (Chair)]: Right, so the initial testimony we've heard from the Board of Medical Practice was, Don't do anything, we're not participating. Then we heard, Don't do anything, we'll think about it. And then we have a recommendation from the department, which I think is very beneficial to this, and looking at what other states are doing, because we do ask that question as well. What's going on in other states, and look at Tennessee, and look at, we've heard from other Well, we've got a lot of this. It's an impassioned, recognized surgeon. I know. We do have that. And that was we're trying to find a path to that person. Yeah.

[Committee Clerk (name not stated)]: We're talking about New York State chat up.

[Senator Virginia "Ginny" Lyons (Chair)]: Yeah. New York had the bill.

[Jen Herbert (Office of Legislative Counsel)]: It doesn't make any changes to the bill as introduced, so there may, you know, there may be things in that house that people wanna tweak. I think they will. On that, and see us.

[Senator Virginia "Ginny" Lyons (Chair)]: Yes, I think could be that

[Jen Herbert (Office of Legislative Counsel)]: Timing or alternatives to the timing for people who have been

[Senator Virginia "Ginny" Lyons (Chair)]: in Vermont sort of waiting for this. Yes, and then the other piece of it is having the bill go through as it is unless the legislature acts. It might be that the legislature must act again in order for it to continue. I you know, so there are a lot of options in there. I think we're at the February. I'm sorry. March thirteenth. Friday. Okay. All right. The board discussion, this is

[Senator Martine Larocque Gulick (Vice Chair)]: My only observation is that we have a lot of really important reports coming to us January 2027 And we're gonna have to, you know, act on all of those because a lot of the really important work that we've done won't go forward unless we, take those reports and act. So hopefully we'll all be back in January, I don't know.

[Senator Virginia "Ginny" Lyons (Chair)]: We'll find out. All right, Jessica, did you want to add a comment?

[Jen Herbert (Office of Legislative Counsel)]: Sure. Jessica Chittenden, Department of Health. And thank you again for your consideration of the Department of Health's work suggestion. And looking into this, a lot of states have passed this legislation, but they're still in the very early stages of implementing it. And the department and the board do have some significant concerns about the amount of resources and the expertise it's going to take to implement this.

[Jessica Chittenden (Vermont Department of Health)]: So, we want to really understand and leverage everything that is happening elsewhere. And there's also a bunch of third party expert organizations that are working to help facilitate these processes like across The US. So, So, want to just make sure that when we do this, we leverage everything that we can. We do it right with the most efficient pathway that we can for both the department and folks seeking licensure in The States. So just ask for that additional time to be able to figure that out.

[Senator Virginia "Ginny" Lyons (Chair)]: Thank you. So I know that it's been difficult. I know there's a lot of work that's been going on with the cohort folks in the southern part of the state on this and trying to reach out to Board of Medical Practice, but it's different from actually coming in here and putting together some recommendations. Appreciate the time the department has taken on this. If we don't do it correctly, little bad will happen that will stop probably programs nationally. Yeah. We're talking about people's lives on both sides. On both sides. Okay. So

[Committee Clerk (name not stated)]: what version are we at? 1.1, I think.

[Jen Herbert (Office of Legislative Counsel)]: Yes. But this not a strike all amendment, so it would be This is an

[Senator Virginia "Ginny" Lyons (Chair)]: amendment to amend the bill after those Got 1.1. That's 1.2. Okay. Any other discussion?

[Senator Martine Larocque Gulick (Vice Chair)]: Will this go to appropriations?

[Senator Virginia "Ginny" Lyons (Chair)]: I don't think it will. I don't

[Jen Herbert (Office of Legislative Counsel)]: think so. There's no, are no, I don't think it'll go to either money community. No money yet. There have been suggestions to consider fees from that website, but it's not in here, so. Gotcha. Maybe the ability underlie.

[Senator Virginia "Ginny" Lyons (Chair)]: Okay. Well, let's I accept a motion on the amendment.

[Senator Martine Larocque Gulick (Vice Chair)]: I'll make a motion to move the amended S142, which is draft 3.1, wait.

[Senator Virginia "Ginny" Lyons (Chair)]: No, no, no, no. So we're just moving an amendment to draft, This is draft 1.1 of an amendment to s one forty two. So we'll do that first, and then the bill is submitted.

[Senator Martine Larocque Gulick (Vice Chair)]: Alright. I moved to you guys do it. Go ahead.

[Senator Virginia "Ginny" Lyons (Chair)]: No, you go ahead. You're doing great.

[Senator Martine Larocque Gulick (Vice Chair)]: I move to amend the bill. S 142.

[Senator Virginia "Ginny" Lyons (Chair)]: All right. Is it 1.2 or one point one?

[Jen Herbert (Office of Legislative Counsel)]: One hundred forty two. Oh, 142.

[Senator Virginia "Ginny" Lyons (Chair)]: Yeah. Okay. Good. Alright.

[Jen Herbert (Office of Legislative Counsel)]: Discussion.

[Senator Virginia "Ginny" Lyons (Chair)]: On the amendment. Okay. Mister Clerk.

[Committee Clerk (name not stated)]: Okay. So, this is for the amendment. So, Senator Benson. Yes.

[Senator Virginia "Ginny" Lyons (Chair)]: I

[Committee Clerk (name not stated)]: think I'm going to do this under the amendment plus the underlying bill. We'll just divide the sections here.

[Senator Virginia "Ginny" Lyons (Chair)]: Yeah, you can do that. Okay.

[Committee Clerk (name not stated)]: Senator Cummings? Yes. Senator Gulick? Yes. Yes. Senator Morley? Yes. Senator Lyons? Yes.

[Senator Virginia "Ginny" Lyons (Chair)]: Okay, now I need a motion to move the bill favorably as amended to the full Senate.

[Senator Martine Larocque Gulick (Vice Chair)]: I make a motion to move S-one 142 draft 1.1 amended version to the full Senate.

[Senator Virginia "Ginny" Lyons (Chair)]: Okay. Any other discussion? I know the House will be working on this. This isn't the end of it, but I think it's a start. Okay,

[Senator John Benson (Member)]: Senator Benson? Yes. Senator Cummings? Yes. Senator Gulick?

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

[Senator John Morley III (Member)]: Senator Morley, yes. Senator Lyons? Yes. Five zero zero.

[Senator Virginia "Ginny" Lyons (Chair)]: So I'm looking at the screen, Senator Gulick. Is this someone that you would like to report?

[Senator Martine Larocque Gulick (Vice Chair)]: Sure, I'd be happy to. I'll be reporting a lot next week, I think, because I

[Senator Virginia "Ginny" Lyons (Chair)]: It's up to you because I think we could find someone else around the table who can report it.

[Senator Martine Larocque Gulick (Vice Chair)]: If someone else has a burning desire, I will acquiesce. Otherwise, I'm happy to do it.

[Senator Virginia "Ginny" Lyons (Chair)]: You wanna do it?

[Senator John Benson (Member)]: I can do it.

[Senator Virginia "Ginny" Lyons (Chair)]: All right. Senator Benson has volunteered. On? That's right.

[Senator John Benson (Member)]: My arm's twisted.

[Senator Virginia "Ginny" Lyons (Chair)]: No, that's good. Understood. Everybody's very busy, so it's important to spread the wealth. Alright. We are down to 154. Alright. Ten minutes ahead of

[Committee Clerk (name not stated)]: our 154.

[Senator Virginia "Ginny" Lyons (Chair)]: 54. Where did you depart? 154 is the biomarker bill. Now, yes, you wanna discuss? Why don't you discuss first? Okay. So, I'll try to do this first. One of the concerns about the bill is that if we don't have a fee in it or some other financial something, we can't get it to finance where it really needs to be, it needed to get to finance. Then with further conversation with joint fiscal and Legion Council, it was clear that if we had some kind of assessment evaluation. What's the name of the study I'm thinking about? What's the study? What what kind of analysis? What's the analysis? Analysis? DFR analysis. Oh, actuarial? Oh, thank you. Oh my gosh. I've I've forget that one. Oh, that one. Why do I forget? Alright. So they insurance today. An actuarial analysis that actually in talking with the secretary, it might go to appropriations with that. But it would give time for assessment by finance should you so desire to have to look at it?

[Jen Herbert (Office of Legislative Counsel)]: So I did put a fee in it. You did, yes. Oh, bless your heart. But I think it's a fee for the purposes of getting to finance. Yes. So I don't I I'm concerned that there will be alarm about the fee.

[Senator Virginia "Ginny" Lyons (Chair)]: Yes. The the issue we're trying to work through is this to make a note at whether or not it's a good thing to Good idea. Medically. Yeah. Finance looks at the impact on health insurance rates. We have, over the years, added things to our exchange plans that were really good things. And individually, every one of them was a small cost. But you put enough grains of sand in, and eventually, you have a beach. And I think the thing that caught my attention is that our Bronx plan or solar plan cost twice as much as it does in Maine. And Maine has a very similar demographic, so we can't say we're gonna discuss what all holds. And if we add this and it is not part of the federally mandated services that we cover, then the state of Vermont has to cover the full cost. And we've heard that individually each one of these tests cost anywhere from, we've heard, $2.50 to $46, but we haven't really had or I've looked at the

[Committee Clerk (name not stated)]: I thought it was

[Senator Virginia "Ginny" Lyons (Chair)]: They haven't looked at the checked on the 2,500 report. Somebody yesterday said

[Committee Clerk (name not stated)]: That was 2,500. Okay.

[Senator Virginia "Ginny" Lyons (Chair)]: But Yeah. But was just But we don't we haven't had time to analyze. How many tests do you get? How many and what impact might that have? We've lost 2,000 people off the exchange so far this year, and they're all pretty great. It's it's good that everybody should have access, but if you can't afford the insurance, then you don't have any access. So we're trying to get it so it gets an analysis so that when, and it's probably when we do it, we know what we're buying it.

[Committee Clerk (name not stated)]: So you're looking for what next year?

[Jen Herbert (Office of Legislative Counsel)]: So we'll look at the language.

[Senator Virginia "Ginny" Lyons (Chair)]: What we're looking for is language that will carry the bill to finance so that they can look at the bill and answer some of the questions that finance Okay. Finance will probably, given our time frame,

[Jen Herbert (Office of Legislative Counsel)]: ask for an actuarial Well, that's what's in here. So that's what I wanna That is here. That's what I

[Senator Virginia "Ginny" Lyons (Chair)]: wanna Then it will go to a probes so DFR can say what that will cost. Okay, let's look at the bill and what's in here, and that's now I think this is helpful. Chair of Finance has given us the overview from that perspective. We know that we feel this is valuable for patients who need ongoing testing and care for cancer or Alzheimer's or whatever other biomarkers are out there. Right. How do we do how do we know? Correct. So,

[Jen Herbert (Office of Legislative Counsel)]: this is a strike all amendment, and it really just directs analysis and reporting. So, I started out with the same definitions as in the bill as introduced, because I think they're important to sort of inform what then we're asking to be cost out. The only one I took out was health insurance plan, because we don't really need it for purposes of the analysis. So I directed the Department of Financial Regulation and Agency of Human Services to analyze the costs associated with requiring health insurance coverage and Medicaid coverage respectively, for biomarker testing for the purpose of, now this is exactly what was in the bill language, purposes of diagnosis, treatment, appropriate management, and ongoing monitoring of the patient's disease or condition when the test is supported by medical and scientific evidence, including, and then again, all of the same provisions that's in the bill as you've introduced. I have the report again coming in by January 15, and DFR would report to this committee and the finance committee, because it's insurance, and House Healthcare, on the estimated amount that health insurance premiums would increase if Vermont were to enact legislation requiring health insurance coverage of biomarker testing as set forth in subsection B, including the amounts of the state's financial obligations for defraisal of premium increases for qualified health benefit plans under federal law, and for premium increases in the state employee's health benefit plan. I've also said by 01/15/2027, the Agency of Human Services will report to this committee and House Healthcare, not finance because it's Medicaid, regarding the approvals that would be needed from CMS in order for Vermont Medicaid to cover biomarker testing as set forth in subsection B, and the costs to the Medicaid program if Vermont were to enact legislation requiring that coverage. Then, solely for purposes of having a fee that gets it sent to the finance committee, So if you don't feel like it needs to go to the finance committee officially, we can take this out, but I believe my instructions were to put in a fee. This is what I came up with overnight. This would be a $5 per person, per month fee from health insurers offering qualified health plans to the Department of Financial Regulation based on each enrollee in their plans. I can see why it's a lightning rod. Right, so that's why I want them to be, I mean, anything you put in here, if you think it needs to you can schedule your appropriations and that time will give you what you need,

[Senator Virginia "Ginny" Lyons (Chair)]: then we can take this fee right back out. I can't see us do anything more than what's already in. Okay. So having the actuarial analysis by DFR is sufficient, and if it goes to appropriations, that would be helpful. It may go. I It's my understanding what we've looked senator Brock and I tried to have this done for doing away with prior approvals. Oh, right. And I thought at that time they do have an actuary on Yes, they do have

[Jen Herbert (Office of Legislative Counsel)]: a contract with, I think, more than one actuary. Yeah, they do.

[Senator Virginia "Ginny" Lyons (Chair)]: So, but what it would cost, I don't. Yeah. Yeah. So it will go to appropriations.

[Jen Herbert (Office of Legislative Counsel)]: So would you like me to take out then this

[Senator Virginia "Ginny" Lyons (Chair)]: What do you And I'm sure the insurance of my take it out.

[Jen Herbert (Office of Legislative Counsel)]: I up fee.

[Senator Virginia "Ginny" Lyons (Chair)]: Yeah. I remember per month.

[Committee Clerk (name not stated)]: Yeah. No. I'm I'm gonna go with the chair of finance.

[Senator Virginia "Ginny" Lyons (Chair)]: They'll move it forward. It's gonna go in the house.

[Joint Fiscal Office analyst (name not stated)]: But let's

[Senator Virginia "Ginny" Lyons (Chair)]: get I think I turn to

[Joint Fiscal Office analyst (name not stated)]: For the record, all I will do my physical office. If you're want to make sure that it goes to appropriations, you can appropriate $1

[Senator Virginia "Ginny" Lyons (Chair)]: Don't take $1 But you

[Joint Fiscal Office analyst (name not stated)]: can appropriate like $20,000 to DFR or something like that to ensure that it goes to appropriations. You probably should do that. But like some amount for the actuarial Although,

[Senator Virginia "Ginny" Lyons (Chair)]: in talking with the secretary, he said, well, if you put an actuarial analysis in for DFR, it'll automatically go to appropriations. Right. I don't think you need to put any money on Right. Your but so

[Jen Herbert (Office of Legislative Counsel)]: So may I delete the I

[Joint Fiscal Office analyst (name not stated)]: guess the question was, are you trying to make sure it goes to appropriations or are you not prepared?

[Jen Herbert (Office of Legislative Counsel)]: Sounds like it will. I think it's very, it's not expecting it and it

[Senator Virginia "Ginny" Lyons (Chair)]: will The secretary says it will.

[Joint Fiscal Office analyst (name not stated)]: Yeah. And it's just a study.

[Jen Herbert (Office of Legislative Counsel)]: Yes. Yes, study. Right. So, may I think of this be? Yes.

[Committee Clerk (name not stated)]: Sorry, you were you thought about it all, like, what?

[Jen Herbert (Office of Legislative Counsel)]: It's okay. It just

[Senator Virginia "Ginny" Lyons (Chair)]: I feel uncomfortable to have a okay. Great.

[Jen Herbert (Office of Legislative Counsel)]: Then this will be we'll make it 2.1, and it will just be the study and,

[Senator Virginia "Ginny" Lyons (Chair)]: whoops, last night. It's it's really a medically just it would be it would be great if it can save health care dollars. It'll be today. Good. Almost sent me twelve hours after. Okay. So I'm going to this third document up on the screen.

[Jen Herbert (Office of Legislative Counsel)]: So this is now I said, 2.1,

[Senator Virginia "Ginny" Lyons (Chair)]: I did that change.

[Jen Herbert (Office of Legislative Counsel)]: Is now 2.1. It is still the same study we just looked at, studies and reports,

[Senator Virginia "Ginny" Lyons (Chair)]: and now just the FHFA. So this is a vote to amend.

[Jen Herbert (Office of Legislative Counsel)]: Yeah. Yeah. It's a start.

[Senator Virginia "Ginny" Lyons (Chair)]: Yeah. It's a start. So then I can just move move to approve.

[Blue Cross Blue Shield of Vermont representative (name unclear)]: Right.

[Senator Virginia "Ginny" Lyons (Chair)]: S one fifty four, tuition point one.

[Committee Clerk (name not stated)]: I made a motion to approve.

[Senator Virginia "Ginny" Lyons (Chair)]: Thank you. 2.1. Last full email thing. Everybody is contacting about

[Jen Herbert (Office of Legislative Counsel)]: They probably wanna do a

[Senator Virginia "Ginny" Lyons (Chair)]: last meet. It was interesting. Yeah. Thank you, Senator, for that motion. Discussion of a motion. Okay. Okay. Senator Clerk.

[Senator John Benson (Member)]: Senator Benson. Yes. Senator Cummings. Senator Gulick?

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

[Senator John Morley III (Member)]: Senator Morley? Yes. Senator Lyons?

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

[Committee Clerk (name not stated)]: Five zero zero.

[Senator Virginia "Ginny" Lyons (Chair)]: Probably. And Senator Cummings, this will be your bill? Yeah. Good. Yeah. And that gives out. Yes. And, you know, as it goes through everything, can always your committee can always take a look at it for us. Yep. I I think it goes this way. Yeah. It's moving in. Yeah. But keep it alive. This is the moment in the house. Still It comes over the. Yeah. Yeah.

[Jen Herbert (Office of Legislative Counsel)]: That's and she won't

[Blue Cross Blue Shield of Vermont representative (name unclear)]: be Not that person.

[Senator Virginia "Ginny" Lyons (Chair)]: And next, I'll just walk forward. You know? So it's and it was okay. Today. Right. Christ. Okay. Agree to have. Sorry. Was that four bills or? Four. Five bills. Five. But you know that we've been working pretty consistently. We do have another bill up there, S194. I'm gonna suggest that S194 is, I've been in contact, it's about the payment reform, conflict free case management and payment reform that we worked on during the budget adjustment. And there's a lot going on outside with the agency human services and our designated agencies. I have some language for an analysis of how the DAs, what the DAs do and the rest. I'm thinking I might bring some language in here for us to look at and suggest to go into the big bill, into the budget, But we don't have time to evaluate that right now. People that we hear, yes. Amy Johnson, my care partners, I think if we hold that one off, we can look at it together, we can make a decision to send a recommendation to the Appropriations Committee for inclusion or we may find another bill that it fits into that comes to us from that house. We really don't have the luxury of time to look at that bill.

[Committee Clerk (name not stated)]: I was just wondering, this not a house version that's gonna be coming over?

[Senator Virginia "Ginny" Lyons (Chair)]: No, probably not. There might be something we could put it into because the agency, I remember Lindsay was here the other day, very supportive and the DA was supportive. Anything else? Are going to take a break and go off live and come back at at five minute