Vermont Legislature SmartTranscripts:

[Sen. Virginia "Ginny" Lyons (Chair)]: All right, so this is Senate Health and Welfare. We're back. Then we have, I'm bringing a proposal to the committee to look at and I'm asking the committee to consider endorsing it rather than the amendment that is currently in the calendar. And we can, if you want to sign on, and if not, no, then we'll go from there.

[John Benson, Office of Legislative Counsel]: Let's do our work. Good morning, John Benson, the Office of Birthday to Counsel. I want to get this new draft form of the amendment that you have looked out for. Because only Senator Lyons had talked to me about it, I didn't put anybody else's name on it. They were just gonna all decide. So, you were all on the prior iteration, so far, to Senator Lyons on this one. And so, if you maybe recall from the last version of the amendment that we looked at, first, just context, this is S-one 190, this is the Green Mountain Care Board reference based pricing, and as introduced, hospital outsourcing clinical care. In the version that we had looked at last week, that people had signed onto, we were looking at changing the cap on the qualified health plan reimbursements for hospitals, instead of using the Medicare adjusted base rate definition that was in the bill as you originally reported out of this committee, we were gonna use actual hospital specific Medicare reimbursement rate, and the rate was gonna change from a 250% cap to a, of Medicare cap to a 225%. This amendment would go back to the earlier version of what you passed out and use the Medicare adjusted base rate. So it doesn't take out all of section two and put in a new section two. It just makes a change in section two. And so it really keeps everything in concept that was in section two of that cap, that cap on the QHPs at 250% of the Medicare adjusted base rate. As you passed out of this committee, The only change that I have retained here is the first instance of amendment in the bill as it was passed out of the committee. It talked about the cap on reimbursements remaining in effect until the applicability date specified in the Agreement Care Board rule establishing the reference based pricing methodology, and we could change that in the amendment to the reimbursement limits remaining in effect unless and until the board establishes a different reference based price. I think there was interest in continuing with that piece instead of what was in the bill as passed, instead of saying the applicability date of Orange rule just get unless and until the board changes reference based pricing as it would otherwise relate to this CAD. So that's the first instance of amendment here. The second instance of amendment keeps something you had done in the amendment that we looked at last week, which was to change the language around the possible kind of relief valve for the caps and the reductions in commercial reimbursement rates being directed to the 250% cap for the QHPs and the rates in excess of 500% of the Medicare rate, or otherwise very high. And you had, in the amendment we looked at last week, allowed a hospital to increase rates for one or more of its service lines, such as primary care, as long as, in doing so, it remains compliant with its overall budget. And again, that was a piece that would be retained in this draft. The biggest new piece here is sort of related to this, to going back to the Medicare adjusted base rate, only in the sense that that has a, potentially has a bigger and yet unknown impact on hospital budgets. And so this language would try to give some reassurance to critical access hospitals on one piece of hospital budgets in 2027. So, I'm gonna stop for a moment with the field language itself, just to talk about an issue that I know the Greenland Care Board has been looking at. I know Health Care has been taking testimony on it. A lot of people in the room have been working on this issue, but I think it's an issue that was not on most people's radar, including mine, until recently, and that is that in Medicare, Medicare requires that a Medicare beneficiary pay a coinsurance rate, so the amount that they're paying as a percentage, not a fixed dollar, their coinsurance amount for outpatient services at critical access hospitals is based on the hospital's charges, the list price for the services, not the Medicare payment rate. So it's based on Medicare payment rate for other types of hospitals, but this is a larger share that can end up falling on the Medicare beneficiary. It's on outpatient what? It's based on the charges. Total charges. Based on the charges for the services, not the Medicare, not the rate that Medicare pays. Am I getting this right? Yes. Correct.

[Sen. Martine Larocque Gulick (Vice Chair)]: It shifts the burden onto the patient, and sometimes they end up paying

[Sen. Virginia "Ginny" Lyons (Chair)]: away from Medicare. So the patient is saying just extra pay, extra charge.

[John Benson, Office of Legislative Counsel]: They can pay for less more, and there's no cap on what the patient can pay, unlike, again, for prospective payment service hospitals. It's 20% of the Medicare payment amount, and there's a cap for critical access hospitals. This is all federal law, so this is not something Vermont did, All federal law. And I believe there are recommendations to the federal government to make changes to it as well. But there's been a lot of attention brought to this issue and being paid to this issue as people are understanding it, although it has been in place for a long time. So, back now to the amendment. This amendment directs the Green Mountain Care Board to convene a working group with representatives of the board, Department of Online Health Access, Department of Financial Regulation, representatives of peripheral access hospitals, of health insurers offering Medicare Supplement Insurance policies, those terms of Medigap policies, because for people who have Medicare Supplement Insurance, that helps with their out of pocket responsibility, so this is falling in part on Medicare Supplement Plans, and representative of the Office of the Healthcare Advocate, and this working group will develop recommendations for ways to mitigate the effects of a federal requirement that Medicare beneficiaries bear financial responsibility for 20% of the amount charged for outpatient services delivered by critical access hospitals. And it would have the board provide the working group's recommendations by 01/15/2027, including the projected impact of each recommendation on patients, critical access hospitals, and premiums for Medicare Supplement Insurance policies and the state budget to this committee and Finance Committee because of the Medicare Supplement piece and others. And then, it prohibits the Green Mountain Care Board from addressing or attempting to address the effects of this Medicare cogener requirement through the board's hospital budget review authority in fiscal year twenty twenty seven hospital budgets. So, this is looking to provide some assurance to critical access hospitals that as you're moving all of these other levers related to the amount that they get paid for services, that this is one that will not be, the board will not use to address this Medicare cost sharing issue through critical access hospital budgets fiscal, possible fiscal year 2027.

[Sen. Virginia "Ginny" Lyons (Chair)]: So, and it's my understanding that there are other ways to handle this than through the budget. Than through hospital budgets? Yeah.

[John Benson, Office of Legislative Counsel]: I mean, I think the working group has to look into what those are, but yes, we certainly, there could be state money provided, there could be Appropriation. Right, there could be appropriation, there could be other ways of listing charges or rates. Refer to the working group to figure out what that is. But this is saying the solution, at least in the short term, is not simply to tell hospitals they can

[Sen. Virginia "Ginny" Lyons (Chair)]: no longer elect this. That's just for the one Just for the one budget Yes, October. Right. Okay.

[John Benson, Office of Legislative Counsel]: And that's it, then we renumber, I made that section one back towards the end of the bill, and then renumbering

[Sen. Virginia "Ginny" Lyons (Chair)]: the effect of the effect to be section one. So we're keeping some of the language that we had in the other, in the initial proposal, in the amendment that's in the calendar, section C and the two section Cs, first and second.

[John Benson, Office of Legislative Counsel]: Right, the sections, right. So yes, those are two pieces of your amendment, but otherwise keeping the

[Sen. Virginia "Ginny" Lyons (Chair)]: two fifty or the QHPs. Based on

[John Benson, Office of Legislative Counsel]: the Medicare adjusted base rate. Okay,

[Sen. Virginia "Ginny" Lyons (Chair)]: and then the other is the working group. So, understood, hospitals are concerned and needing reassurance about taking another step within the current budget process that might be a straw. So, anything we'll hear from Yeah. From that side with that.

[Sen. Martine Larocque Gulick (Vice Chair)]: I really appreciate the work of this. This is really good. Thank you very much. I I I will do whatever it takes to move things along, but I just wanna say I'm very uncomfortable with calling a Fremont board the care board what to do. They're our regular regulator. We should let them regulate, and I I don't like that we are I don't like that little beat at the end of this. And I also I just don't understand why it's our willingness give us insurance to the girls' care hospitals.

[Sen. Virginia "Ginny" Lyons (Chair)]: So I'm just struggling with that. Understood. Understood. I know it feels very uncomfortable to have the board to be prescriptive to regulatory board. Completely understand that. So any other questions or comments? I might go outside the table for just a brief minute to hear folks around the room. My enthusiasm for this actually is about having the two fifty FAC in place and knowing that there's going to be a level playing field and that we could actually see some savings through our quality health plan premiums for patients, our small businesses, our individual groups. Our individuals. So why don't we listen to folks. Have a little bit of time. Short comments would be helpful. I see everybody in the room and I'm assuming everyone in the room has a comment to make. We posted it earlier, and I

[John Benson, Office of Legislative Counsel]: know you've seen it. Want people to come up here?

[Sen. Virginia "Ginny" Lyons (Chair)]: No, I want people right there, I want you right

[John Benson, Office of Legislative Counsel]: there. So,

[Sen. Virginia "Ginny" Lyons (Chair)]: love your advocate, Mike I'll

[Mike Fisher, Chief Health Care Advocate (Office of the Health Care Advocate)]: start and then Debbie can push back. Mike Fisher. I appreciate the move back to base Medicare, and I appreciate the two fifty. Those are good changes. I am troubled by the Medicare cost sharing, that's language. Language? Medicare cost sharing language. I get it that we can't ask the hospitals to do everything. I get it that we have to be really careful about the amount of pressure we put on hospital diet. The status quo stinks. We think it's about $30,000,000 that are being overcharged to Vermont's rural seniors and disabled Vermonters. And it's not money going to the hospitals. It's money going to the federal government. Right. We think it's about 11% of the Medigap plans, Blue Cross' Medigap plans that are related to this overcharging. And I'm sure that hospitals so just to say it again, the hospital only gets what Medicare allows. So this is not about excess money going to the hospitals. It's about how much of that money comes out of someone's pocket or their secondary payer and how much comes from Medicare. And so I don't know whether we can do anything actively in this budget cycle, but I sure don't wanna rope that off. I want to keep pushing. And and about the working group, we fine. We had a working group in effect two days ago. I think there's a lot more work that needs to happen. You know, it might not have felt like a working group because the board can't meet in any way other than in an officially warned meeting. But but I think that the people were pulled together, and they were asked to bring their seat up to the table. And many critical access hospitals did and expressed an interest in that. I'll just say related, not exactly the same, but I just want to say it out loud. We think that this also affects Medicaid through the safe dollars here and maybe more than $10,000,000.

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

[Sen. Martine Larocque Gulick (Vice Chair)]: We hear you.

[John Benson, Office of Legislative Counsel]: Anyone else would like to call me?

[Devin Green, Vermont Association of Hospitals and Health Systems]: Yeah. That's my two.

[Sen. Virginia "Ginny" Lyons (Chair)]: I'm gonna go right down the line.

[Devin Green, Vermont Association of Hospitals and Health Systems]: Devin Green, Vermont Association of Hospitals and Health Systems. First, I wanna thank the chair for putting the critical access hospital cost sharing piece in. We are committed to working on that problem, and we think a work group is an appropriate way to do it. I will say that the Green Mountain Care Board does have other options besides public meetings. In the past, they've had working groups on certificate of need. They've had working groups on-site neutral that were not official board meetings. And so I would hope that that's a process that we can use going forward, but we agree that this

[Sen. Virginia "Ginny" Lyons (Chair)]: is a problem.

[Devin Green, Vermont Association of Hospitals and Health Systems]: We don't think the hospital budget process is the right way to solve it. You have asked us to cut our administrative positions. We have done that. We are very lean on resources. You're asking us to do a very big thing with the 250%. And we agree that something needs to happen on affordability and we are working on it, we want to do the 250%, but our hospitals are at a point where we can only do one big thing at a time, especially the critical access hospitals. So, what this tells us is that the 250% is the priority for right now, and in the meantime, we will continue working on this federal issue as opposed to taking funding from the critical access hospitals to address this federal problem.

[Sen. Virginia "Ginny" Lyons (Chair)]: I understand that federal government, Jen, correct me if I'm wrong, federal government is also looking to repeal this provision or

[John Benson, Office of Legislative Counsel]: I don't know if that's true with the ED pack that advises, has raised this and recommended changing it, but I'm not aware, others may have a greater sense of where things are federally, but I'm not aware of any active proposals The to federal government worked so quickly we can expect it to be.

[Sen. Virginia "Ginny" Lyons (Chair)]: That's the key. So alright. So thank you, hospitals. Gonna go to her in a minute. And so your concern is having to address both of these things at the same time, and I will just say we hear your concern. We also hear the concern about, you know, all this money going to federal government. Doesn't sound great. I will also understand that this bill is moving from the Senate to the House health care. So there is time for a broader consideration. I agree with Senator Gulick. I don't like putting in language that ties the hands of our regulatory board. That's problematic. However, under the situation that we're in and hearing the concerns for our smaller hospitals, I think it's reassurance and it is time limited. It's for one budget year. This would happen regardless of anything. It came up at the tippy end of what we're talking about. And so if the board decided to do everything all at once, we would see a lot of our hospitals without their reserve funds and their inability to continue. I'll stick with it for now and listen to the Green Care Board.

[Elena Bearby, Director of Policy, Green Mountain Care Board]: Yes, thank you. So first, Barabee, Director of Policy at Green Man Care Board. Think I echo a lot of what we heard from the health care advocate. This is a really big issue for some of our most vulnerable seniors. Again, the med pack recommendation even highlighted. The issue here is not how much hospitals are getting paid. Any solution can and should keep hospitals whole. The issue is that with this charge rule, our most vulnerable seniors are paying sometimes more than what the hospital is bringing in. We're actually sending money back the federal government in some of the most egregious cases, and that happens around four percent of the time. So you're asking their most vulnerable Vermonters to pay some of the highest prices in the state and pay the whole bill.

[Sen. Virginia "Ginny" Lyons (Chair)]: As of right now, are those fees in place? Yes.

[Elena Bearby, Director of Policy, Green Mountain Care Board]: Those are in place all over the state. Yeah. It will not be addressed by the reference fees pricing issue because the charges will be untouched. Again, this is not about reducing hospital revenues. This is about making sure that Medicare is paying their fair share and that we're not, you know, driving driving higher burden on some of our most vulnerable patients. And so

[Sen. Virginia "Ginny" Lyons (Chair)]: it becomes, as you're speaking, there's clarity here that the QHP and this rule provision are two separate organisms, two different things. QHP is one that we're really supportive going forward on, I'm hearing that. And this one over here is something that has come up and that folks are concerned about. My question for you and it's probably for the board and for hospitals, what kind of administrative actions would be needed and how much would be needed in order to undo the effect of the medical care pricing in the hospital. I think that's where we

[Elena Bearby, Director of Policy, Green Mountain Care Board]: agree that we need to work together collaboratively to really detail out the impact of these various solutions and work together to find the best solution. Okay.

[Sen. Virginia "Ginny" Lyons (Chair)]: So there is a need for some kind of a little working process there. Yes. So that's the group?

[John Benson, Office of Legislative Counsel]: Yes. Yeah. Okay. So the one piece I do wanna clarify about, at least about how the language reads currently, is that it prohibits the board from using its hospital budget authority. It doesn't say nobody can work on coming up with solutions. I think it's sort of, it's effectively saying it wouldn't happen

[Sen. Virginia "Ginny" Lyons (Chair)]: in a unilateral way. In October. Not gonna change the budget this year to do it, but there could be another proposal that could help. They might ask us for money, that's the other problem.

[Elena Bearby, Director of Policy, Green Mountain Care Board]: Right, thank

[Sen. Virginia "Ginny" Lyons (Chair)]: you, clarity is helping. Okay, Senator.

[Elena Bearby, Director of Policy, Green Mountain Care Board]: Okay, question, just my experience with the Green Mountain Care Board is relatively limited, as is my time in the Senate. So I'm wondering, is the setting of any kind of a precedent to be telling the board to not do this thing that they've been in statute, they've been sort of told to do. I'm just wondering if this is a weird precedent setting.

[John Benson, Office of Legislative Counsel]: I guess I'm not there. What do you

[Sen. Virginia "Ginny" Lyons (Chair)]: mean they're told in statute to do? It's telling them

[Elena Bearby, Director of Policy, Green Mountain Care Board]: they They're the regulator, right? The hospital regulator, and now we're saying actually wait, we're putting some restraints on your ability to regulate.

[John Benson, Office of Legislative Counsel]: I mean, think what you're hearing as a description of the issue is that it's not really, I mean, has the, a solution I think has the potential to affect a hospital budget, but I don't think it's necessarily restraining their ability to develop hospital budgets that comply with statutory requirements. It's effectively saying not to use a piece of regulatory authority to address an issue that affects individuals. I'm hearing behind me that that makes me

[Elena Bearby, Director of Policy, Green Mountain Care Board]: Well, and I'm not the lawyer, so you should have another opinion from the board. Elena Bearby, Green Mountain Care Board. I I think we have a broad obligation and duty to to improve affordability of health care in our state, and I think that is part of the budget process as much as guidance and benchmarks and these very discreet things are. So I you know, the board does not agree with the language that restricts its ability to act. So I think we do agree with, you know, developing a robust understanding of the issue, which we've been doing, as you've heard. There's still more details we need from hospitals to understand that particular impact of these different solutions. But we do not feel like we should jump ahead and say don't do anything about it. If there's something worth doing, we should

[Sen. Virginia "Ginny" Lyons (Chair)]: leave the door open to do it. So what is in here is don't do this within the '27 budget, but there's nothing that precludes the board from making a recommendation for the '28 budget and there's nothing that precludes the board from finding an alternative solution.

[Elena Bearby, Director of Policy, Green Mountain Care Board]: I think if there's a solution that we find this year could provide relief and permit millions of dollars to Vermonters Mhmm. We ought to take it.

[Sen. Virginia "Ginny" Lyons (Chair)]: Okay. And then I'm gonna go right over to Vaz, then I'll come back to Senator Cummings because I'm going to hear something about the administration of that solution. I don't know.

[Devin Green, Vermont Association of Hospitals and Health Systems]: I agree with that. If that relief comes, if that millions of dollars of relief is in the budget process, it's coming from our hospitals.

[Sen. Martine Larocque Gulick (Vice Chair)]: Or Medicare. We don't know that. It could come from Medicare. Okay. Again, if it's in the

[Devin Green, Vermont Association of Hospitals and Health Systems]: budget process, it's coming from our hospitals. I don't think, what we have heard from the Green Mountain Care Board is we are going to put something in your budget guidance, which is due at the end of the month on this issue. And it's been very vague about what that is. It's been very hard to plan our budgets around that. So if we have something in the budget guidance that just says we're going to do something to your budgets about this issue, we have a very difficult time planning going forward. And so that is why we're asking for this clarity right now.

[Sen. Virginia "Ginny" Lyons (Chair)]: Understood. Okay. Senator Cummings. I had her on this. Is essentially a copay that you go in, you have a procedure, the hospital sets the copay? No. No.

[Devin Green, Vermont Association of Hospitals and Health Systems]: Well, you set the charge You set the copay.

[Sen. Virginia "Ginny" Lyons (Chair)]: Makes up of it. So Medicare only pays x amount. You set the charge, but under this, the individual person has to pay the difference between Medicare pays the difference after the co pay. So if 20% of the

[Elena Bearby, Director of Policy, Green Mountain Care Board]: charges is more than what Medicare pays, Medicare doesn't pay anything. Patients pay everything and more. It is incomprehensible. I

[Devin Green, Vermont Association of Hospitals and Health Systems]: I I have good

[Sen. Virginia "Ginny" Lyons (Chair)]: supplemental insurance. And then it goes Supplemental insurance? I don't even you have to deal with this. Okay.

[Devin Green, Vermont Association of Hospitals and Health Systems]: Well, do. Well, mean, someone's paying for it.

[Sen. Virginia "Ginny" Lyons (Chair)]: I paid a lot for it. Think my Social Security checks

[Elena Bearby, Director of Policy, Green Mountain Care Board]: Especially if we're going to critical access costs.

[Sen. Virginia "Ginny" Lyons (Chair)]: This is how right? Okay. So there is a charge and that the hospital sets out of service. I go in. I pay a co pay that is set by who?

[Mike Fisher, Chief Health Care Advocate (Office of the Health Care Advocate)]: 20% of the charge.

[Sen. Virginia "Ginny" Lyons (Chair)]: It's 20%. So I pay the co pay that is 20% of your $2,000 charge. So so But that's a Medicare requirement. Just That's a Medicare requirement. Right. Medicare said you gotta pay the 20% of the charge, but if that 20% of the charge, if the charge is high enough

[Mike Fisher, Chief Health Care Advocate (Office of the Health Care Advocate)]: 500%.

[Sen. Virginia "Ginny" Lyons (Chair)]: Then Medicare pays nothing because my co pay hasn't covered what Medicare wouldn't pay. So I'm paid. Medicare is getting off the hook for paying anything, and the hospital is ending up with the same amount of money. Or we have our financial assistance policy, and we're covering it with that. From me.

[Devin Green, Vermont Association of Hospitals and Health Systems]: If you can't pay.

[Elena Bearby, Director of Policy, Green Mountain Care Board]: Or it goes to bad debt. So there's also a scenario where this is a loss for hospitals. So if we can address the patient cost share, you're actually providing financial relief to hospitals.

[Devin Green, Vermont Association of Hospitals and Health Systems]: Right. No one likes this policy. We want to address it. We don't think the budget is the right place to address it for this year if we are doing this major shift to revenue based pricing.

[Mike Fisher, Chief Health Care Advocate (Office of the Health Care Advocate)]: You take part of the study, right?

[Sen. Virginia "Ginny" Lyons (Chair)]: Yeah. Right. Senator, I'm gonna have you describe it on the floor. So how long has this provision been today? It's ancient history. Yes. And it's so it just sort of bubbled to the surface. Well,

[Elena Bearby, Director of Policy, Green Mountain Care Board]: it's it's been made worse and apparent through skyrocketing charges. When charges were lower and reasonable Yeah. Close to cost, this wasn't an issue. Now our charges are sometimes upwards of 11 times. Exactly. The cost. So and that money beyond is what you know, patients are still paying that. 11 20% of 11 times.

[Sen. Virginia "Ginny" Lyons (Chair)]: Okay. And then private insurance is also paid. Yes. And Medicaid. And Medicaid. Yes. Other hospitals are still gone financially. But they don't get to keep it. They don't get to keep it.

[Mike Fisher, Chief Health Care Advocate (Office of the Health Care Advocate)]: It goes back to Medicaids.

[Sen. Virginia "Ginny" Lyons (Chair)]: Well, they charge me and I When we overpay, the difference goes back

[Elena Bearby, Director of Policy, Green Mountain Care Board]: to Medicare. Hospitals receive the same thing no matter what. We are subsidizing the federal government by owe your pay. No.

[Sen. Virginia "Ginny" Lyons (Chair)]: Don't like government. The hospitals don't like it.

[Devin Green, Vermont Association of Hospitals and Health Systems]: No. No. I'm letting my

[Sen. Virginia "Ginny" Lyons (Chair)]: advocate doesn't like it. But we don't like it. Our goal here is to ensure that as our critical access I mean, if you want to go through it somewhere, then we are getting

[Devin Green, Vermont Association of Hospitals and Health Systems]: paid our reimbursement. If it's more than that, it goes to medical.

[Sen. Virginia "Ginny" Lyons (Chair)]: Right. But no. Private insurance. Absolutely. Medigap. Medigap. One of those ERISA.

[Devin Green, Vermont Association of Hospitals and Health Systems]: Yes. So what we're worried about with the ERISA piece is that we change it's through the hospital budget process, they they change your

[Mike Fisher, Chief Health Care Advocate (Office of the Health Care Advocate)]: charges. Okay.

[Devin Green, Vermont Association of Hospitals and Health Systems]: The ERISA plans can they will follow the charges that are now at the Medicare level, and that will devastate our hospital. Okay.

[Sen. Virginia "Ginny" Lyons (Chair)]: Okay. So, not in the middle of a sentence, but it was a better conversation.

[Devin Green, Vermont Association of Hospitals and Health Systems]: I get it. Understand. Sorry.

[John Benson, Office of Legislative Counsel]: Do want need it for the bill that's

[Sen. Virginia "Ginny" Lyons (Chair)]: in I want I wanna say one thing because I really do take seriously the effect that that last paragraph has. I I don't think any of us like telling the board what they can't do. We were not going to extend this. This is a one time deal, honestly, and Senator Gulick has brought that issue up, and I think we need to be very clear that the board has to have that regulatory authority. We're in a as we've said before, we're in this very strange transitional time when there's a lot of upheaval and imbalance in the affordable discussion, affordability discussion, the money from hospitals, critical access hospitals and others. We know there's a delicate balance with our insurers. We know there's a delicate balance with our policyholders. This is a one time deal if that little section stays in where it shall happen only, only, only, only, only for the '27 budget. Only for that '27 Have I said that clearly? That's what the proposal is. I don't use a critical access hospital. I use the large academic medical center. A lot of people do use the little hospitals across the state. Some people use Rutland or Southwest or Northwest. They use a larger hospital so that they're not affected but there's certainly enough folks who are affected by this and those hospitals disappearing or having concerns would be problematic. So committee comments, questions for the discussion, folks you'd like

[Sen. Martine Larocque Gulick (Vice Chair)]: to hear from here sitting around. Senator Feuer. Oh, I think Senator, I again appreciate this work. I will not be signing on just because I we've talked so much about trust in this room, in this session, and I do think that last paragraph is not affording the trust that we need to have in our regular, so fine.

[Sen. Virginia "Ginny" Lyons (Chair)]: I'm okay. Do you wanna sign on? Sure.

[John Benson, Office of Legislative Counsel]: Well,

[Sen. Virginia "Ginny" Lyons (Chair)]: it's a charge that goes to patients that if it's not covered by Medicare, it's an excess, it's paid out of the patient pocket. And so it's the hospital charge. That's a key here. First. Patient patient patient pays pays The patient's percent is equal to or greater than what Medicare would have paid. Medicare pays nothing. Right. So in this case, usually your insurance pays first and you pay the difference. In this case, you pay first and if there's no difference, the insurer doesn't pay.

[Mike Fisher, Chief Health Care Advocate (Office of the Health Care Advocate)]: I agree with that. That's what okay. Just want to make sure she's paid it right. That's what I

[Sen. Virginia "Ginny" Lyons (Chair)]: That's my It's like an out of pocket

[Sen. Martine Larocque Gulick (Vice Chair)]: before anything else happens. Yeah. But can you

[Mike Fisher, Chief Health Care Advocate (Office of the Health Care Advocate)]: add secondary.

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

[Mike Fisher, Chief Health Care Advocate (Office of the Health Care Advocate)]: Out of pocket or secondary. Yeah. Or It

[Sen. Martine Larocque Gulick (Vice Chair)]: affects employers. It affects individuals. It affects Medicaid. It affects Yeah.

[Mike Fisher, Chief Health Care Advocate (Office of the Health Care Advocate)]: Yeah.

[John Benson, Office of Legislative Counsel]: Yes.

[Sen. Virginia "Ginny" Lyons (Chair)]: So I understand your hesitation, Sandra, is. Alright.

[Mike Fisher, Chief Health Care Advocate (Office of the Health Care Advocate)]: So

[Sen. Virginia "Ginny" Lyons (Chair)]: This has been fun. So I will take it upstairs. I know there will be questions on the floor about undermining the board authority, that's to be understood. This has a pathway forward. I did talk with the chair of the board last night and he shared the concerns that Elena you have shared and that it would be important to him that the board be consistent with state law and there's language in there that would literally undermine the provision as written. I understand. We don't want board to fail. We don't want our hospitals to fail. This is a one time deal and it's for '27. And we do make exceptions to the rule from time to time. Does offer reassurance. The trust that we need to engage with this is with the hospitals.

[Sen. Martine Larocque Gulick (Vice Chair)]: I'll go back with this.

[Sen. Virginia "Ginny" Lyons (Chair)]: Understand if you can.

[John Benson, Office of Legislative Counsel]: So, any other things you'd like to do today? That's a fun one. Happened in Melbourne?

[Sen. Virginia "Ginny" Lyons (Chair)]: Oh, we're Your budget is on the bus. We we we canceled the budget. Dawn was not available today. He's busy with the That's what all the budgets have.

[John Benson, Office of Legislative Counsel]: Thank you, Jennifer. Yes.