Vermont Legislature SmartTranscripts:

[Senator Virginia "Ginny" Lyons (Chair)]: Dear, live. All right, so this is China Health and Welfare. It is still April 9, and we are. Thank you for being here. We're getting a quick look at what's happening with the Rural Health Transformation Grant, and I will say this right up front. Every time we talk about doing anything, either in appropriations or in here, the comment is, well, won't the grant take care of that? Or how does that work with the grant? And I am as guilty of asking that as anyone else. And also knowing from my perspective and approach and then trying to integrate budget here, that decisions were made in the budget before the grant became a reality. So we're just trying to sort out what's happening so we can have a finger on the pulse. Absolutely. Appreciate you coming in.

[Jill Olson, Medicaid and Health Systems Director]: Well, we're glad to be here and introduce myself and a new team member too. So, we'll introduce ourselves then. Okay, go right ahead. So, I'm Jill Olson and I am the Medicaid and Health Systems Director.

[Sarah Rosenblum, Interim Director of Healthcare Reform]: And I'm Sarah Rosenblum, I'm the Interim Director of Healthcare Reform. Hello,

[Samantha Heffron, Rural Health Preservation Director]: Samantha Heffron. I'm joining this team this week as the Rural Health Preservation Director. And I come from over a decade of experience working with the state supporting other EHS projects. Excellent. Thank you. Yeah. Thanks for being here. So we are thrilled that Samantha is on board.

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

[Jill Olson, Medicaid and Health Systems Director]: Yeah. It's gonna be great. Both my brains

[Sarah Rosenblum, Interim Director of Healthcare Reform]: on the project.

[Jill Olson, Medicaid and Health Systems Director]: We're really excited. So I don't have new slides partly because this happened a little bit last minute and we have to get all our slides approved. So I only have old slides.

[Senator Virginia "Ginny" Lyons (Chair)]: It's okay, but what you're saying will bring us up

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

[Jill Olson, Medicaid and Health Systems Director]: Yes, exactly. So I'm going to just remind you of a few things and I'm going show you some old slides, just remind you of things because I'm guessing you've thought about many many other things since the last time Sarah and I sat in these chairs, and then I'll go over, we'll go over some some of the things we wanna update you on and and take your questions. Okay. Just to orient all of us. So Rural Health Transformation

[Senator Virginia "Ginny" Lyons (Chair)]: hello. Nice to see you.

[Jill Olson, Medicaid and Health Systems Director]: Rural Health Transformation is a $50,000,000,000 initiative from the Centers for Medicare and Medicaid Services and was passed as part of the reconciliation bill in July. And its focus is really on improving access to rural healthcare. Our first year award, we're going to get a different award every year potentially. And our first year award was $195,000,000 plus. You can see it on the slide. And what I always say about this, I think it's good for people to remember is that the way the program worked, we had $100,000,000 that we expected every state to get. And what was that question was how much states would get up to $200,000,000 So we were asked to apply for $200,000,000 and that was sort of, that second $100,000,000 was the competitive part. There were parts of the application over which, of the scoring, over which we had no control. So, were measures of how rural Vermont is that were what they were, and we did not expect a score especially high on the way that CMS was using metrics, their rural metrics. We also didn't expect to score very high on some of the policy initiatives that the administration and folks states had. And so, the only way get from our 100,000,000 to our 200,000,000 was the strength of our application. So the fact that we came as close to 200,000,000 as we did, I think speaks to the strength of the application. Now some states got more, Texas got more like $280,000,000, but some states, bigger states than us, got less. So on a per capita basis, we had one of the highest per capita awards in the country. So it's great news for Vermont. We always talk about the award type because I think it's really important for people to remember sort of the world that we're now living in in terms of managing these dollars. Rural Health Transformation is not a grant. It is known as cooperative agreement. And that means a high level of interaction and scrutiny by CMS on everything we do. So what we've been working on, especially as recently as this week, is making sure that CMS has approved release of all of our funds. And all that means is we're allowed to write RFPs and grant opportunities based on those dollars. If there's a line item that hasn't been released, we offer the opportunity. So our focus this week has been on getting final dollars released. And I can talk a little bit about, we will get into why some of those were held up. But they will be approving every single subrecipient grant, every single contract we sign, every payment model we put out, they will approve all of those things. They're subject to approval. Right? Okay, approve them all. So there's gonna be a pretty detailed process in the next phase as we start moving into having actual awardees for these dollars. So, I just think it's important to understand, there's just this, there's a lot of back and forth. We need room to negotiate with CMS. They may ask us to make changes. And I think that that means it's really important to keep the authority where it is with AHS because we need to be able to do

[Senator Martine Larocque Gulick (Vice Chair)]: the back and forth.

[Senator Virginia "Ginny" Lyons (Chair)]: We are interested in changing that. Do you want us to change it?

[Jill Olson, Medicaid and Health Systems Director]: No. I just like to mention it. And then and so okay. So we have our annual report that's due on August 30, and that report will be the basis we expect of our second round of funding that will begin on October 1. So, we'll be in year two as soon as October 1. So, that's a deadline we're really focused on in terms of getting dollars appropriated or obligated and really being able to also meet some milestones that CMS has laid out that I think all of us, all states are finding a little confusing about how we're going to demonstrate compliance or that we hit the milestones. So, think it doesn't sound like it's just us. We expect more work on that with CMS. They have been pretty good about providing a few guidance. We have to obligate our funds by October 30, but of course that means we have to do all this negotiating with CMS in order to have a fund obligated. And then once obligated, obligated means a contract is signed, a subrecipient signed, that's all it means. There's another eleven months to spend the dollars. So we're spending the first year money until September. And anything that we got awarded this year that we can't spend, and this is true for all states, back in the pot for redistribution in year two. And the first year is a bit of a planning year, and so I do think it's likely that dollars from states are gonna

[Senator Virginia "Ginny" Lyons (Chair)]: probably end it back in the bottom.

[Jill Olson, Medicaid and Health Systems Director]: Anything I missed on that?

[Senator Virginia "Ginny" Lyons (Chair)]: They go back in the fund federal level?

[Jill Olson, Medicaid and Health Systems Director]: Yeah. And then they're redistribute for year two. Year two. Yeah. Yeah. Every state gets rescored every year. We don't reapply every year, we get

[Sarah Rosenblum, Interim Director of Healthcare Reform]: scored every year. Scored against, like, our progress on the original application that get a

[Jill Olson, Medicaid and Health Systems Director]: new award every year. Yeah.

[Senator Ann Cummings (Member)]: And the interesting one the deal with FEMA and obligated funds and all that nice stuff. So once you get obligated, you're you're pretty much guaranteed the funds, I guess, they accept it if you did something outside of the scope of what you were supposed to do. Am I saying that

[Senator Virginia "Ginny" Lyons (Chair)]: correct?

[Jill Olson, Medicaid and Health Systems Director]: Yeah. I would say that's right. Yeah. There's an expectation that what the plan that we submit is that the subsequent grant submitted is what we'll do. But yes. But but Obligating should be

[Senator Ann Cummings (Member)]: Exactly. But not guaranteed is what they have. Obligated is not guaranteed. But if you didn't do something that didn't fit to your scope or whatever like that, they could

[Senator Virginia "Ginny" Lyons (Chair)]: grab those dollars back. I'm sure they could.

[Jill Olson, Medicaid and Health Systems Director]: Yeah, I think so. Yeah,

[Sarah Rosenblum, Interim Director of Healthcare Reform]: I think that's very unlikely, even from like, just even from an AHS compliance perspective.

[Jill Olson, Medicaid and Health Systems Director]: You know, we want people to be doing the thing we- No,

[Senator Virginia "Ginny" Lyons (Chair)]: you don't have to. Right. Absolutely. Right.

[Jill Olson, Medicaid and Health Systems Director]: And I think the one thing that I do feel like is that the, because it's a cooperative agreement, because we're going have all this back and forth, because they're gonna approve every single individual budget to every subrecipient, that should make it much more clear that we're on the same page, so that aren't surprises after the fact about whether or not we did what they thought we

[Sarah Rosenblum, Interim Director of Healthcare Reform]: were doing, right? Because they're gonna have signed up on everything. Yes. The only part of the award that CMS, well, has explicitly said is up for that is if we don't achieve our policy commitments. Right. You don't get your outcomes?

[Jill Olson, Medicaid and Health Systems Director]: No, no, no. Just any policy. Some state may have lot of policy commitments. Yeah. So

[Sarah Rosenblum, Interim Director of Healthcare Reform]: if you wrote in your application that you were gonna change your certificate of need law by certain date, which we did not write, sorry, was just using the table, and you don't achieve that, CMS has said we will come after June for the dollars back.

[Jill Olson, Medicaid and Health Systems Director]: From the average top line scan. Okay. So I just like to always go over the application parameters. So the application, when submitted the application, there were a lot of different parameters outlined and we try to think of these dollars essentially as one time funding. So, we're trying to use it to launch things, to transition to new things, to buy stuff. It's it's not a 100% that, but that's the idea because we're truly trying not to build out, like, to the base. We're trying to have a sustainability plan for anything that we put forward. So we may start up things that, for example, then have an opportunity for a provider to use a billing and then it becomes sustainable through the sort of normal reimbursement mechanisms. But we might have helped get it on.

[Senator Virginia "Ginny" Lyons (Chair)]: But you can't obligate a future budget. Right. So,

[Jill Olson, Medicaid and Health Systems Director]: there's some big limitations. We cannot supplant the state budget. So, you can't say, we're gonna cut this, we'll just pay for it with RHG.

[Sarah Rosenblum, Interim Director of Healthcare Reform]: You can't

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

[Jill Olson, Medicaid and Health Systems Director]: We unfortunately have real limits on the kind of construction that we can approve, which is too bad because construction will be a great use of one time honey. But CMS has said that it has to be limited to changes that don't increase the value the property value. So that's pretty limiting. So we could, like, maybe move some walls around to get a new piece of equipment in, but there's a refurbishing is not really in the cards, which is too bad because there is a lot of infrastructure in Vermont that I'm sure we could use these dollars for. Present company excluded.

[Senator Virginia "Ginny" Lyons (Chair)]: I'm just thinking that you can fix up the inside of your house and you don't have to let the assessor come in.

[Sarah Rosenblum, Interim Director of Healthcare Reform]: I will I'm not too bad. Wow.

[Jill Olson, Medicaid and Health Systems Director]: Okay. Okay. And then we also can't fund otherwise billable services that are already being reimbursed. So we can't we can't actually raise rates. We can't fund things that are that are that can be billed. It it looks like we can bill we can initially fund things that are billable while we figure out how the payment is going to work. I think we can do that. Sarah's looking

[Senator Virginia "Ginny" Lyons (Chair)]: at the mail and paperwork. So there is

[Jill Olson, Medicaid and Health Systems Director]: You can start things up, but billable services have to be billed.

[Senator Virginia "Ginny" Lyons (Chair)]: So, I know that some language can you clarify? Yes. In RHT that relates to primary care and blueprint. Yes. And it would be, we would like to put additional funding in for primary care, just as one example.

[Jill Olson, Medicaid and Health Systems Director]: Yep.

[Senator Virginia "Ginny" Lyons (Chair)]: So how can we do that without crossing a line? Yes, so yep,

[Jill Olson, Medicaid and Health Systems Director]: we can do those payments that we put in because they are not billable services. That's the reason.

[Sarah Rosenblum, Interim Director of Healthcare Reform]: They are like per member, per month payments that aren't tied to specific services, but are tied to community health teams or practices that participate in the Blueprint. And so, because of that, it's different from this rule. They're not available.

[Jill Olson, Medicaid and Health Systems Director]: Where they, where it does start to become an issue is the next bullet, which is that provider payments cannot exceed 15% of the total award. That's gonna 15%

[Senator Virginia "Ginny" Lyons (Chair)]: of the total Award. Oh. So, it's about

[Jill Olson, Medicaid and Health Systems Director]: $29,000,000 in year one. As far as we understand, it's gonna change every year depending on the size of the award. And so we were waiting for a while for CMS to clarify for us what provider payments meant to them, how they defined them. And there were three categories of our three projects, numbers four, twenty and twenty one, that were held up because we weren't able to provide a justification to CMS because we didn't have the guidance from them. So, it just was a little bit of a waiting game. So, they held them up because they thought they might be provider payments and we couldn't answer the question absent the guidance. So, we now have the guidance and essentially CMS has said if you are using the dollars to take care of a person, that is pretty much a provider payment. So something that would be,

[Senator Virginia "Ginny" Lyons (Chair)]: you know- That's okay. That's a PIP.

[Jill Olson, Medicaid and Health Systems Director]: Well, that is a provider payment. That's a provider payment. From cap purposes, accounts are at the cap. And also quality incentives. So, certain kinds of incentives also count toward the cap. So, we worked through looking at the different PMPMs and we were able to get, we've had some back and forth emails with CMS and we believe we now have agreement about which ones, and it wasn't all, of the PMPMs are provider payments and which ones aren't. We also asked them a question about another project that we're doing that I'm not sure it's gonna launch this year, so it's probably not relevant this year, but it may be that might that they were how it's been viewed in other states because it's something that other states have done, so we may have to rejigger things yet again, but not right now. We're just trying to get the dollars released.

[Sarah Rosenblum, Interim Director of Healthcare Reform]: Alright. So, the remaining funds that we have restricted still by the federal government are all restricted because of this provider payment cap concerns about that. As Jill said, we now we have a solution. We think we're gonna submit a budget revision this week, which will hopefully be approved, and then the restriction will be lifted, and that would be all of our funding for this year would be unrestricted at that stage. Wow, okay. Yes.

[Senator Ann Cummings (Member)]: Interesting. I wasn't aware of that. We're looking at, the physician bill basically, so the PMPM per member per month, you're gonna get around $29,000,000 that you can put towards what you want as long as we just 50% of your total award, right? And then my concern it will be after five years you lose

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

[Senator Ann Cummings (Member)]: That so I mean, just don't want you to it.

[Jill Olson, Medicaid and Health Systems Director]: Oh yes,

[Senator Ann Cummings (Member)]: we Massive, all over five years.

[Jill Olson, Medicaid and Health Systems Director]: Yes, so we, I think that's something that's top of mind. We did talk in the application about, you know, hoping that we can transition back to having some kind of federal model where there's Medicare participation. That's how we have done it in the past. We're between federal models right now. And so, part of what we're trying to do here is make this work while we're between federal models. That's one of the ways in which it potentially fits into other types of initiatives. That's a whole other day.

[Senator Virginia "Ginny" Lyons (Chair)]: So another week of work. Okay,

[Jill Olson, Medicaid and Health Systems Director]: these are our initiative categories. This came up, we were just in the house just a few hours ago. So CMS has said that we were just in Baltimore two weeks ago, three. No longer oriented. It's the time. Neither one of us. But we were in Baltimore, and one of the things CMS really emphasized, the officials who were there, was plan is the plan. What we said we were gonna do in our narrative is what we are executing on. We're not doing new things, we're doing what we said we were going to do. That said, these are the initiatives that CMS thinks of our work as both these five buckets of initiatives, and then they think of them as individual activities underneath the initiatives. And so what's not as clear to me at this moment in time, and really we're not even exploring it, is the extent to which there'll be any flexibility within an initiative as things roll out or maybe sort of roll out and are completed in future years. I think all states are going to be asking that question. Nobody's asking that question so much right now that I know of because we're all focused on the plan that we, as we have already promised it.

[Senator Virginia "Ginny" Lyons (Chair)]: Are you adhering, I mean I have the initial of

[Jill Olson, Medicaid and Health Systems Director]: the five with your All of our buckets. Are

[Senator Virginia "Ginny" Lyons (Chair)]: you still adhering to that?

[Jill Olson, Medicaid and Health Systems Director]: Yeah, we are making changes on the budget side. So we're making the change this week, as Sarah said, on the provider payments to get that adjusted, to get those funds released. That actually changes words, I think, but not number. Oh, no. It changes yeah. It changes words, but

[Sarah Rosenblum, Interim Director of Healthcare Reform]: not totals. And it doesn't change projects. It's literally like Yeah.

[Jill Olson, Medicaid and Health Systems Director]: We're sort of saying like We're clarifying certain things, what things are. It pulled one thing out of the cap, left it did leave one thing in. Then, where was I going? Oh, but then we, so the other thing that's happening is we've been working on actually developing RFPs and notice of grant opportunities. So our various departments, including the Office of Rural of Healthcare Reform, but also DAAL and DIVA, other departments within AHS are working have been assigned some the responsibility for implementing some of the projects. And as the teams of subject matter experts have dug in to the project, sometimes they're finding that we didn't budget enough or we budgeted too much because there needs to be more planning this year, and we probably won't be able to spend some of the dollars till the second year. So we're seeing some ups and downs. And while we have some flexibility for ups and downs, we can actually adjust with up to 10%. We think we have enough that we're gonna do a new approval process with CMS to adjust the budget, which we expect will, they know it's coming.

[Senator Virginia "Ginny" Lyons (Chair)]: So they're okay with it.

[Jill Olson, Medicaid and Health Systems Director]: We won't know until we've done it, but they are aware that we have that in the works. I can't imagine that's not common in what persists. It was such a vast application project that there's a lot of estimating that had to be done and once you get closer to it, I think just more is revealed to us.

[Senator Virginia "Ginny" Lyons (Chair)]: Get down into the details and questions. Go ahead.

[Senator Martine Larocque Gulick (Vice Chair)]: Are you gonna share with us the list of RFPs that you're gonna put out so we know what it is? Yeah.

[Jill Olson, Medicaid and Health Systems Director]: I'm gonna tell you where to find them. I don't have them on the slides because of my requirement to have slides preapproved,

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

[Jill Olson, Medicaid and Health Systems Director]: I do have a list, and I and I'm we do have a website, and they're on the website. So I'll be right there. I promise.

[Senator Virginia "Ginny" Lyons (Chair)]: The website is good. Oh, thank you. I

[Jill Olson, Medicaid and Health Systems Director]: well, don't I know why I'm here. Yeah. I can hear it though. Yeah. Okay. I I'm not gonna go over this. This is just sort of our quick, this is so this is the initiatives, and these are the official categories. This is more how I bucket it in my head for what that's worth and some examples of some of the projects. I'm not going stay on that one very long today. So getting to your question. So we do have an RHT landing page. So if it's a website, and it has a few things. It has a public contact form, people can email us. It goes to a dedicated inbox that, I don't know, five or six of us have access to, Sarah, pretty much the key monitor right now. And we actually use it both internally and externally. That's where all the questions come to us. We really are trying to be the central repository for questions from team members within NHS up to CMS. So that's the place that we communicate from. That's where we get information in. But it's also the contact form on the website goes to that same advice. So, we are receiving information there. And then also on the website is our project narrative, like literally the application we submitted, a very short summary. And then what I'm finding is the thing people seem the most interested in, which is a list of projects. And so it's a list with a short description. And so it's just people who are interested seem to sort of like that one the best because it really gives you some granularity without having to read this 60 page application where things are duplicated and confusing just as the structure of the document. Also on that page are instructions for signing up for our email list. So we do have, we are sending out, by we are sending out an email blast every week letting people know which RFPs have been released. So one thing, I said this upstairs, that we found was that the provider community and the vendor community were really anxious that they were gonna miss announcements about RFPs and grant opportunities. And so we're doing two things. We're posting them on our website so that if people, you know, are thinking about it and wanna go look, they have a place to go look. And we are pushing it out on a weekly basis to say, hey, these are the ones that came out this week. I'm gonna actually stop sharing and then go to my just My notes. Stay in the meeting though, just in case. So, projects, the RFPs and grant opportunities that have been posted to date are the dialysis ventilator and nursing home project. That was I think the first out of the gate. LNA training programs with Tufts for nursing homes. Substance use disorder recovery housing. Mobile dental and healthcare units. Pharmacy test to treat, and then also support for the healthcare delivery strategic plan that's due in 2028. We felt like we needed more help to help us. We put it in into the application and it was approved. So that will give us just more bandwidth

[Senator Virginia "Ginny" Lyons (Chair)]: And that for that was approved. I mean, you couldn't do that even though we legislated that you have a

[Jill Olson, Medicaid and Health Systems Director]: Yes. We have to spend the dollars you appropriated first toward that effort, but we're gonna need dollars over time, both for the strategic plan. Is really important And then for someone to help also the analytic vendor will be able to have ongoing analytics support, pay for ongoing analytics support using these dollars. That would be actually an extension of an existing contract because that was already in the procurement process when we started.

[Senator Virginia "Ginny" Lyons (Chair)]: Yeah, I was going to ask that question so it won't be a new RFP because that would continue the contract.

[Jill Olson, Medicaid and Health Systems Director]: No, so to the extent that we have existing relationships that make sense, we're utilizing them. Okay. Next up, we've been working kind of in batches. So we have some of the Blueprint clinical practice support projects, there's a few of those, Then there's some technology projects, and they've been sort of moving through the process together. Some interrelationship, and so they're probably all gonna go out likely at once in the

[Sarah Rosenblum, Interim Director of Healthcare Reform]: coming weeks. I think there's maybe 10 more that will come out. And our I so there's six oh, is that right? That are out right now? Yep. Six that are out right now. The first go ahead. The first one's closed on Friday, so they all they were all closed at different times. They have different closure dates. The first one closes on Friday. That the same website that Jill talked about on a previous slide, we have a page on that website that links to all of the active RFPs or NOFOs that are currently public, and it's like cross posting. So some of the departments have posted them, but then we're also keeping them on our RHDP website so that people can just check one place for updates.

[Jill Olson, Medicaid and Health Systems Director]: And that structure does seem to have, I think, reduced some of the anxiety that was out there at really Centers of Health, just for people to know how to hear about things. So, I'm glad we did. How many responses are you getting for each RFP that you send out? We don't know yet because they would close. They had to close. We can't look until they close.

[Senator Virginia "Ginny" Lyons (Chair)]: And let's see the timeframe that you're using for closure.

[Jill Olson, Medicaid and Health Systems Director]: They're different because it depends on when they went out. So some are closing on Friday, some are closing probably a week later. It's a very layered process. Iterative process. Iterative is actually the word for this. Iterative is huge. Yeah. It's kind of a good one. Yeah. Sometimes it's really what's happening and this is the case. I think that's everything I wanted to cover. You guys, do you think that No. I

[Sarah Rosenblum, Interim Director of Healthcare Reform]: I know you had questions before we chat live.

[Senator Virginia "Ginny" Lyons (Chair)]: No. I want make sure. This is just fine. I understand where you are. I do have my recurring questions about how can we leave up primary care and how can we help some of the places that are all, some of the organizations and services that are already in place, and I'm getting, I'm understanding a little bit more that that is happening. I just have to be patient with it. And then, you know, my ongoing concern about Chittenden County inclusion and where that is. Is there something you can

[Jill Olson, Medicaid and Health Systems Director]: I needed a little more time? We did to sort out the provider payment question in order to make final decisions about how we were going to handle morality for every project, and we are thinking about it project by project, but we needed to understand which things were gonna be limited and which things were not gonna be limited. So we're just getting that clarity, and I think in another week or two, we're gonna have to be able to share more.

[Senator Virginia "Ginny" Lyons (Chair)]: Because as I look at the budget and I'm going through some of the downgrade, lowered funding in some of the programs that exist. For example, there's one at the Howard Center for integrated care, basic care for folks that for behavioral health through the Department of Mental Health that's being reduced. It's a really important program and trying to understand how that could be supported because there's a whole bunch of people being supported there and it goes out to some of our rural schools, students in our rural area schools, Gulick, Jericho, you know, Hunter Hill, Huntington. So that that's that's the big question. That's one of the questions. Yeah.

[Jill Olson, Medicaid and Health Systems Director]: I think it's and there's two things there, right? So there's

[Sarah Rosenblum, Interim Director of Healthcare Reform]: the rurality question, Jill said she we need a little bit more time on. But then there's also does that cause or project, for lack of a better word, fit within the scope of one of our existing projects that's already been approved by CMS?

[Jill Olson, Medicaid and Health Systems Director]: Mhmm. You

[Sarah Rosenblum, Interim Director of Healthcare Reform]: know, we did talk at the beginning about the plan that CMS has said. The plan is the plan. Mhmm. Plan that's been approved is the plan for the next five years. There is of course, you know, every project has a certain degree of flexibility within it, but there are also limitations. So the second question is, does that align with with an existing project? I know.

[Jill Olson, Medicaid and Health Systems Director]: And then the supplementation risk as well is always the other piece of the technical.

[Senator Virginia "Ginny" Lyons (Chair)]: I look at establishing clinically integrated network of care and services projects and telehealth. Some of these things, regardless of where they are, with that broader definition. Yep. Just That's

[Jill Olson, Medicaid and Health Systems Director]: why we're doing that project by project. Some things are like make sense. It's just there is no rural sort of worry and other things it's more of a zero sum game. Yeah. It's our imagination. Okay. Senator, do like a very quick question? Don't answer it if you don't feel like you can or should. Oh boy. I like that for you. When you're looking at the investments into the nursing homes, are you differentiating between which ones are locally owned, privately owned, private equity owned, or just looking at starting see the illustration date? We are not there yet because we're waiting to see who is obliged to do these projects. We have not considered that.

[Senator Virginia "Ginny" Lyons (Chair)]: We're getting past our Yeah, know it's last question and then we're gonna call it.

[Senator Martine Larocque Gulick (Vice Chair)]: On transportation, we know there's a lot about how to get people from home through their appointments with that being an eligible cost. So that's not really charged. Yeah.

[Sarah Rosenblum, Interim Director of Healthcare Reform]: Good question. Yeah. It's and we are not the subject matter experts. I will say, at at the moment, we don't have a project that pays for transportation services currently and direct applicant directly as part of the application. We do have a couple projects that will support our transportation system. So we have a project that is gonna support our EMS system, and they have a project that's gonna support inter facility transportation. So if you needed to move from a critical access hospital to a larger hospital supporting that infrastructure.

[Senator Martine Larocque Gulick (Vice Chair)]: Yeah. Well, was just thinking in the blueprint, as we start looking at where services are provided, that those services may no longer be available.

[Jill Olson, Medicaid and Health Systems Director]: That's right. No. It's a really important issue. Yeah.

[Senator Martine Larocque Gulick (Vice Chair)]: I could see how that might fit into that.

[Senator Virginia "Ginny" Lyons (Chair)]: Yeah. That's a big part. Yeah.

[Jill Olson, Medicaid and Health Systems Director]: It may it may work under some of those. Yeah. Mhmm. Yeah. And I can talk to transportation.

[Senator Virginia "Ginny" Lyons (Chair)]: Yeah. So we are going to call it a day.

[Jill Olson, Medicaid and Health Systems Director]: Alright. Well, thank you. We

[Senator Virginia "Ginny" Lyons (Chair)]: could talk for hours with you.