Vermont Legislature SmartTranscripts:

[Jen Garvey (Office of Legislative Counsel)]: You're live.

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: Our guest live. It's good morning. It's Tuesday, April 14. This is Senate Health and Welfare. We're looking at age six eleven. And see anyone who likes to. Okay. We're looking at H611, and we will be hearing eventually from council and Alex. But in the meantime, are there some folks in the room who would like to speak on page six eleven? Okay. We have, like, Fisher and Devon Green. Yeah. Let's let's just

[Devon Green (Vermont Association of Hospitals and Health Systems)]: just wanna recognize,

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: but Devon and I have just fought so much this year with us.

[Devon Green (Vermont Association of Hospitals and Health Systems)]: Are we gonna literally hold hands?

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: No. I'm sorry. Exactly. How y'all thinks, man? That was an almond burger.

[Jen Garvey (Office of Legislative Counsel)]: No. I know.

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: Don't worry. We'll find it later. But today, we're we're together with the concept.

[Devon Green (Vermont Association of Hospitals and Health Systems)]: Deb Ingraham, Vermont Association of Hospitals and Health Systems.

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: I'd to share about your activity.

[Devon Green (Vermont Association of Hospitals and Health Systems)]: And I we're coming together with a concept with the caveat that we don't understand the implications to DEMA or Medicaid at this moment in time, but we are hoping that it is streamlined enough and easy enough that we can implement this pretty quickly. But what we're looking at is, right now, there's, Diva is doing, Medicaid is doing a hospital global budget pilot project where a couple of hospitals are having a global budget for Medicaid, which means Medicaid pays them a certain amount and that is their budget for the year and they work within them. Because that's their budget for the year, they take on a lot of risks when they do that. In thinking about this, one of the tools to mitigate risk that payers have is prior authorization. Prior authorization is a huge administrative burden for hospitals. I will say that Ziva had worked hard to streamline the prior authorization process, and we appreciate that, but previously, under the One Care Model, what Diva did was they had a sort of prior authorization waiver. Most prior authorizations, providers did not have Diva. It was very, I think there are reports, and we can submit those that show that it's pretty successful. We would like Veeva to implement that sort of waiver of prior authorization in this Medicaid global budget because the hospitals are taking on the risk. There's no real need for prior authorization if the hospitals are taking on the risk. They're not going to do an end the MRIs that cost money when they will have to pay for them. And so, they're just looking to ease their administrative burden and reduce costs by having a very, very, very reduced prior authorization process. I think what would still be in play are things like durable medical equipment and some other sort of clinical safety issues, but otherwise it would be very streamlined. And we're just trying to continue the good things that came out of one care into our next payment requirement.

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: So just to say it again, in other words, the logic behind why the Medicaid prior authorization exemption for one care is identical to the that mandate in the global Medicaid global budgets. And not only is it good for providers, it's good for the people too. And it should be good for Medicaid as well. That's the concept that we wanted to bring to you, and there is language floating around, and I think Devin just said this. We have not talked to Eva about what these implementations would be? I mean, they did just do it. Let's just remember. They were just doing it last year for One and Tricky Labs. I'll add another sentence. There were things that were tricky in the one care context because it was lives that traveled around. This is simpler. This is care having bad consequences. And so it should be much easier for everyone to understand. We had fights, particularly with Dartmouth, for some reason, about Dartmouth. Dartmouth would say, needs a prior authorization. We would say, no, there's no prior authorization. Dartmouth would say, we're not doing a charity for the prior authorization. Those kinds of things would

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: So what you're suggesting is a new section in the bill that would have the prior authorization continue as as been in the ACO. And this is as I asked this question earlier in January, but they should start losing this. So I'm glad to hear that it's beneficial for both the people and the providers.

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: And I'll just say that prior authorization exemption in One Care model was a, from our perspective, a good. So

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: my question with you is language. So Jen is not here, unfortunately, but I'm sure she will be able put something together for us.

[Devon Green (Vermont Association of Hospitals and Health Systems)]: Sent some language to Jen, and I think we would like some time to discuss with Diva a little bit about the specifics and make sure that

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: we get that language right. So when you send it to Janet, you can probably make it. Okay. But we'll look at it. And then I'm sure she'll be reaching out to you.

[Sen. Ann Cummings (Member, Senate Health and Welfare; Chair, Senate Finance)]: So I understand this, the possible move to receive payment that would cover their Medicare cost.

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: Medicaid. Is

[Sen. Ann Cummings (Member, Senate Health and Welfare; Chair, Senate Finance)]: that on a patient basis? Is that on just the hospital basis? How was that determined? Here's how much they

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: would receive. It'd

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: be really good to have medication, but I figured.

[Devon Green (Vermont Association of Hospitals and Health Systems)]: There is, I would have to go back and look at the exact way that they are, implementing it. I think it is looking at the hospital's previous I'll I'll have to go back and look at it and figure

[Sen. Ann Cummings (Member, Senate Health and Welfare; Chair, Senate Finance)]: out how that works. And then if if the hospital gets the emergency end of their fiscal year and their costs have exceeded what it is that they had expected to be, What I see happening is a couple of things. Cough giffany because the hospital still needs to somehow get paid or trying to limit the. So I worry about those things and how those would work. In the perfect world, it should work fine. But I could see where for some reason, the number of patients or number of treatments is actually more than what they have seen in the last, although,

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: what they may just figure it out. Think it's so is experimenting with this. There's a handful of hospitals that are experimenting with medically. I think I'm sure these are the details they are figuring out in this pilot, and we are just adding

[Sen. Ann Cummings (Member, Senate Health and Welfare; Chair, Senate Finance)]: It's an

[Devon Green (Vermont Association of Hospitals and Health Systems)]: existing concept, and I think everyone shared your concerns around access and sustainability of the hospitals and risk and everything else, but the hospitals that I've spoken to, feel like it's going well so far. And I know that there's Medicaid that's thinking about the access fees and that it's more than just here's your money. That's it. I think there are some safeguards going through.

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: Thank you so much. Yeah. Okay. Ask them about that. Yeah. Right. That's perfect. Hi. Hello, Alex. Good morning.

[Alex McCracken (Director of Communications & Legislative Affairs, Department of Vermont Health Access)]: Hello. Good morning. Thank you for having me and accommodating me virtually today. I also want to say I will try not to get too distracted by the adorable unicorn on your table. Think our four year old has the same one.

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: Like our unicorn. Alex, we're wondering if you might be able to comment on the discussion that we just had around prior authorization.

[Alex McCracken (Director of Communications & Legislative Affairs, Department of Vermont Health Access)]: I can comment very briefly. For the record, Alex McCracken, Director of Communications and Legislative Affairs for the Department of Vermont Health Access, and I use sheher pronouns. This conversation has just very recently come to the department's attention as of this morning, so we don't have a very well prepared response, but I can say from the top level that if this committee is interested in pursuing this language, I would highly recommend having Alicia Cooper come in and talk as our subject matter expert on hospital global budgets. Generally speaking, what is being proposed would require a pretty large systems change because the structure of this model is very different from the ACL model with regard to PA interactions. So, we would really encourage the committee to hear more from Alicia Cooper and the Diva side. And also, we will happily work with the hospital folks on this language. We understand the benefit of the prior authorization waiver from the ACO, and it's something that we're interested in pursuing any avenue that we can to alleviate provider burden, but this would require a pretty large lift from our end.

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: Okay, thank you, Alex. We will make sure that we reach out to Alicia Cooper and ask her to testify and have a discussion about this. Thank you. Alex is what else did we want to speak to Alex? Alex Alex is gonna be available. Okay. For questions. He'll be available for questions. Great. Thanks, Alex.

[Alex McCracken (Director of Communications & Legislative Affairs, Department of Vermont Health Access)]: Yes. I'll be here. Thank you.

[Jen Garvey (Office of Legislative Counsel)]: Good morning. Jen Garvey from the office of legislative council. I believe you are planning to do markup. Yep. So I can put the bell up on the screen, if that would be helpful, and we can look at it together to see where you might want to make changes. Okay. So this is h six eleven, an act relating to miscellaneous provisions affecting the Department of Remodel abscess. It starts off by making some changes in the existing statute on prescription drug cost transparency that would remove DIVA and the Medicaid drugs from what's reported to the Attorney General's office. As far as drugs that have recently experienced a significant increase in wholesale acquisition cost, I think the stated rationale was just the very different prescription drug pricing in the Medicaid program because of the federal parameters, and so the lack of perceived utility of this requirement.

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: And we just know that while we're going through, I know we've had lots of testimony on this. There's something that folks have testified to identify. I don't know if anything read me. I

[Jen Garvey (Office of Legislative Counsel)]: don't so I don't believe I have been in the room for a lot of your testimony that you have received on this bill. So, we don't have

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: to deal with your interest in. I

[Jen Garvey (Office of Legislative Counsel)]: did have, let's see, I didn't have, let's hear the last time we took testimony to

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: John Blue Cross, and others, but I think

[Jen Garvey (Office of Legislative Counsel)]: that was on a proposed decision.

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: You have proposed changes to this to that section? To that section? I don't know if it would be that section. But I think as just as we go through the bill Yeah. If we have heard testimony and there's a concern for an improvement or an okay, feel free. I think that you should need to break because I know you work here. Alright.

[Jen Garvey (Office of Legislative Counsel)]: The second section deals with the reading board and CD drug pricing, and I think not specifically on the language that is struck here, but relatedly, you have a proposal from five states

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: around

[Jen Garvey (Office of Legislative Counsel)]: adding some language to the existing subsection B that you can't see here because of the asterisks, that is BTBSA4682B, and adding in the reference to 340B covered entities in addition to contract pharmacies.

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: Yes. I mean, we should probably Why don't we put that in a motion?

[Jen Garvey (Office of Legislative Counsel)]: Do you do you have a spare one? Or

[Sen. Ann Cummings (Member, Senate Health and Welfare; Chair, Senate Finance)]: Go ahead.

[Jen Garvey (Office of Legislative Counsel)]: Alright. I'm just gonna ask Melissa to.

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: I don't

[Jen Garvey (Office of Legislative Counsel)]: know you have earphones. I can't it. Sorry. I this is seems to be one I didn't print a as it has by house searching for my.

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: Easier if I can write down as. Thank you. Alright. But I can read some notes.

[Jen Garvey (Office of Legislative Counsel)]: Okay, section three has to do with the makeup of the Medicaid and Exchange Advisory Committee, and making a few changes including specifying that the membership has to include individuals who are also members of the beneficiary advisory committee as a recent federal requirement. Making a few language changes throughout. Not sure if you've heard anything else on this. I'm not aware that you've heard anything else,

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: Section so to

[Jen Garvey (Office of Legislative Counsel)]: four is removing the reference to employees of small employers from the reflective health benefits plan statute, because that's really a benefit for individuals, now that you have a separate individual small group market, strike the reference to employees of small employers. Section five, make some updates to the clinical utilization review board, noting the potential for board members, getting rid of some outdated language, and allowing some more flexibility around board member terms. Thank

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: you for your help on that.

[Jen Garvey (Office of Legislative Counsel)]: Section six has to do with the calculation of household income for the B Farm program, and this was to lead language talking about household income being calculated using quantified adjusted gross income. She goes, was like,

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: When you know, I'm just,

[Jen Garvey (Office of Legislative Counsel)]: We're good. I was just making my note right in the draft.

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: All right.

[Jen Garvey (Office of Legislative Counsel)]: The VPAR. All right. Yep, so that was the VPAR. Income level or income calculation, has not been done using modified adjusted gross income. Sorry, Ann said.

[Sen. Ann Cummings (Member, Senate Health and Welfare; Chair, Senate Finance)]: Oh, I guess John had to take

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: the printer to the chair.

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: Yeah. Section

[Jen Garvey (Office of Legislative Counsel)]: seven relates to the increased amount that an individual would be allowed to have in a prepaid burial arrangement without losing eligibility for Medicaid

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: Sections. That's significant. It's like which that means. We don't have do that right now. That'd absolutely.

[Jen Garvey (Office of Legislative Counsel)]: Section eight and nine relate to the Medicaid coverage for, state plan amendment for Medicaid coverage for doulas. Do you think there was a suggestion? Change a date. Change need to roughly push it back, right? Well, this does push it back, but I think there was a suggestion. I guess for A, maybe?

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: It's A A A A. Yeah. So,

[Sen. Ann Cummings (Member, Senate Health and Welfare; Chair, Senate Finance)]: In both places it? Yeah.

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: I don't see how it would be an effect. Alright.

[Jen Garvey (Office of Legislative Counsel)]: And that was it. And then the act takes effect in 2026. I think more what you've gotten is an effort of proposal for additional sections.

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: Yeah. This is language that I am sharing that would just put put some add some language to the bill that in the event the FDA approves psilocybin that we would be able to do, or I guess synthetic psilocybin that we would be able to act accordingly. So, I've been having some communication with the

[Jen Garvey (Office of Legislative Counsel)]: health department and my colleague, Michelle Childs, trying to understand if this language is necessary. I think it's not clear that this language is necessary given the existing new statutory and rule language around regulated drugs, but I I don't feel like I'm the best one to speak to that. I think there were questions about whether it was I was just communicating with them this morning about whether this would be necessary. Who would would make that determination for I think you probably wanna hear from Laura Lyons at the health department. Okay.

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: I don't know if you guys have a take on this or if you're even following. Yes. You know? Chittenden, you let us know what the decision is Or let Jen know. Well, I don't know if you have anything add if you want. Yeah.

[Jessica Chittenden (Vermont Department of Health)]: Jessica Chittenden, Department of Health. So we have, as Jen mentioned, been looking at this, and we do think because of the language in 18 BSA forty two fourteen that adding this additional language isn't necessary. It would if a drug becomes fully approved by the FDA, it wouldn't be subject to the prohibitions in the regulated drug rule. It would just be subject to any of the controlled substances. You know? It would be regulated normally as any other controlled substance would be in the state. So we don't think the legislative language is necessary to have that take effect immediately if the drug was approved fully by the FDA.

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: Is that a final decision or are you still looking at?

[Jessica Chittenden (Vermont Department of Health)]: I mean, from the health department's perspective, yes. And we were we were looking to a lunch council for some guidance on that, and it seems like, as Jen mentioned, Michelle Childs did weigh in and that that interpretation seems to be accurate. So

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: Yeah, sure. Lucy Ginny on behalf of Compass Pathways. Our understanding is because psilocybin is illegal both federally and in state that it needs to be taken off the controlled substance list, which needs to be done legislatively. I'm happy to work and talk with Michelle and the health department if that's helpful. Okay. That would be helpful. Okay. Find out in the probably make sure we do it by every every day. Yeah.

[Sen. Ann Cummings (Member, Senate Health and Welfare; Chair, Senate Finance)]: The

[Jen Garvey (Office of Legislative Counsel)]: other piece that I know you could heard or had a request for related to coverage for the pre and post exposure prophylaxis for LYGRAZZ or HIV prevention. And there was, the language proposed was around, I think it was coverage without cost sharing and allowing pharmacists to prescribe, dispense, or administer these medications. We've heard testimony the other day from the DFR about the language and the potential betrayal impacts.

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: I think

[Sen. Ann Cummings (Member, Senate Health and Welfare; Chair, Senate Finance)]: I oh, I'm sorry.

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: I don't remember who the testimony was from, but the pharmacist should keep allowing them to prescribe, but they're not given any compensation for these added duties. There was a suggestion that they might be able to find a way

[Sen. Ann Cummings (Member, Senate Health and Welfare; Chair, Senate Finance)]: to

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: And

[Sen. Ann Cummings (Member, Senate Health and Welfare; Chair, Senate Finance)]: I thought, well, one, were kind of, I think it was a threat. It basically getting covered up in pad, and they supplied me the septic I remember some exam, and that was the one that they were having the most part, but I thought.

[Jen Garvey (Office of Legislative Counsel)]: So the PrEP is already included in what is required to be covered under federal law without cost sharing because it has a US Preventive Services Task Force A rating. Pept is not included in the recommendations. It's not preventing. It's after exposure. Well, it is. Is. It's post exposure prevention. So it is still yet preventive, but I think it may be newer. So it is not currently required to be covered without cost sharing under federal law. I don't recall looking at

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: my notes. Don't which means we have to pay the full cost. Right?

[Jen Garvey (Office of Legislative Counsel)]: If you were to create a requirement to cover something that is not currently that is not, yes, that is not mandated, was not either a previously mandated or required under federal law, then yes, the state has to defray the increased premium attributable to that coverage requirement. And then what we heard from Sebastian the other day, which actually was not on my radar, so now I've been looking more into that as well, is that the proposals from the federal government in the proposed payment parameters for plan year 2027 are considering requiring state to frail for all new mandates enacted after 2011, even if they were in the state's benchmark plan. That was the bog shot. Yes. Yeah. And it seems like that may, you know, it may end

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: up getting Alex has her hand up. Go ahead, Alex.

[Alex McCracken (Director of Communications & Legislative Affairs, Department of Vermont Health Access)]: I don't mean to interrupt, but I I would like to just weigh in here briefly on behalf of the department because we have not testified on this potential amendment yet. There would be a cost impact to Medicaid for this amendment. We do already cover PrEP and we do cover a lot of this without step therapy or prior authorization or the things mentioned in the bill. But the increased coverage, the expanding coverage would carry a fiscal impact and thus would require an appropriation. And there's a second issue that we wanna flag, around the second part of the language, indicating that, shall not refuse, reject, or deny a prescription for any covered HIV prevention drug on the basis of the type or category of health practitioner in regard to the the pharmacists, I would believe. For Medicaid, we require per CMS that providers are enrolled in Medicaid. So this language would be problematic for us because we would need the provider to be enrolled in Medicaid in order to provide that coverage and reimbursement.

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: Understood. Sorry to interrupt, John. Thank you, Alex.

[Jen Garvey (Office of Legislative Counsel)]: Sure. Yeah, would you like to say something? Yeah, just to

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: add something out of the day service organization, just a couple of comments. I don't anticipate that there would be a problem recommending that language to require that the nurse became provider to do that. In terms of the cost, like, we do not have information from the doctor now, but we can look into that and see what that is. And just to clarify, cath has to be taken within seventy two hours as exposure to prevent HIV. So it is preventative on the. Do you have the dollar to help give you? I'm sorry. Yeah, we have dollar cost. No, I don't, but I can focus on that. I also wanted to let the committee know that the pharmacist part, I know OPR is interested in possibly putting that into OPR bill and some of the other options. Don't have. Above Above our paper? Yeah. So that last provision in the amendment for this committee would possibly not be in page six eleven. That last prediction

[Jen Garvey (Office of Legislative Counsel)]: was the largest. Right, that may end up moving forward in the GIV ops committee in your PR bill. So, yes, I mean, think if you were to proceed with some version of this language, I would want to make some amendments to the language that was proposed anyway, and it is, I think you'd wanna understand the reason for that language that Alex was pointing to around the healthcare provider issuing prescription or practice setting, just because I'm not, this looks like language that was not, is not necessarily Vermont specific in its scope, and I'm not sure, that's not a provision I'm familiar with seeing, I think, in almost any other type of health insurance provision, so I'm not sure if it's necessary for Vermont maybe addressing an issue that is not a problem in Vermont, or it's not a problem for the insurers that you can regulate, or plans you can regulate. But I think it'd be helpful to understand what the rationale for that language is.

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: So why don't we look at the language, improved language for this, then we need to know what the costs are, and data needs also to know. Did everyone get that? Yes. Okay.

[Jen Garvey (Office of Legislative Counsel)]: So, it sounds like there is interest in this language and you'd like to see it drafted the way I would suggest drafting in fewer employment. Okay. Yeah, I don't think we need to say anything about benefits being the same for a covered spouse and covered dependents. Again, that's just basic in our insurance and health insurance laws. So I think there's some of what's in

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: here that can come out. We

[Jen Garvey (Office of Legislative Counsel)]: did hear from Blue Cross that they can't distinguish between the same prescription being used for prevention versus treatment. They have concerns about waiving cost sharing based on a diagnosis.

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: Are we talking still here about? Prev Yes,

[Jen Garvey (Office of Legislative Counsel)]: still talking about Prev and Pep. I'm not sure, I don't know enough about the medication, but I don't know if there are other uses for those medications other than this pre and

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: post

[Jen Garvey (Office of Legislative Counsel)]: exposure prophylaxis. If not, then I it it sort of seems like a that doesn't seem like

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: a particular barrier. If there's only

[Jen Garvey (Office of Legislative Counsel)]: one purpose for which the medication would be prescribed, then it's not really an issue of what the diagnosis is. Go ahead.

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: I'd to share a healthcare advocate about the prescriber, about the pharmacy prescriber, the access of the pharmacy counter. I don't have a strong opinion about where that language lay lands. I do have strong support that it lands somewhere. And I guess I just wanted to articulate here that I understand that OPR has process that they wanna go through, and I wanna honor that process. And I want us if looking for some language that would move the move the concept forward through that process so that we have a timeline for moving through that process and taking a step. Right.

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: It's going on. Taking a

[Jen Garvey (Office of Legislative Counsel)]: and I think OPR, Jen Collins from OPR had provided the care and the language that they are looking at or have provided to Seneca Buffs in connection with the OPR bill in case we wanted to add it here, we could their revisions

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: would be appropriate for consistency. By the way, we'll put that at the so I can will include that instead of this language. It would be a separate. That's Okay.

[Jen Garvey (Office of Legislative Counsel)]: Alright. So it sounds like

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: I'm not

[Jen Garvey (Office of Legislative Counsel)]: coming up with any other proposals that you don't

[Devon Green (Vermont Association of Hospitals and Health Systems)]: think that you have heard.

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: I do have a question here.

[Jen Garvey (Office of Legislative Counsel)]: Except the one that you talked about at the beginning of your time together today. I'm not sure where you were with that on the prior authorization.

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: Oh, he would like to add that. Yeah. He'd like to add that.

[Jen Garvey (Office of Legislative Counsel)]: And I think you're aware of what adult information

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: they might need as far as, so. Okay. Well, we wanted to hear from

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: all the chicks who part of

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: it, Jacqueline did Greg's favor of that. Okay. And I

[Jen Garvey (Office of Legislative Counsel)]: had just had some questions that I sent to Devon to understand where and how I would draft it. So,

[Sen. Ann Cummings (Member, Senate Health and Welfare; Chair, Senate Finance)]: that prior authorization, that was just for the couple of hospitals that I'd do again?

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: That's the one you wanted to make with no cost. I getting I don't know that I've what I I guess, what would the cost be if I I'm not sure. I wanna raise wave a red flag in front of.

[Jen Garvey (Office of Legislative Counsel)]: As far as adding a mandate? Yeah. If

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: that is a real threat that we could get

[Jen Garvey (Office of Legislative Counsel)]: stuck with the cost of all of defraying all mandates exists whether you add something now or not. It's just in the it's just it's in their it's in what they're proposing for all states going forward. I have you know, in in looking at some of the commentary on it, it sounds like there's a push to maybe move it to 2028, plan year 2028, rather than plan year 2027 because of the, you know, the premiums are already well in development for plan year 2027. And I don't know if the, you know, if there's a strong outpouring from the states against the proposal, maybe it won't end up in the final version of

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: the rule, but right now, it's basically the proposed federal regulations are already proposed.

[Jen Garvey (Office of Legislative Counsel)]: Back to 2011. For all mandates, yes, required after 2011, regardless of whether it's in a state's essential health benefit plan, and that's the piece that is new for us, is that previously, or as it's been implemented so far, based on the plain language of the statute, it has been, or the regulation implementing the statute, it has been only for mandates that are not part of the state's essential health benefit plan. So, if it's not sort of your benchmark plan of what's already being covered and the state is adding something new on top, or if there's going to be new premium that there hadn't been

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: for

[Jen Garvey (Office of Legislative Counsel)]: a premium for a benefit that hadn't been required to be covered in the past, that's what we would have to pay to Bright Alarm. Now they're saying anything the state has has required since 2011, even if it's in that benchmark plan.

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: So, have to benchmark it.

[Devon Green (Vermont Association of Hospitals and Health Systems)]: We

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: renegotiate with vets, right, to get it included. So, there are a lot

[Jen Garvey (Office of Legislative Counsel)]: of benefits that were in our benchmark plan because the way you got a benchmark plan was to pick from among several existing plans offered in your state at the time. And so our initial benchmark plan was the Blue Cross Blue Shield small group plan with the largest enrollment, I believe. And the state was the benefit package that became our benchmark plan. Then a couple years ago, we were able to add a few new things based on a new federal opportunity that was made available. That's how we ended up with hearing aid coverage. Hearing aid was by agreeing with the feds based on certain fairly strict parameters that we could add something else. And so we did. So now our benchmark plan is everything that we have been requiring to be covered plus hearing aids. And so the rules had been, if it was part of your benchmark plan and already being covered, then effectively there was no new premium even if attributable to it because it was already being posted out in the premium. But if we were to add a new mandate that had a new cost attached to it, that's the part

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: of the state would be on the hook to pay.

[Sen. Ann Cummings (Member, Senate Health and Welfare; Chair, Senate Finance)]: So has anyone looked at mandates going back to 2011 and the potential impact?

[Jen Garvey (Office of Legislative Counsel)]: That's what DFR said that so when Sebastian touched on last week, he said they were compiling, they were compiling a list of those, or those That would be a great statement. So there, you know, and there are a number of things that the state has done to kind

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: of mirror what was required at federal level

[Jen Garvey (Office of Legislative Counsel)]: to safeguard against any changes at the federal level.

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: Would be financial exposure from them.

[Jen Garvey (Office of Legislative Counsel)]: Regardless of whether you had any risk coverage here.

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: So that's what the federal process requires. That is how I understand. I don't know if anybody is different. Yeah. You know,

[Jen Garvey (Office of Legislative Counsel)]: any stakeholders have a different Okay.

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: If I could just say that Fisher, incredibly frustrating. It is out of our control, but the EHB process included an analysis of richness of whether there's room within the EHB to add something like hearing aids, and and there was. And so we did. Now the contemplation that even though it fits within the richness of our regional central health benefit, we might get big points. It's frustrating. While I'm speaking, can I just also add, I know that the chair of finance often talks about grains of sand adding up, and so I want to recognize that? And I also want to say, with regard to HIV prevention, this is a very small population of people who really need it, and the investment is the right thing to do. Thank you.

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: Thank Thank you. So, be ready to move on to each they would serve us each cell. You're the babies left. She's on her way with them. Okay. Great. Katie's on her way. So any other phone number? 611. Jessica

[Jen Garvey (Office of Legislative Counsel)]: Chittenden, Department of Health. I just wanted to note that the department has been in conversations with OPR folks and other stakeholders about the pharmacist prescribing fees. And we're interested in ensuring appropriate access and uptake of this important treatment, but I think we're in the same boat of needing some more time to explore all the different pieces and making sure that it's working the way that it's intended and dealing with some of the issues that we know might arise to make sure pharmacists are being paid for providing these services, making sure that we have time to develop those protocols in collaboration with the stakeholders and figure out what the appropriate clinical pathway is for pharmacists to do it. So I think while we are supportive of the goal and moving forward on this, we'd like to have some more time to really figure out the details.

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: So in terms of time, our is very short in here. Yes. And the next time we take this up, I think we'll be taking it up to complete workup and bone. So that's the time we have. That could be as quickly as Friday or maybe as quickly as Tuesday. That that's where we are. We're we're gonna try to move as quickly as we can on these bills, which we been looking at quite a bit in the house, but I do understand that we're adding some stuff in here. It's different. Anything you can tell us

[Sen. Ann Cummings (Member, Senate Health and Welfare; Chair, Senate Finance)]: I think the OPR bill's gonna be moving coming up in the not too distant future.

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: Oh, you know what? Probably this week or next week?

[Sen. Ann Cummings (Member, Senate Health and Welfare; Chair, Senate Finance)]: I think it may move this week. But it seems like to me there's a timing issue that OPR had with it. Same thing that she just said. I think they're gonna be looking at trying to do that, I

[Mike Fisher (Chief Health Care Advocate, Vermont Legal Aid)]: they honestly still fairly soon. Great. To keep us close to our medicine. I certainly did. To have you over there.

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: What about she would take a short break? Or, you know, when Katie comes in, we'll get back in. But, Jen, do you need anything else for us?

[Jen Garvey (Office of Legislative Counsel)]: I don't think so. I think I I have some direction about what to prepare, and it sounds like for the most part it's just adding on to the bill that you have as

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: opposed to taking anything. Alicia Cooper and Jess Pichafano, Those are what others you know, she's got what I want to do. So we have Yale stuff folks too.