Vermont Legislature SmartTranscripts:

[Sen. Virginia "Ginny" Lyons (Chair)]: Alright. Alright. So we are back. This is Senate Health and Welfare. It's still April 17, and we're picking up some additional testimony on 06:11 from the department. Alex, you're here. Is Alicia also here? Good

[Alex McCracken (DVHA Director of Communications & Legislative Affairs)]: morning.

[Sen. Virginia "Ginny" Lyons (Chair)]: Good morning. Alicia, thank you for seeing the process. We've been talking about the prior authorization piece. So

[Alex McCracken (DVHA Director of Communications & Legislative Affairs)]: each of us will be speaking to a different amendment this morning. Alicia will start us off on the prior authorization piece, and then I will speak on the HIV amendment. So I'll pass it to Alicia to start.

[Sen. Virginia "Ginny" Lyons (Chair)]: Okay. Second of that. Jen, did you wanna say your full person? Alright. So listen.

[Alicia Cooper (DVHA Director of Managed Care Operations)]: Wonderful. Good morning. For the record, Alicia Cooper. I'm the director of managed care operations for the Department of Vermont Health Access. I'm here to offer some comments on the proposed language that was discussed earlier this week regarding a continuation of the prior authorization waiver that had been implemented as part of the Vermont Medicaid Next Generation ACO program. I'll start with a little bit of background for anyone who may not be familiar. In 2017, when DIVA implemented the Vermont Medicaid Next Generation ACO program as part of our contract with One Care Vermont, the program included a waiver of Medicaid prior authorization requirements as part of that ACO contract. Under this arrangement, providers did not have to seek prior authorizations for any Medicaid members who were attributed to the ACO for services that were part of the ECO's total cost of care or their financial accountability. This prior authorization waiver was in effect from when the BMNG program started in 2017 through when it concluded at the 2025, and was a very popular feature of the Medicaid ACO program. The PA waiver also provided DEVA with a lot of valuable data to inform some of the changes that we have been able to make to our prior authorization requirements more holistically as the Medicaid program. And so currently, the main categories of Medicaid services that still require prior authorization are out of state services, services that are high cost, for example, genetic testing services, or areas where we have greater potential for fraud, waste or abuse, like durable medical equipment and supplies. So with that as background information, I would like to share two primary concerns that we have with the proposed amendment. But if there are any questions on the background, I I'm happy to follow-up your questions. Just one, please please send that in your testimony. Yes. Can do that. So the first concern that we have with the proposed amendment, would continue the prior authorization waiver from the ACO program, is that the ACO model and the hospital global budget model, which we are now implementing, are very different with regard to the shared financial accountability framework. Under the ACO model, Medicaid was comfortable waiving the prior authorization requirements for certain services because both we, as the payer, and the providers who are participating in the ACO arrangement were sharing in that financial accountability for the total cost of care, regardless of where it was being provided. Under the hospital global budget methodology, the shared financial accountability is more limited to those services that are specifically happening within a hospital organization. Since many of the services that Medicaid requires prior authorization for are either high cost or are occurring out of state, or not with those hospital organizations that are participating in the global budget model. A prior authorization waiver that continued would be less likely to directly impact the hospitals in the global budget model and would affect certain things that would happen in Cal State.

[Sen. John Benson (Member)]: So does this exclude them or include them?

[Alicia Cooper (DVHA Director of Managed Care Operations)]: Yes, I would be happy to share some specific materials from our documentation. We do have less stringent authorization requirements for those facilities that are sort of on the border of the state or where we know we have a lot of Medicaid utilization to our Vermont Medicaid population. So the out of state services that I'm primarily thinking of are complex specialty services where someone might need to go to Boston or New York or somewhere that's further outside of our regular patterns of use for our identity centers. The second concern that we have with this proposed continuation of the prior authorization waiver is more technical. It has to do with how the PA waiver was implemented in our system. And it was implemented based on the ACO model, which had attribution. We had specific Medicaid members who were attributed to the ACO, and we were able to implement the prior authorization waiver by asking our system to look for claims for those specific Medicaid members. In our Hospital Global Budget Model, we don't have an attribution framework, meaning that a hospital that's participating in Hospital Global Budgets will have that hospital global budget model for any Medicaid member that comes to them at any point during the year. There's no specific list of members that are attributed. And so when we established the PA waiver for the ACO program based on attribution to the ACO program, we had to build it into our claims processing system. And in order to do something for possible global budgets, we would have to build something different into our claims processing system. Are you saying that not all

[Sen. Virginia "Ginny" Lyons (Chair)]: of the communications were part of that?

[Alicia Cooper (DVHA Director of Managed Care Operations)]: Yes. I can get specific numbers from the most recent year. It was a relatively small proportion that were not, but primarily members who were not having Medicaid as their primary payer were not attributed to the ACO. So anyone who was dual eligible or anyone who had other sources of insurance coverage is not attributed through the Medicaid ACO program, but their claims are considered part of the hospital global budget methodology. So those are the two reasons that we have concerns with this proposed language. And for those reasons, we do not recommend including the proposed amendment.

[Sen. Virginia "Ginny" Lyons (Chair)]: But it's pressure to. So, really, your concern is about the administration. It's that

[Alicia Cooper (DVHA Director of Managed Care Operations)]: from a technical standpoint, I don't know what it would take to be able to operationalize it. And from a policy perspective, I think we don't have the same shared financial accountability. So the the financial risk of waiving those prior authorizations would be mostly medically programmed. I can't relate. It's on the event, but it's actually. It's not I think we're having

[Sen. Virginia "Ginny" Lyons (Chair)]: a problem. No. It's the pressure on his life. Should be. Right on. Got it. For slight strep. The do not add is

[Sen. John Benson (Member)]: the best way Sounds make

[Sen. Virginia "Ginny" Lyons (Chair)]: like you're really supportive of this.

[Alicia Cooper (DVHA Director of Managed Care Operations)]: I will say, and I had a chat with Devin earlier this week. I think we're very interested in looking at our Medicaid prior authorization requirements for the full Medicaid population rather than thinking about it in this concept of a waiver of prior authorizations that would be specific to either certain providers or certain pockets of our membership. That kind of fits with our treatment history. It was just that it I seemed like a good idea. Thank you.

[Sen. Virginia "Ginny" Lyons (Chair)]: So, Kevin, do you wanna? Sure.

[Sen. John Benson (Member)]: I'm happy to

[Sen. Virginia "Ginny" Lyons (Chair)]: But before we get to you, Alex is on the screen with information that we've had. Okay. Of

[Alex McCracken (DVHA Director of Communications & Legislative Affairs)]: course. If you'd like me to go or if Devon wants to to go and talk about the waiver amendment, that's fine too if you wanna group them that way.

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

[Devin Green (Vermont Association of Hospitals and Health Systems)]: Devin Green, Vermont Association of Hospitals and Health System, and I appreciate the testimony that I gave in today. As I mentioned earlier, we needed to understand the operational policy and sort of unintended consequences that this may have. And I think for now we will pull this proposal and we're happy to do that. And we're also happy to work with Diva in the future. They've done a lot of work on prior authorizations and we'll continue to work with them to bring down administrative burden for hospital to patients.

[Sen. John Benson (Member)]: Okay.

[Sen. Virginia "Ginny" Lyons (Chair)]: Thank you for that. If there's anything you think we should include in the bill that will keep this moving along to us. Alex,

[Alicia Cooper (DVHA Director of Managed Care Operations)]: are ready for lift it.

[Alex McCracken (DVHA Director of Communications & Legislative Affairs)]: Hi. Good morning, everyone. Thank you, Chair Lyons and members of the committee. For the record, my name is Alex McCracken. I'm the director of communications and legislative affairs for the Department of Vermont Health Access, and I use sheher pronouns. Thank you for the opportunity to testify today regarding the proposed amendment to h six eleven on HIV medication coverage. This language would require insurers, including Medicaid, to provide additional coverage for HIV prevention and treatment medication with no cost sharing. Respectfully, the Department of Vermont Health Access would request if the committee wishes to move forward with this amendment that the language be changed to exclude Medicaid. There are a number of reasons for the department's position. Vermont Medicaid already covers a brand or generic formulation of every available PrEP and PEP medication without prior authorization, including long acting injectables. Many HIV drug treatment drugs are covered and available without prior authorization or step therapy. Additionally, HIV prep drugs do not carry a copay for Vermont Medicaid members. It is important to also reinforce that this change would result in a significant fiscal impact. Diva is working to determine the estimated cost, but this impact is due in part to the increased utilization, but largely due to the loss of Diva's ability to manage the class for the lowest net cost to Medicaid, which allows us to capitalize on rebates. The way that Diva Pharmacy currently manages this class of medication allows Vermont Medicaid to collect supplemental rebates. Medicaid, as you know, has a duty to provide quality care in a fiscally responsible way. Currently, this category is brought to DIVA's Drug Utilization Review Board or DERB for review a minimum of every two years and frequently more and typically more frequently than that. Additionally, it is worth noting in the context of increased federal interest in and scrutiny of Medicaid program integrity across the country that HIV medications are often a target for Medicaid fraud in part due to the high reimbursement amounts. Diva is also concerned that the inclusion of this language in our technical housekeeping bill could jeopardize the movement of H-six 11 through the legislative process. This amendment would require a stop in appropriations that would otherwise be unnecessary, and we want to ensure that the important elements in sections one through nine of this bill, such as Medicaid coverage for doula services, burial fund eligibility limits, and reducing administrative burden on DIVA staff, do not get delayed in a fiscal detour. Finally, as other witnesses have noted, the current proposed language regarding providers' authority to prescribe and dispense these medications is problematic. This language is simply not workable for Diva as written as CMS requires all providers to be enrolled with Medicaid. It is the position of the department it is the position and recommendation of the department that if the committee wishes to move forward with this amendment, Medicaid be excluded from the language. Diva can be open to a report on fiscal impact and a continuation of this discussion during the 2027 session.

[Sen. Virginia "Ginny" Lyons (Chair)]: Thank you. Thank you. And will you send us your regular testimony?

[Alex McCracken (DVHA Director of Communications & Legislative Affairs)]: Of course.

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

[Sen. John Benson (Member)]: Just a question, Alex. Have you sent us some suggested language or cross outs?

[Alex McCracken (DVHA Director of Communications & Legislative Affairs)]: We can provide suggested language. Absolutely.

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

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

[Sen. John Benson (Member)]: so much. That

[Alicia Cooper (DVHA Director of Managed Care Operations)]: is helpful.

[Sen. Virginia "Ginny" Lyons (Chair)]: That's it. That's it. We covered round this morning. So thank you all for being here and we're going to call her back.