 So good morning everyone who's listening via YouTube. This is the house health care committee and we are doing our first video committee meeting. So bear with us. I think we have a general understanding of what we need to do to have this go well. We have all of our committee members here this morning and we are live on YouTube. So I think the first order business is simply to welcome our witnesses. We have scheduled, I'm looking, trying to look at my schedule in front of me. So let me start first by saying just very quickly that thank you to the committee members and to acknowledge that the work that we did before we left the state house on House Bill 742 proved to be very important in laying the foundation for moving ahead with emergency measures, some of which we're going to hear follow up about today and later next week. And of course we know that 742 became the vehicle for additional legislation as well of emergency basis. This morning, we're focusing on insurance issues in this time of dramatic changes. We want to make sure that we as a committee understand what has now been set in motion to try our best to ensure that for Monters, whose lives have changed dramatically and suddenly continue to have as much access to health insurance as they can. As much access to health insurance as possible. Our witnesses this morning include Sebastian, I don't think I've heard her last name pronounced before so I'll just say Sebastian for now and let you introduce yourself. Well, we have the Department of Financial Regulation, then we here have the, from Diva, we have Addie Stromelo, who's going to talk about the open enrollment on the exchange. And we've asked Susan Gurkowski and Sarah Teachout to be with us to update us on changes that MVP insurance and Blue Cross Blue Shield of Vermont have made. We'll try our best to stay to our schedule but appreciate your flexibility. So with that, Sebastian, I would welcome you to introduce yourself by name and what role you're playing. And I understand that you are prepared to walk us through an emergency rule that DFR has recently promulgated with regard to some aspects of insurance. So with that, I'll turn it over to Sebastian and I'll remind committee members that if you have questions, if you raise your hand on the screen and I'll try my best to track that but let's first listen to Sebastian. So good morning and welcome Sebastian. Thank you for joining us. Good morning. Thank you, Representative Lippert. My name is Sebastian Arduango and I am an Assistant General Counsel at the Department of Financial Regulation. As you know, the language in 742 regarding DFR's emergency rulemaking during the COVID-19 outbreak includes expanding patients access to and providers reimbursement for healthcare services delivered remotely through telemedicine, telehealth, audio only telephone, and brief telecommunication services. For the last week, we have been working with stakeholders including the Vermont Medical Society, by state primary care, Blue Cross Blue Shield of Vermont and VP Healthcare and others to develop an emergency rule on healthcare services delivered through these means. And I wanted to share with you what the work we've done on that so far. So the rule has been drafted and we sent a draft out to the stakeholders for feedback and I just wanna say thank you to all of the stakeholders for their very timely and thoughtful input. And in response to that input, we made some changes to the rule and that is what I'm going to share with you today. So the first- Sean, can I interrupt? Just say that I do not believe we have seen the rule in its draft form. So if it's possible to review the rule generally as well as changes that have been made by the stakeholder input, that would be helpful. I will send the draft and the red line with the changes we made in response to the stakeholder feedback to Demis so you can take a look at that. So what the rule does in very broad terms is that it allows health insurance plans to or requires health insurance plans to provide coverage for healthcare services delivered remotely through telehealth or audio only telephone as though they were provided in person. So this is sort of the telephone office visit situation and it also requires health insurance plans to provide the same reimbursement rate for these services using equivalent procedure codes as though the service was being provided in person. Because these services are supposed to be equivalent to in-person office visits, health insurance plans can charge the deductible co-pay or coinsurance that would be otherwise permissible if the service was being provided in person and health insurance plans have to cover the same number of telephone or telemedicine consultations as they would for in-person covered services for each covered person. In addition, the health insurance plan has to notify members in advance that, sorry, the health insurance plans may require practices to notify members in advance that services delivered remotely will be billed as an in-person visit, but the practices can permit providers to notify members during the same call and no other consent to receive remote services are required. Finally, with respect to the telephone and telehealth office visits, health insurance plans can't require providers to have an existing patient relationship with a member. So to the extent that plans have existing member requirements for telemedicine or telehealth, we're going to require them to waive those requirements during the duration of the COVID-19 outbreak. The rule also addresses coverage of telephone triage services and these are brief calls where say a member is calling their provider to ask whether they need to go in or receive any follow-up services. We are requiring health insurance plans to provide coverage and reimbursement for HCPCS code G2012, which is consistent with guidance issued by Vermont Medicaid. And this code covers virtual check-ins via telephone. And I think the biggest change between what we're doing and what Medicaid is doing is that we are requiring coverage of the G2012 code for both federally qualified providers and rural health centers as well as all other providers. So for commercial insurance, the idea is that all providers will use that code for telephone triage services. We are also requiring health insurance plans to waive any deductibles, copays, or coinsurance for telephone triage. With respect to coverage of store and forward, we are requiring health insurance plans to provide coverage and reimbursement for HCPCS code G2010, which is the remote evaluation of a recorded video or image. So the idea here is that if a member has a rash or something like that, they can take a picture of it and then send it to their provider. And then the provider can follow-up later with a diagnosis or instructions to come in or pursue any follow-up treatment. And with that service, we are also instructing insurers to waive any applicable copays for the duration of the COVID-19 outbreak. We're also exercising our authority under each 742 to move up the implementation date for the store and forward provisions in the bill to May 1st, 2020, if a declared state of emergency related to COVID-19 exists at that time. And the reason that we chose May 1st as a date was to give the insurers time to implement that. So I think that should strike balance between what the insurers need and what the provider community wants. We also addressed the issue of claims retroactivity in the emergency rule. And we are directing all health insurance plans to process and reimburse appropriate claims for telephone trios services and healthcare services delivered by a remote means, i.e. telehealth office visits retroactively to a date no later than March 13th, 2020. Which would be consistent with Vermont Medicaid. And to the extent that any state regulations require compliance with HIPAA as far as the devices used for telehealth or audio only telephone services, we are leading the consistent with guidance issued by the Department of Health and Human Services. So providers will be able to utilize any non-public facing remote communication product that is available to communicate with patients. So for instance, a provider could use Skype to provide telehealth services to a patient but they could not use Facebook Live. The rule also addresses mental health parity and for the mental health parity section, we have more or less parroted the language that is already in Vermont law in Title VIII, section 4089B, stating that health insurance plans cannot establish any rate term or condition that cases a greater burden on an insured for access or treatment, access for or treatment for a mental health condition delivered remotely through telehealth, audio only telephone, store and forward or brief communication services. So that language is the same as in our mental health parity statute. And finally, we've addressed the physical location of remote services, saying that health insurance plans cannot deny or limit coverage or reimbursement of healthcare services delivered remotely based solely on the physical location of the patient or the provider. Okay, does that cover the provisions generally? Yes, that was pretty much all of the major provisions in the emergency rule. Okay, you mentioned that it's a draft at this point. Can you talk about the likely effective time, effective date or what the plans are to have it become effective and whether you've received all the stakeholder input that you had requested? Yes, at this point, we anticipate 8742 to become a law on Monday after review by the governor's office. And our plan is to have the rule become effective as soon as 8740. We just lost you. We just lost your connection is frozen, Sebastian. Can you hear me? No, I can hear you again. Okay. You had said it froze just at the point you said the law becomes effective hopefully on Monday with the governor and then you intended and then it froze. Okay, our intent is to have this emergency rule become effective when 8742 becomes law. Okay, so this is all being done in anticipation knowing what the contents of H42 authorize you to do. Is that correct? That's right. Okay, good. Okay, anything else you wanna add before we open it up to questions, Sebastian? No, I just think all of the stakeholders again for their timely input on the rule and for helping to put it together so quickly. Okay, can you briefly, before we open up, can you briefly indicate who the stakeholders were that you asked for input from? Again, Sebastian, you appear to be frozen without sound. Should there, maybe you're back. I'm sorry about that. I have DSL internet at home and my wife is teaching a school on another Zoom call at the same time. Yeah, it's... Okay, so I was asking about the range of stakeholders and maybe if that doesn't make sense to list, let me ask this, did the healthcare advocate's office were they invited to have input? We did reach out to the healthcare advocate and we had significant input from the provider community and from the insurers. Okay, I think at this point, let's open it up for questions and I see that Representative Donahue, I'm gonna do unmute you, your hand up. If others have questions, please indicate by quote, raising your hand and I will try to recognize you. Representative Donahue, I don't think I'm hitting unmute. I don't know if it's actually... No, I think I had to unmute myself. Okay, okay. So I wouldn't have thought of this question if it weren't that we had an email or some of us had an email inquiry the other day. Am I correct that after the new bill has passed, if an out of state physician who can then ask for an emergency license for practicing in Vermont and at that point, those services would also then be covered. So it's my understanding as far as out of state physicians that the state has widened its request under the Emergency Management Assistance Compact. So that enables any physician or other provider that's licensed in any other jurisdiction in the country to practice in Vermont. And we also issued an emergency rule last week waiving provider credentialing requirements for insurance companies. So it is easier for insurers to bring out of network providers into the network during the COVID outbreak. So does that mean based on the emergency rule that could happen right now? It doesn't require action from the medical board. The medical board, it just requires, it just means the insurer would be able to immediately credential. That's right. It means that the insurer wouldn't have to go through the credentialing requirements that are normally required as far as licensing and that there are fewer barriers to reimbursement for those providers. Okay, great. We actually gave misinformation to the person who was inquiring because we thought they had to wait for the law to be signed and for that provider to get a temporary license. But that could happen right away. And I'll let that person know to contact their insurer. Okay, I see several other hands up. I'm going to go to Jen first in the event that you have something that you want to inquire about with regard to what we've been talking about. And I, my, there you go. Thanks. So Jen Carby, legislative council, I just wanted to clarify, I'm not familiar with the emergency medical assistance act that is referencing the language. It's the emergency, it's the emergency management assistance compact. Okay, but the language of H seven 42 would allow a, as soon as it's signed would allow a, any provider who is licensed anywhere in the country to be deemed licensed in Vermont to provide services through telehealth or on the staff of a license facility without getting, without needing to get a temporary license or anything from the board of medical practice or OPR. Standing from them had been, that was the way to allow people to begin practicing in Vermont or delivering services to Vermonters immediately using things like telehealth. And I would defer to the, to DFR and that carriers as far as how the provider gets credentialed or gets the service covered for the Vermonters. Okay, I'm going to go to representative Houghton. I believe you. I've only needed you on my end. I'm good. Thank you. So I have two clarifying questions, Sebastian. The first one is you. I thought you said waving of co-pays, but I'm actually lurking at the emergency rule online. And it says a health insurance plan or a worker's comp insurance plan may charge. A copay. So I just want to get clarification on what that is about. So there, there are two distinct types of telephone and telemedicine services. One is meant to be a stand in for physical. A telephone triage. So health insurers can charge co-pays for office visit equivalents, but cannot charge co-pays for telephone triage services. Okay. Great. Thank you. That helps. And then my second question is, I kind of want to boil this down to how it helps providers and how it helps patients. So correct me if I'm wrong for providers. This will mean they will be reimbursed from insurance companies for both telemedicine services. They will be reimbursed from insurance companies for both telephone triage, as you call it, as well as other types of telemedicine and soon to be stored forward requirements as of May 1st. And for patients, it's going to help because they should have greater access to the healthcare providers while staying at home. Are those two statements accurate? That's right. Great. Thank you. Okay. I see that. So can you clarify again what the. Impact is on deductibles and out of box out of pocket maximums? The, uh, the rule does not address, um, deductibles and out of pocket maximums, um, except to the extent that it says that normal cost sharing applies to, um, public services. Um, office visits provided via telehealth or audio only telephone. We are, um, we have a call scheduled on Monday with the provider community, the healthcare advocate and the insurers to discuss. Waving, uh, um, Duration of the pandemic, but we did not address that particular issue in this emergency role. Okay. And, but am I. Was I, am I correct and understanding that with regard to specifics of COVID-19 testing and treatment, they have been waived. Apart from your rules. Yes. We issued a bulletin at the beginning. In the beginning of March. That waves, uh, cost sharing for COVID-19 testing, including, um, Any visits that are associated with that testing. Right. Okay. So just. If I can clarify at least again, that the rule that you're the, the draft rule, the emergency rule that you've been discussing with us. Is broadly applicable to telehealth services. Not just restricted to COVID-19. Treatment and triage, et cetera. That's correct. Yeah. Okay. I think it's important when we discuss these that. We understand what is broadly applicable. To all health health services and what is restricted. What changes may be restricted within quote, COVID-19 treatment, uh, testing and treatment, et cetera. Thank you. Uh, I see Brian. She has represented. She has a question. I'm going to unmute you. I think you should be free to talk, Brian. Okay. Thank you. So I think, chair, I think you just asked a lot of the questions I was going to ask, um, which is, which is good. So I won't repeat them. I just, just for clarification, I am going to ask, um, if I heard this correctly, that currently telephone. Uh, triaging telephone calls and are free from cost sharing. That telemedicine equivalence to visits or not, but it's, but you said that the department of financial regulation and insurers and the healthcare advocate are meeting to talk about the idea of waving, um, cost sharing for the duration of the pandemic. I don't know if I said exactly what you said. I, what, what's unclear to me is, uh, are you saying that you are looking at the option of waving all cost sharing or just, or all cost sharing associated with COVID-19. So eight seven forty two has three prongs as far as the data and the emergency rules and the emergency rule I was discussing just addresses the third prong, um, which is, um, expanding access to telemedicine and audio only telephone. The waving of cost sharing I was referring to in my earlier testimony had to do with the first prong, which is, um, waving or limiting cost sharing requirements directly related to COVID-19 diagnosis, treatment and prevention. And then we'll have another call, uh, with the stakeholders that is to be scheduled regarding the modification or suspension of health insurance plan deductible requirements for prescription drugs. And that's the second prong of the department's emergency rule making under eight seven forty two. Okay. Um, is there any discussion of, of, of waving the cost sharing for treatment for the mental health, um, needs of people related to the pandemic? There's been no discussion of that, uh, as of yet, but I expect that it will come up when we discuss the first prong of our emergency rule making authority with the, uh, stakeholders. Are you set, Brian? Yes. Thank you. Okay. I'm going to move on to, I see that, uh, represent Rogers has a question. Uh, I'm. I'm muting. You should be. Yep. I think. Um, yeah. Thank you, Sebastian. I was just wondering, I know, um, from the providers I've spoken with, there's, there, some of them are just struggling with the lack of consistency, um, insured one insurer to another. And I know that DFR can, cannot regulate, um, insurance plans that, that are covered under arrest. But I was just wondering from your perspective, if there are efforts being done to kind of mirror some of this work with maybe SIGNA or other insurers that, that, that, that DFR cannot regulate or also to mirror between the on exchange and off exchange plans, um, with Blue Cross Blue Shield and MVP. So the regulation, um, would apply to all fully insured plans. So that would be plans that are on the exchange as well as. Large group plans. Unfortunately, we, uh, we don't have any authority, as you said, over self insured plans under ERISA. But I suspect that that's something that will be addressed by the federal government in the next round of, uh, COVID related legislation to come out of Congress, just like how they addressed, um, COVID testing in the legislation that, uh, just went through the Senate this week. Okay. That's, that's helpful information to have. Thank you. I'm on. Okay. We're, uh, I'm just going to note that we're approaching not imminently, but within eight minutes or so of our time when we have scheduled, uh, the department of diva, uh, to talk about open enrollment. And my understanding is that they have a fixed time that's available of 30 minutes. Am I, do I have this right? Maybe I don't. But why, why don't we go on Emory, you have a question. And while you're asking your question, I will double check to make sure I have my time frames correct. So go ahead, Emory. Hello. You should be unmuted Emory. Hello. Now can you hear me? Yes. Yes. Just to be clear, this is not just for COVID related. Diagnosis or treatment and triage. This is for if somebody has a heart problem and can't go into the doctor because of COVID. All these other pre-existing conditions are covered under this. It's just not COVID stuff. That's right. This is a generally applicable rule. Um, it will apply to all healthcare services that are clinically appropriate to cover, uh, to provide the telehealth or audio only telephone. Okay. Thank you. Okay. Uh, any. Not seeing any other hands raised any further questions for Sebastian from DFR. Well, I'm going to thank you, Sebastian. And, um, will we be able to stay in touch with you throughout this period of time as we are going to want to hear about develop further developments at DFR? You would be the contact and appropriate person that we can ask to become a witness again at a later point in time. Okay. Thank you. Yes. And I will send Demis a copy of the draft rule as well as the, um, red line that we made in response to stakeholder input. Okay. Hearing no other questions. I'm sorry, Bill. I'm sorry. I have one last question. I'm sorry. Um, Sebastian, would it be possible to have you notify Demis who can notify us the day that you are putting this final, um, finalized bulletin out? Sure. I can copy Demis on our mailing to the secretary of state's office. Thank you. Yeah, that'd be good. Thank you. Thank you, Lori. Okay. Um, I think with that, we're a few minutes before our next witness, but as I said, they have a very fixed period of time and I think we have a lot that we want to hear from them. So I think at this point, uh, hearing nothing further, I'm going to say, thank you, Sebastian. And you can, uh, stay on and listen on if you, as you wish, but I'm sure you have other things you might want to do. Um, so committee, I'm going to just during the few minutes before, I mean, we're scheduled to hear from Addy Stramelow, who I do not see on our line yet. Unless, oh, yes, there. Yes. I see Addy. You're on by, are you on by phone, Addy? I am. Hello. Okay. Um, are you. So since you're on the line and I understood that you had a fixed period of time, is that correct? Perhaps we could start already and start a few minutes early.