 All right, we're back. Thank you all. We've had a little break and now we're back at work. Although we probably were working during break, which is typical for all of us. So committee we've we heard a great deal of testimony on S 120. My suggestion on this bill is to have take a minute and let Jen go through the proposed amendment that that I have put up on our web page. Then we'll let's take some time to go through that. And then comments will go through with a kind of a discussion mode if we can. This morning is then to move S 120 over to Thursday. We certainly need more time and I would suggest that we're going not going to be able to pass this bill until Friday. And so what for Friday we have h430. We're going to look at h430 today briefly and then we'll try to act on 430. As soon as we can, along with some of the other bills that we're looking at tomorrow. So our goal is to our goal is to pass all of the bills out that we have on our agenda. Today and tomorrow and Friday, but I'm just restructuring the timeline because we've heard so much new testimony today. I think it will be helpful for all of us to dive into it and we keep. And I will say this we keep getting emails and notes from people wanting us to add things into our budget member wanting us to add things into our bills and you know we're just about. To fill up with information. So, I mean there's no reason why you can't keep sending things for those of you who are out on the in the audience we certainly do welcome your comments but understand that our timing is very tight, and we'll do just the best we can. And we have another year of our session to cover some of the things that we can't get to this this year. So, Jen. Hello, there you are. Why don't you sending the 430 language to Nellie for. Oh, good. Oh, good. Okay, great. Thanks. Let's do let's go through the 120 proposed amendment and then we'll move on to 430 and budget memo. Okay, great. I will put up that language. I just committee FYI I did send you an email about this over the weekend, hoping that you would just have a chance to look at it. I tried to triage some of the more problematic and difficult complex areas out of s 132 to streamline that a bit and then to add some comments in to s 120 that reflected I think has reflected some of the testimony we heard today but the language certainly is open for modification further modification, of course, but so, Jen. Okay. So this is, I didn't put it in as an actual amendment format, but some proposals from Senator lions. The first relates to this study committee that she has re branded a little bit different name although did you send me even something else after this, and I did not. I did I thought that it should we should elevate it it's a value to commission rather than committee. So I want to call it commission on affordable. I think that's, but that's another. We can, we can discuss because I had was of a short duration and comes back with a report it seemed like a study committee but you can call it whatever you want. So the change in the findings, a couple of changes. One relates to adding a finding on the cost of prescription drugs. This is the ever increasing cost of prescription drugs continues to significantly increase the cost of health insurance and limit individuals ability to access care. Probably care and treatment, you know, because drugs are treatment. But, okay, let me can make changes as we go along, or make that in my version. I've indicated all of the changes in highlight with new language in bold. So again there's the change to the, whether it's a committee or commission but instead of being joint legislative healthcare affordability it's a committee or commission on affordable accessible health care. So I've renamed that in a couple of places. Then under the powers and duties the committee shall explore opportunities to make health care including prescription drugs, more affordable. And then in the under the powers and duties the second one on the all payer model, looking at the efficacy taking that out and changing it instead to look at how alignment of Medicaid Medicare and private insurance patient care management rules and guidelines affect access to an affordability of care, including access to referrals for extended care counseling and social services. Then think that is it on on what has been s 120 and then there are certain provisions from s 132 that are included and so I tried to indicate where and s 132 those had come from. The first couple of sections deal with ACOs. The first one here being what had been section five and s 132 on data collection and analysis. And then I took out the language referring to what the Green Mountain care board with would do with that information because that those provisions are not in this version. I still have the ACO collect and analyze clinical data and report that to the Green Mountain care board but it would not be specifically used by the board to inform other work that they're doing. Because that other work is no longer called for. What is now here section for had been section six and s 132 is that language giving the auditor state auditor access to the ACOs records. You have to placeholder in here for health insurance coverage for hearing aids. You have the language that you're recommending in the budget memo to be part of DFR is benchmark plan review was a little unclear what to do with what if anything to do with the remaining provisions at this time, including, you may need a better understanding of what Medicaid currently covers my understanding from them they think they already cover what the bill would have them cover. So you may want to hear that from them. Then we move to the state health improvement plan so what is section 15 and s 132 and this is where the bill would give specific direction to the commissioner of health and not just the secretary of human services or designee to be the one to adopt the state health improvement plan and updated as necessary, and then a new section that would be would have the commissioner of health submitting copies of the current state health improvement plan by January 15, along with any updates to the plan and a timeline for adoption of a new state health improvement plan to this committee and the House committees on health care and human services. Additional reports that come from s 132 just renumbered here so the first is the Green Mountain care board report on increases in health insurers administrative expenses for the last five years and how that compares with increases in the consumer price index. So that is again renumbered the section 18 of s 132 report requiring the ACO to provide a description of its initiatives to connect primary care practices with social service providers and have that report come in by January 15. And also is that we have the primary care visits without cost sharing reports from section 19 of s 132. So we have the primary care visits and those. It seemed that everything could take effect on passage because in the underlying bills they all took effect on passage so none of the ones unless you do something else with the hearing aids or something else didn't require separate effective dates, and then there would likely need to be a new title reflecting whatever you have in the bill. I'm going to take it down. Okay. Yeah, so committee open to conversation questions, thoughts at this point, I do want to add one thing as we were going through the, the work that we have done and just wanted to remind us that in h 315 which has now been allowed to become law. There is support for a JFO to hire a consultant to study the, the ACO. So there will be some that will be what I think we might consider an objective analysis of the ACO that the only piece I'm aware of that has JFO hiring a consultant, I think is around, and maybe I didn't want to speak to this but was around advising the committees on global commitment, the global commitment waiver. I don't think JFO was going to be hiring someone to do an ACO ACO right you're right so but it is tangentially it is very much related to that work. Senator Taranjini, go ahead. Thank you, Senator Alliance I just took a note when we were hearing from one of our witnesses about the s 120 bill and it. If it's true it's a little concerning, and unless I misunderstood this individual said that s 120 would has the potential to increase adult premiums by $1,000. I'm not sure if we increase the Dr dinosaur funding, and does anyone have any insight into that. I think we can find you the report. It was done a few years ago. And if others have other recollections. I'm happy to let you respond. In the context of several reports that have been done on primary care Dr dinosaur and others and it was in Devin greens testimony. So there is some, there is some specific testimony that as we go through that testimony will be helpful maybe to focusing on the goals of the of the group. It just seems, you know I'll read the studies and look into it a little more just seems a little counterproductive to what we're trying to do here as we as we look to expand coverage for children yet. We're saying, you're going to have to pay more in your premiums to adults. I don't like the balance so. And so it's something that will have to be weighed out risks, benefits. And so I see Senator Hardy and then Senator Cummings. Senator Cummings, were you going to comment on both of you going to comment on this. Is the Dr dinosaur in this bill. No, that's in another bill. I think it was the study piece, you know, analyzing if that expansion would be a route to take for savings. And so then the comment is a study there's no. Yeah, anything we do in this bill wouldn't. I mean, so this bill does include. The top of page four of what we just went over and in the and as 120 itself. In number C five opportunities made available by the Biden administration it does look at expanding Medicare to cover individuals between 50 and 64 years of age and for expanding Vermont's Dr dinosaur program to cover individuals up to 26 years of age. So that's the study there is a link in Devon's testimony haven't clicked on the link yet but it may be a quick way to get you to that report my my general recollection of the rationale behind the cost increases that younger individuals tend to be healthier and less costly and so removing those lives from the spread risk had the result of increasing premiums but there's I'm sure much more information in that. And we are now separating those markets. Because of changes. Right. Yeah, but yeah if you remove younger healthier individuals from the pool, the price is likely to go up for everybody else that's been a constant dilemma if we add covered services, the price for the remaining services goes up. And the guidelines if you don't mind if I ask a follow up here. The way the way this is written right now this, this is another study so we vote to support it. It's not saying we are raising premiums nothing we are enacting this or that this is allowing for a study to happen. And the next step would be for the legislature to take action upon that study. Yeah, so I mean there have to be a legislative recommendation. Right. Yeah, so many steps. Okay, go ahead. Thank you, Senator Lyons. I'm still absorbing a lot of the stuff we heard this morning it was a lot of testimony so I'm not sure I can fully relate, or you know, relate all of it to our conversation but to Senator Taranzini's point. I think it was Devin or somebody who mentioned that there have been tons of other reports done, and including this one that's mentioned about Dr. Dinosaur and I think having some reference to those reports and I don't know how we reference because it sounds like there are tons of them, but maybe some generic language that just says that the committee shall take under consideration previous studies or something like that so it's, you know, there's some charge to look back at other things that have been done. Yeah, I think having a knowledge base built into the committee work makes a whole lot of sense because people people out there don't have a lot of that knowledge. And there's no need to reinvent the wheel or re-study things that have been studied so I would support that and that would sort of get at some of the concerns that I think Senator Taranzini has about, you know, maybe doing something that's already been studied and whatever. Yeah. Okay, Senator Cummings follow up and then Senator Hooker. I'm just go ahead. The difference is that there have been changes in DC. And so, if I'm reading this, it's to say, okay, we've got all these studies but have recent changes, you know, cause the change in the conclusions. And there will be more changes before we're done with this. That's a good point. I think one of the goals of the committee in looking at what's going on is pretty key. Absolutely key. Senator Hooker. Just to follow up, you know, we do have to look at what's happening in DC, but with regard to the reports that have already been done, it'd be interesting to see what recommendations were made and what things have been put into place here in the state, as well as, you know, what's happening now in DC. So it, I think that there's a real value to looking back, but certainly a need to look at what's happening now. No, I think that is the point we don't, but I think as Senator Hardy has said, we don't want to reinvent a wheel. So the goal is to build on what's there. But we, you know, just sort of identifying some of the good work that's been done and whether or not recommendations have been followed up on and so on. So, so there's a sense of, of what we can do to move forward. Okay. Any other questions. Comments. Yes ma'am. I was just looking at some of the language suggestions that Jessa Barnard made. She had some specific language. And I just noted, oh, see her wording suggestions I'm just looking at them right now. I think it might be helpful to consider that she has changes in the same section you made changes, though, so I don't know if they're consistent with what you were trying to do. You know, listen, I heard the same thing and I think that that we should probably give ourselves a little time and a little time, very little time to go through, go through that and I wrote down the same thing Senator to, I thought that some of those suggestions might fit. So let's go through. Let's give ourselves that assignment. Let's go through the testimony and, and then as we come back to this tomorrow I'm hoping we can get back to it tomorrow. I'm hoping we can get some time and then firm up our discussion for mark up and vote on Friday so let's give let's do that that's let's go through this testimony and try to bring some thoughtful recommendations we don't have to doesn't have to be a lot, you know, just enough to make it succinct and effective. And we don't. So we've heard a lot so good yep good suggestion. Committee does that make sense to everyone I know no one has free time right now but can sit on the couch at the end of the day and do some very informative reading. I'm going to play the last few nights doing the same with all of our bills so yes. All weekend, all day, Monday, it's good. So that would help and I know each of you has a specific interest. And my suggestion is can we please make this a committee process you're going to be inundated with people telling you what to look at what not to look at. So we've heard a great deal of testimony let's try to make this a committee process from this point on, and I know there are very interested people out on YouTube right now, wanting to influence us and our thinking, and, and that's going to happen regardless, but I do think if we can make this a committee process where we've got. This is a great group of people to do this work. Thank you so much. Thank you so much. Thank you so much. Thank you so much. Thank you. Thank you. Yeah, thank you. To one quick question and then to to your point about this being a committee process is their value in making this just a committee bill rather than having it the number since it's a combination. I don't know what the process works right now in terms of, but wanting, you know, sit, saying it's a product of all of our thinking or that's a good question for our ledge council. Hello, Jen. Hi, I think that's really a policy slash political question. Oh, yeah. Okay, I'm happy to make it a committee bill whatever I mean either way you'd still either way it has not met crossover. So I know it's going to be, it's going to be a heavy lift, regardless, but so I'm, I'm happy to make it a committee bill, so as we can get to a place that I'm happy with, that's fine. Yeah, I just it's more for the your point about it, all working together kind of thing. But my other question is specific to the hearing aid section. Jen mentioned, when she went through the bill, whether or not the stuff that we are recommending to be put in the budget would sort of take care of the first steps of that, or if there's more that should be added to this. It seemed to me like what we did there might move us down that road. Yeah, I think you may be right. And Senator Cummings, did you want to add something? No, I from conversations I've had it sounds like that the benchmark would be the way, because if we add it then we have to pay the additional costs with state funds. Right. If we say it's a required coverage, and it's not in the benchmark so I think that's the best place to have the discussion. So, and Jen is there anything else I'm trying to remember there were three sections and I know the, the, is there any one of those sections that we might keep or should we just say the benchmark work is doing its job. Well, what I can tell you is what's in the bill right now so what's in the bill right now is are in the s 132. Sorry there's nothing in in the language we're just looking at except the placeholder is the section 12 of s 132 has the coverage for in a large group market also Medicaid and state employees and teacher plans. Section 13 is the application to change the benchmark plan so it sounds like you've wanted to wait on that until you've had the benchmark plan analysis. And section 14 is directing the Agency of Human Services to seek approval from CMS to provide the coverage that is called for in section 12 which as I said they have indicated at least to me that they believe they already cover and so that would be unnecessary. So I think those three sections are probably unnecessary given the work that the DFR is doing and others on the benchmark plan. Right, so I think the policy question for you is whether you want to enact the large group requirement. Now, or if you are looking to address it in all of health insurance at the same time after the benchmark plan review. Okay. Do we have any analysis as I'm assuming these are the non-erisous or essentially state employees and the teachers and right and the commercial large group. Okay, that's spot. Do we have any estimate on impact on rates. I don't I don't know if I mean it's an actual real question so I'm not sure if Nolan has heard from any of the carriers or the state employee plan administrator. There has been some conversations about what the impact would be but I don't have anything that I can provide you at the moment. Yeah I know that I know the companies were interested in testifying and they are submitting some testimony and writing, but this conversation might sort of obviate the need for that. I think we've sent it a coming point to the state impact would be the state employee plan. Yeah. I've heard enough from teachers about they have high deductible plans at this point. I think everybody wants it but I'm not sure they want it to the tune of having their premium go up $1,000. I'm not comfortable doing it without knowing. Now and I agree with you which is, and I think if we wait for the benchmark plan analysis that will help us make decisions going forward and it's not just this committee, it's obviously your committee that's very much involved so my suggestion is to take those three sections out. That doesn't mean we aren't very supportive of hearing aids for our citizens regardless of age and income and and coverage so for the record I don't see anything that would make premiums go up $1,000 a year. I'm just throwing that out I have no idea. Okay. And I'll start getting lots of you wait you're influencing our thinking senator. Okay, does that make sense to people though, really to to I hate taking hearing aids out because I think they're so important, but we have that language that we're Will the benchmark study also gives give us any information about the other plans, the You know what it might cost for the other plans to add hearing aids bank it's going to be specific to the exchange mark well to the individual small group markets because that's what the essential health benefits applies to. So maybe go ahead and all and sorry. I think I would recommend you talk to Blue Cross Blue Shield MVP because I believe that they have done their own internal estimates already. Yeah I think both, and they both. If we want to continue and add something in about having that analysis. Then we should have them in to present. I think that you would also probably want to hear from DFR because I don't think that's within the scope of what they have requested the federal funding to do. Right. Right, but could we could we ask the private insurers to do that analysis and report back to us. We could just ask them, and they probably have already done the work. Yeah. If we get information about the small group exchange or exchange programs and then we get information about the others and we have it all together to look at make a decision for everyone. Next session, right. That's sending you emails about it already. Blue Cross and MVP in before we make this decision. I think we need to do that. So I think that we'll ask Sarah Teachout and Charles Storrow who represents they represent their respective companies and they have contacted me, and I will. Nelly, did you think they would not. I think it's great. Let's try to get them in first thing tomorrow morning. Hopefully they're available. Not the first thing because we have people on but the second thing somewhere tomorrow. You may also want to hear from SIGNA as I believe they have some of the large group insured market. Okay. Who's a signal representative at this point. Jean Kennedy. Oh, Jean. Okay, good. All right, let's do those three tomorrow. Nelly, and asking them for written testimony that we just, you know, they understand the gun that we're under the time frame we're under so if we can get their information and writing and then they can come in briefly. The sooner we get the information, the better. The message to the YouTube world. Please, please get us what you have. Okay. That was that's good I think that's a good place to end the discussion on hearing aids. Anything else. To the S 120 draft that we'd looked at I have at least for now put in an additional item under powers and duties and a new five and I move five to six to say, so this would be the committee shall consider the following the findings and recommendations from previous studies and analyses relating to the affordability of healthcare coverage in Vermont. Excellent. And I hope that addresses the excellent issues raised. Okay. Okay. Anything else. Slowly but surely we're going to make some progress. All right, so let's this is our this is our goal tomorrow. We'll find some time. We'll put Nellie Nile. However it happens will will put S 120 up, and we'll have the insurers come in. And hopefully they'll get us some written testimony testimony prior to our meeting tomorrow. Then I'm also going to suggest while we're just talking about tomorrow. We'll just do read through H 210 again. And there are a couple other folks who have asked to testify they'll be testifying but that's going to be very brief testimony. And then we'll be talking about S H 210. Then we'll also be looking at S 120. That'll be next in line. And then we'll try to finish off our work on H 46 and H one 104 so that means to do a little bit of reading on those bills and thinking where we are on those bills. And then today right now, Jen I'm going to ask if you would please take us through H 430. And I know there's been some. You've done some great work with diva on this to help clarify what can and should or should not happen in the bill so maybe I think put up the proposal. The suggested changes that diva was offering, and then explain the reason why we have that please. Thank you for and Nellie hasn't hosted. I think after some technical difficulties. So if you, you may need to refresh again. I will put up the language. We know when you're ready. All right, we have draft 2.2 upgrade and this is the one that you have in front of us so Jen go right ahead. This is so this is H 430 this is expanding coverage under Dr dinosaur although as we'll look at it's really similar to Dr dinosaur for individuals who are not eligible for Medicaid because of their immigration status and I did work collaboratively with diva and coming up with language that they think will more appropriately meet the stated intent of providing coverage to individuals who are we had referred to undocumented immigrants or people who are not eligible because of their immigration status. And the issue with that is that it potentially requires a full Medicaid eligibility determination with a denial based on immigration status in order to then provide this coverage so in trying to allow for a more streamlined process to determine eligibility for this particular benefit. We have moved it to a different part of chapter of title 33 of chapter 33 in the same chapter but a new sub chapter that I've just called covered for additional populations. And now be Dr dinosaur like coverage for certain Vermont residents, because if we call it Dr dinosaur it suggests they'll be on a program, which is a Medicaid funded program this would be state dollars only. I'm not sure what you're reading, but just for for I wanted to keep. If they thought it was okay I wanted to keep this reference to Dr dinosaur because I think it's helpful to the rest of us and understanding what's contemplated. Don, I was looking forward to having some creative name but that makes a lot of sense. So that so yes open to other suggestions but that's why we like Dr dinosaur like. As used in the section the term Vermont residents who have an immigration status for which Medicaid coverage is not available includes migrant workers who are employed in seasonal occupations in the state. That had been something that was a priority for the House committee the health care committee, and then it requires the agency of human services and instead of saying requires them to provide Dr dinosaur because as we discussed that in operation would not be quite shall provide hospital medical dental and prescription drug coverage which is all of the coverage in the Dr dinosaur program to the following categories of Vermont residents who have an immigration status for which Medicaid coverage is not available, and who are otherwise uninsured. So this is children under 19 years of age whose household income does not exceed 317% of the federal poverty level, and pregnant individuals whose household income does not exceed 213% of the federal poverty level for coverage during their pregnancy and for 60 days postpartum. And so this description here of of who is eligible and the income levels are aligned with what is offered in the Dr dinosaur program. So the incomes are 312% with a 5% disregard that's how we get to the 317 and 208% with a 5% disregard that's how we get to the 2013 for pregnant individuals. And it allows AHS to adopt rules under the Vermont Administrative Procedures Act carry out the purposes of the section. And then the remaining provisions are making conforming changes to use that new terminology and the new location where the language would be codified. So it still has 1.4 million in one time funds to the agency of human services and FY 22 for grants or reimbursements or both to healthcare providers for delivering healthcare services during FY 22 to children and pregnant individuals who and instead of saying are undocumented immigrants, we say who have an immigration status for which Medicaid coverage is not available. And I want to pause there for a moment as well I should have mentioned under the undocumented immigrant piece. Using that terminology diva had concerns that there were other types of folks who were not eligible for Medicaid because of their immigration status, but we're not undocumented undocumented immigrants per se and these are things like I'm not going to get the numbers right but the H one agricultural worker visa program, those people are in the country legally but they are not eligible for Medicaid because of their that is not an immigration status that makes someone eligible for Medicaid. And that was a big part of moving away from this undocumented immigrant terminology and referring instead to immigration status is for which Medicaid cover just not available. Then we so it was still now back to this 1.4 million and FY 22. It's also for grants to Vermont organizations that work with members of and I kept this language here for months undocumented immigrant community, because it still seemed reflective of the types of organizations that you would be looking for but I'm open to other language there, or with members of the healthcare provider community to provide outreach and information about opportunities for children and pregnant individuals in Vermont to and changing this language, have an immigration status for which Medicaid coverage is not available to access health care services at lower no cost in FY 22 and thereafter, and implementing the technological and operational processes necessary for diva to administer the coverage for Vermont residents to have an immigration status for which Medicaid coverage is not available as set forth in this recodified section beginning on July 1 2022. And then, in section three still asking for this estimate but calling this Dr dinosaur like coverage rather than dinosaur cover Dr dinosaur coverage expansion. And so requiring a chest to provide information on the estimated FY 23 costs of providing coverage to Vermont residents who have an immigration status for which Medicaid cover does not available pursuant to 33 vs a 2091 beginning on July 1 22 as part of the agency's FY 23 budget presentation to the various committees. And then, in the effective date section section two is the same, or second, subsection a is the same subsection be again making this language change, and the codification change, keeping the language about subject to appropriations for the purpose. And then renaming the bill and I'll put this in proper format if it's an amendment, but renaming the bill to an act relating to expanding coverage for spending eligibility for Dr dinosaur like coverage to all income eligible children and pregnant individuals regardless of immigration status. Perfect. Yeah, and with the explanations going forward and that there is time here for some fiscal analysis it doesn't go into effect right away so that that's helpful. And, and just in terms of the administration of this that was it was, which was a question that I was going to ask. I just, I just have to share with folks because this brings back so many memories to me about my work with migrant workers, years and years ago, and have continued somewhat but in establishing just a migrant care program for kids but a family clinic and going around and taking people to the hospital and then accessing a physician or to to provide immunizations and take care of kids and families, and we established a clinic for these people and today that clinic has expanded from one area farming community area to cover. I think it's the whole county, a huge county in New York but I'm. So, this could be the beginning of something good is what I'm saying that never know. Any questions for Jen. Senator Senator Cummings does. Okay, can't see you. Okay, I can see me, and I can see you. Vermont resident. And that term going to give us any issues if you're talking about people in on a farm workers visa. They're here for a month, two months to harvest apples. I'm just standing from diva that their rules address Vermont residency and are fairly broad in their, in their interpretation of it, while still requiring some kind of a physical presence here. So they're later on in the bill you said there is the seasonal folks and so, right that's right here in the beginning it includes migrant workers who are employed in seasonal occupations. So, they are considered by Medicaid residents. I'm trying to write that's my understanding that they and they showed me in their health benefit eligibility and enrollment rule there's a quite extensive. Yeah, description and definition. Okay. Good question Senator Cummings any other questions. So if you have a question, please speak up. Okay, this is Ruth. I had sent Jen a few comments last night and I can go through those. There were three to pretty minor and one that I needed Jen's advice on. Go ahead, why don't you find the place in the bill. Jen, would you know the spot in the bill. I think the first one is right here so I figured I just leave this language right up. Yeah, the first one is right there to just add seasonal and agricultural occupations in the state and the reason is I'm from Addison County and we have lots of dairy farms and dairy farm workers are not generally seasonal, because you have to milk cows all year. So I wanted to add that to make it clear it covered those workers and the coverage, but it says includes my, the word includes means that they're that it goes beyond that so. That's meant as an addition to, you know, to the extent that there would be a question about residents that migrant workers who are employed in seasonal occupations would be considered. Fit this definition so we could certainly say includes agricultural workers and migrant workers who are employed in seasonal occupations in the state if that's a concern or of interest otherwise I don't. And this underlying language includes the people that you're talking about who are here year round. Okay, I understand that that includes now is about the temporary state status of rather than that. That's fine. And then further down in paragraph two, I believe on page two that and this is about the outreach and information and I just was hoping we could add culturally and linguistically appropriate outreach and education. Just to make sure that you know when it's necessary that it would be done in Spanish or whatever language is appropriate. This is often a challenge for state government and so wanting to make sure that that is covered. This became a really big issue last year at the early part of the pandemic when a lot of the information about coven was not translated yet. And yeah, it's an and Department of Health we added language and some of our bills around this. So how would you say that Jen is it is should be related to culture and language or simply language. Culture probably is important. Yeah, I think Senator Hardy's recommendation of culturally and linguistically appropriate outreach and information seems to work. That's what the committee is interested in. Is anyone on the committee not interested in adding that. Okay, so let's do it. Okay, I put that in my actual draft. Thank you. And then the final one and this was what I needed your advice on was some kind of guarantee or at least assurance of confidentiality. This was something that we had included in the bill that we did about the stimulus equity payments last year that started in Senate Agriculture Committee, and was a big concern about that to make sure that this information would again be shared with the federal government and cause, you know, deportation or, or any problems like that so I don't know specifically where it makes sense or what the language should be I believe, Michael Grady had something in that bill. But Jen I would defer to you on your expertise on that. Looking up I know there are some fairly significant confidentiality provisions around Medicaid itself. And I just wanted to look at there is confidentiality of Medicaid applications and records and I know we talked about this not being Medicaid like it. But I'm, I'm, let me check in with the diva folks I think maybe just a cross reference to this provision saying she'll be subject to the same confidentiality provisions as in this existing section 33 vs a 1902 a might be sufficient we could put that right in the statutory section creating this program. And then if you wanted we could also put something in that outreach. I think that is a very good addition. I think there's something like and the confidentiality of information submitted to obtain coverage something like that I'll look at that does that sound like what you're looking for Senator Hardy. I think so. I just want to make sure we're just able to give people assurances that this wouldn't lead to them or family members or separation from their kids or anything like that that is, you know, a very real and understandable fear and so anything we can do to make those assurances so if you want to check in with diva that would be good, but just want to make sure we're explicit about it. I will. Yes, so that that would be my thought let me check in with them, but I'm thinking adding something in section, I'll put the language back up and show you where I'm thinking. So I'm thinking, potentially putting in something like a new see here that says the agency shall adhere to the same confidentiality provisions as in section 1902 a of this chapter, and then putting something here with the grants. So we already have the culturally and linguistically appropriate going in here before outreach. And then adding something right here at the end that would be, you know, and the confidentiality of any information submitted to obtain this coverage, something like that. So, so Jen. Regardless, even though this is a Dr. Doris or like program or and as with any health care. This is HIPAA protected. Well, this isn't that this is, I don't know how to answer that question this isn't treatment. So it's there are confidentiality provisions that apply but I'm not sure the extent to which it's specifically HIPAA in an application for coverage so I so I don't know how to answer that question. Okay, so forget I asked it, but I think that we should add the pieces in that we've been talking about here. Okay, I'm thinking maybe just to say in the confidentiality of information provided by applicants, something like that, applicants and enrollees I guess, right. For regarding at like, okay, yes, I will work on that language in consultation with the diva folks. Thank you. Sure, thanks for raising it. Yeah, no those are good. Those are good things to add into the bill. So, let's do this then let's, this is Senator Hooker. Did you have a question. Yes, thank you. Just a small point with regard to the renaming. Expanding eligibility, but is this not a new program would it be more like just plain eligibility right eligibility rather than expanding since it's not really. You're talking about the new title. Correct. I think that's a good point. Yep, I will take it out. So eligibility for Dr. dinosaur like coverage for all income eligible children and pregnant individuals regardless of immigration status. I think that thank you. That's a good. Yeah, so keep your eyes open, go through the bill again and general bring back language for us and this bill we will look at tomorrow I think rather than Friday to try to get it. We'll get it out along with H 210 of 46 and 104 and anything we have that spills over spills over to Friday and pretty sure 120 will be. We'll, we'll, we'll talk about it tomorrow I think that we'll probably finish it on on Friday, just just the timing of it all. Okay. Thank you. That's great. Thank you for making huge progress. Jen, so let's take a look at the budget memo yet again. And I did make a, I forgot, I forgot something so you'll have to help us. Okay. So I put that and I wasn't sure I put it in under additional proposals for consideration because I don't think you have a dollar. Unless you have a dollar amount. No, we don't. All right, well I will just for now put the language up. And then when we have it finalized I can send it to Nellie. So the only two changes, I think since we looked at it earlier that as I've highlighted them to make it easy to find for additional one time appropriations we have $25,000 to the Vermont donor milk center to provide Vermont infants and their families with access to pasteurized donor human milk which is the term that they use that look like what folks were expecting. That looks good to me. Thank you. Sure. And then down here under additional proposals for consideration. I put in consider increasing Medicaid reimbursement rates for primary care services to 105% of the Medicare rate. So that's been a that's been an ongoing issue. And it does help to promote primary care in the state that. But the question is the what is the, what's the fiscal note on that one. So we're not adding in the fiscal note we're just putting it in as a recommendation and if we can find the dollars for that I think that would go a long way, with primary care docs and others, APRNs perhaps as well, but in the state and actually attracting more so that is anyone not want to put that one in. Let me know now. Nolan, you have your hand you know want to put it in. Go ahead I can't see you so you have to speak up. So I did a little bit of work for this for Senator Hooker. And I did have an estimate. If you want me to talk about absolutely. I'm just reading my notes here so diva does have a program where they attest that the providers board certified primary care provider so that's an enhanced primary care program. These providers already receive 100% of Medicare for their identified primary care codes. So to increase. And so this is this is this is so to increase the rates for primary care codes for these providers to 105% would be a $1 million gross. Now the reason I highlight that is because it would be increasing it for people who are, I've been identified as a primary care provider versus just using a primary care code. So if you did the, if you just increased all, if you just increase it to 105% for primary care codes, regardless of whether people are part of this primary care so they might be like a non primary care person using a primary care code, then that would be a $1 million gross. So I think that if you one way to, to specification you could say is increased primary care codes to 105% for those board certified primary care providers who are participating in any hands and medicaid enhanced primary care program. And that would be a million so you could be specific, the specific or you can. So that's just. It was based on the 2020 primary care rates. So probably a little bit more than the $1 million, but that's your sense. Is there a way do you think there's a way to have both of those in. So an or as an or I mean one's a one's an umbrella the $8 million and then the other one is greater specificity. I think that if you say increased primary care rates for primary, you know, 205%, just leave it as it is. Okay, it's unclear. Yes, could be as much as a million $8 million. If you want it to be clear, you could be more specific. Yeah, I think it does make sense to leave it as it is because then there's some decision making that can go on based on what funds might be available. Go ahead, Senator Hardy. Thanks centerline. I think I actually think we should be more specific if we're going to include this because our goal is to help primary care providers themselves. These codes could be used by any kind of provider just that is doing something that would be coded as a primary care. That is my understanding if I'm understanding Nolan correctly so it could be like a podiatrist, not to become podiatrist, but who might be doing something that would be coded as primary care. But if our goal is to really focus more dollars to primary care providers, then it would seem to me that we would want to be specific about it. Then it's cheaper also but but that's I mean, this is benign we're just including it in a list to consider so if we but you're right if we put it in and it's and it's with specificity. It is cheaper. So then when the question is asked of Nolan, how much is this going to cost us Oh, it's a million dollars maybe that's actually, and you can be more specific you can be a million dollars gross 440,000 general funds. Yes. Okay, so. Okay, so. Senator Taranzini any thoughts on this one. Senator Hooker. He's got his guys thumbs up. Senator Cummings. Like the more limited. Okay, let's do it then. Are you looking for this and you're still in the additional proposals for consideration or do you want to do an additional one time appropriation dollar amount. I think it's in our wish. It's in the additional proposals. Okay, I think it has to be at this point. And so what was the language for the narrower. And again, and just to clarify this is my I'm explaining in the way that was explained to me so I hope I did it justice to explain that maybe you'll hear from you. I'm sure you did the medical society doing actually but I did, you know, 105% of Medicare for bird board certified primary care providers who participate in Medicaid's enhanced primary care program or something like that. Can you say that again. To 100 105% of Medicare for birth board certified primary care providers who participate in Medicaid's enhanced primary care program. And maybe this is listening and she'll send me an email clarifying a better way of saying that but I was just I was just asking to have you repeat it because Jen is typing away. Entering data. That's great. Okay. And then you could say it's a million dollars estimated to be approximately a million dollars gross or 440,000. Well, see that's 2020 rate so to be a little bit more, but so I just say approximately a million dollars gross or $440,000 general funds based on 2020 Medicare rates or so, estimated to be something like that. And then I can work with Stephanie if they were to do that on a more specific number. Okay. Well it's on the list and now we have an understanding of what it is and I guess the Nolan. Does the word does the phrase board certified come to you from diva or do they need to be board certified, I guess my question. Right I think that's quite a subset. Yeah that is you're muted Nolan, if they're participating in the. Yeah yeah so what you exact sorry I apologize I would mute it. I think you're about to go down the road you can just say physicians participating in the enhanced primary care program because. So when you say physicians do you really mean physicians or because we had primary care providers and that's. Okay, in Medicaid enhanced primary care program. And yes. Okay, do we keep them as primary care providers or it doesn't even need to say that if they're participating in the Medicaid enhanced primary care program. I'm guessing that if I think test that they are board certified so I think you're right you don't have to say that you can just say participate in. All right, but Senator lines do you want to keep it as primary care providers who participate in the Medicaid enhanced primary care program. Yes. Okay. Okay, so. What does it look like. Yes. All right, let me put this back up for you. Sorry school vacation week. Kids are coming this afternoon. Goodie. The last two days. They're going to have fun playing out in the snow, Senator. All right. So here's how I revise that consider increasing Medicaid reimbursement rates to 105% of the Medicare rate for primary care providers to participate in the Medicaid enhanced primary care program. The estimated cost is approximately 1 million gross 440,000 state based on 2020 Medicare rates. Okay. Committee. Senator Taranzini, Senator Hooker, Senator Cummings. Okay. Senator Hardy, I know you're fine with it. I think. Yep, looks good to me. Okay. All right, so are we fine with our memo. This memo has taken its toll of time. Will it be posted on our page or what's the yeah. I think so. I mean, I would, my plan, I didn't want to send, keep sending. You know, Yeah, I think you probably need to get it off versions of the tropes and then. Yes, but if you're good, I will. Should do we need to vote on it? Yeah, I think we just, you know, we don't usually vote on it. We just all agree that this is the memo we'd like to send. So is there anyone who is not interested in Senate sending the memo. I don't know. I don't know. I don't know if anyone would take a vote. I guess. We're good. Thank you for all your hard work on this. It's been a, it's been, this has been a, this has been good work. Do you want me to send it to you to send to appropriations? Do you want me to send it to appropriations and copy you? How do you want to do it? How do we usually do that? I don't know. Just send it. Okay. Send it on my behalf and on the behalf of the committee. We'll do. All right. We're good. Okay. And it's the precursor to all of these money bills that we're sending out. So they'll get a flavor for what, what's coming. All right. So tomorrow I'm going to work with Nellie a little bit on restructuring the agenda, but we will start out with. As to 10. And I know that there are people who keep asking to testify. So I keep getting. People asking if they can testify and. The answer is we'll, we'll make a decision based on the time that we have. But certainly anyone who is very much interested in as to 10, because it is an important bill. Should please submit some written testimony. And if you have suggestions for improving the bill. That's good. But I also want to. I want to make sure that the bill is. Warn us that, you know, we want this bill to go forward. And we're going to, if, if there are differences that the house can't tolerate. We'll have a conference committee. So we do want to make sure that the bill is as. As effective as we can get it. So. We'll keep working on that one. But what we're going to do is. We'll have the board meeting on the 4 at H1 04 H46. S one 20. H4 30. We're all on our agenda for tomorrow. So we're good. I'll see you all.