 Okay. Good morning. This is January 13th and we are in a joint meeting of health and welfare in the Senate and house health care. Representative Lippert, Bill Lippert is chair of house health care and he and I will be sharing the work of the day moving the committee along, chairing the committee. I'm Senator Ginny Lyons. Any comments? Representative Lippert that you'd like to make? No. Just to say that I think it's again to appreciate that we're doing this jointly. I think it's efficient for our committees and also for our witnesses and we both are committed to moving this forward in an expeditious manner. Absolutely. And just FYI for committee members, the house leadership from house health care asked Jan Carby to put together a new grid for Act 6, Act 21 with a column for recommendations and that should now be up on both of our web pages and I want to say thank you, Representative Lippert and others who made that happen because I think it's extremely useful. So with that in mind, we have a long list of folks to testify and I know that a couple of people may be on time crunches. I know that David Hurley he is so we'll probably start with David and then I'm going to look at chair Kevin Mullen of Green Mountain Care Board. Do you have a time crunched? It helps to get off mute first. No, I'm at your leisure. Okay, good. So we'll we'll move through the witnesses. I can't promise that they're going to be in the same order. But ultimately, we will get to some level of conversation so that we can keep this work moving forward. I think both committees would like to make it happen with quickly as possible. Yes. So David Hurley he is here. And why don't you introduce yourself for the record and then we'll hear your testimony. Today. Thank you. Good morning, Chair Lyons and chair Lippert and other committee members. I'm David Hurley. I'm the executive director of the Board of Medical Practice. Go right ahead with your testimony. So I participated in the work group that was created under Act 21. And I also participated in the full group and in the subgroups and attended the majority of the meetings held. And I know I you heard a lot of testimony from Lauren Hibbert last week. And so I think I can be brief and just say that I agree with with virtually everything that Lauren said. The the board's perspective was was made known during the work group process. And I and I believe that our perspective which was pretty much shared with OPR was was addressed in the process. And we support the recommendations of the report both for the short term solution for transitioning away from from where we are right now with unknown number of out of state unlicensed practitioners practicing by by telemedicine with with Vermont patients and instituting the short term solution which calls for a registration beginning by April 1st. And we also support the long term recommendation which is to create a couple new classes of credential to provide for you know less burdensome but credentials that but that also come with less scope of practice in terms of the time or number of patients or both. And I think that it reflects an appropriate balance between the desire to to encourage out of state licensees or out of state practitioners to become licensed to practice and Vermont serve Vermont patients and increase access to care. And on the other hand it also is balanced with the desire of the state to provide for the safe care of its residents through the the licensing and regulation process. The the a couple small points where OPR is asking for sort of an add on. It's not really at the core of the telemedicine issue for the ability to issue provisional licenses and the board of medical practice discussed that and it's not something that the board desires that kind of authority. And I know that OPR presented that with themselves separately and we don't take issue with them doing that but it's it's not something that the board is interested in. So and I don't know if anybody has any questions. I'd be happy to answer any questions you may have questions for David Hurley. Okay. Thank you. That was very clear. Appreciate it. Okay. Great. Thank you. Okay. Thank you. All right. We'll we'll move on. So I'm I'm going to move to Chair Mullen of the Green Mountain Care Board simply because you were not at our committee earlier to testify on this and to see what additional information you might have beyond what we have heard from folks and then we'll go back to Lauren Hibbert and others who are on the agenda. This in this if I may this this is a focus is on an act six COVID flexibility extension which is my understanding. Yes. Yeah. Thank you so much for the record. My name is Kevin Mullen chair of the Green Mountain Care Board and for the most part we would support the proposals that are in front of you. I did want to bring up a couple of caveats. What worked well for the Green Mountain Care Board under the previous legislation was the flexibility that was allowed to make changes to the processes and definitely could see how that could be helpful moving forward for a period of time. Not so sure that I would go all the way to March 31 of 23. But again I'm just looking at it from the Green Mountain Care Board's perspective because we don't do a lot of regulatory work during the first couple months of the year. So if I was to make a recommendation it would be for calendar year 22 and not going out as far as it is. But there may be valid reasons for others to have the extension to May 31st. The flexibility worked great. We were able to take out the non financial aspects of the budget process and you know short in the time frame and took away some of the reporting requirements. And that was necessary in that particular point time. I wouldn't like to see a blanket statement in any legislation like what I saw in the letter from the Association and specifically let me focus right in on the point where I don't agree with what the group has proposed. And that is the blanket exemption for workforce retention and new hires and such. The board always takes those matters into consideration. And I would say again not speaking on behalf of the whole board but I would say that a number of my votes in last year's budget process were directly with the understanding that there was going to be pressures on the workforce and that's why they needed larger than historical increases in the budgets. So the big concern is that if you were to do a blanket statement you would basically exempt all those expenses related to the workforce due to the shortage and in doing so if it's not carefully worded you would take away for example there could be an increase in revenue because there's more dollars going into the workforce because of higher demand and so in some some respects those could offset some of the costs that are going to be seen in what's going to be necessary to have a suitable workforce. The board recognizes that hospitals are under extreme pressure right now and are going to have to pay to retain and pay to recruit and this isn't something new. We've been talking about this for the last five years about fact that we were in a workforce crisis and the pandemic has just exacerbated that and it's really exacerbated it into almost all fields of labor. Even the military now is creating sign-on bonuses up to $50,000. So yeah. Yeah. Sign me up. Yeah. I don't think they want us old people. They don't. But that's my my biggest concern with the language that I've seen in the Association letter. I don't think that it's necessary because we take those factors into consideration before we make a decision and I could see where it could do some harm in some cases if they're if the language is such that it's just specifically exempted. So. Do you think you could get your testimony in writing? I mean just a few bullet points about the comments that you've made. It's really about the exemption workforce exemption when the within the budget process is what I understand. Yes, that's that's my concern. Okay. And let me just be further more clarity on that. If there is that exemption in the budget process, it would put extreme pressure on the commercial rates because the change in charges would have to be adjusted to reflect that. So you're putting the total costs of the workforce situation on a subset of the people using health care. And that's those that are commercially insured. And so it'll just be more pressure for people to gravitate towards what I would call underinsured plans and because that's what they would be able to afford. And so those are the considerations really and I can put that into bullets and get it to both committees. Thank you very much. That's helpful. One quick question before Representative Goldman asked her question. How remind us how the federal dollars are counted within the budget or not. So they are counted in the respect that we're looking at a number of different benchmarks. One of those benchmarks is days cash on hand. So federal dollars have done amazing things to protect our hospitals and in really a shout out goes to our congressional delegation because senators Leahy and Sanders and Congressman Welch have tirelessly fought for Vermont. And I think that Vermont has benefited from their leadership in Washington in that the rural dollars especially that have helped come to Vermont are probably more per capita than a lot of other states, which is true of a lot of things. And we're thankful for that congressional delegation help. And because of that, some hospitals, especially the smaller ones really haven't seen the full squeeze of what some of their peers have seen elsewhere. And so I'm glad to say that today knock on wood. We don't have a hospital that's on the verge of closing their doors because of financial reasons. That doesn't mean that we have, you know, sustainable hospitals moving forward because we know that that is not the case. It's very difficult for rural hospitals, not only in Vermont, but across the country. And we also know that UVM has had some very tough things that they're dealing with that has placed them in a totally different financial situation than they were just a couple of years ago. So, you know, there's a lot of concerns still, but, you know, a lot of gratitude to for congressional delegation and those monies have have continued to come in. And so just to give you an example of one of our smallest hospitals, Springfield, within the the last two months of the of the previous calendar year, they received two payments of approximately 1.4 million each under that, which isn't a lot of money for somebody like UVM, but it's a heck of a lot of money for these small hospitals. And it's been a big help. And so we factor all those things in and there's a number of benchmarks that we compare them to their peers in the Northeast and across the country and to their peers within specific classes of hospitals. So you're comparing critical access hospitals to other critical access hospitals, you're comparing your community hospitals to other community hospitals, and you're comparing your academic medical center to other academic medical center. So there's a lot of different variables in the process. But certainly that money is looked at. It's not just forgotten. Thank you. You know, that was helpful. The we know that the hospitals were in dire straits, many of them prior to the pandemic and having federal dollars come in has been a real terrific support. Thank you. Representative Goldman has a question. Thank you. And thank you, Chair McMillan. I was just wondering if someone or maybe Jen could point to where on the spreadsheet she created Chair McMillan's comments on concerns about exempt expenses would live. So I don't have that spreadsheet. So I'm going to have phone Jen phone a friend. Jennifer. Yeah, Jennifer Carby Legislative Council, I think it's actually in testimony that you will be hearing this morning from the provider coalitions. I think they have proposed some language. I'm not sure if it was in an earlier version, but it is not in the not in the spreadsheet. Okay, thank you. For one thing, it wasn't underlined. So I didn't realize until Chairman McMillan started talking about it. And I went to look for it that it was proposed new language. Okay, question answered. Thank you. Any other questions for Chair McMillan? I would just say and we have course when we made a decision we're hearing testimony at this point in time. But to the degree that Chairman McMillan puts forward this proposed difference that I would ask if he would work with Legislative Council to also have language that we could consider. Absolutely. Thank you. That's good. Then we can make a decision. We have to look at it first before we can decide if we like it. Yeah. Good. All right. Well, why don't we just move on to Lauren Hibbert then. Lauren is here. Good morning. Would you like to skip over me? I'm totally fine if you want to go straight to the coalition. Yeah, you know, I was I was going to ask you if you would mind if we did that. Okay, I'm happy to be skipped. Okay. So then it's just a Barnard and Devin Green. Are you testifying together or separately? We're testifying together and I will start and I apologize. I do have to hop off at 930 to testify on the fire prohibition on firearms and hospitals bill in House judiciary, but I will try to make my remarks brief and then I'll be back on as soon as that is done. And I think where I'll start is the broader picture from the coalition letter and then I'll talk about Vaz's proposal around agreement and care board. So following up on last week's testimony, as we mentioned before, we're at the most critical point when it comes to staffing right now. And so that's why we're urging you to extend regulatory flexibilities and we really appreciate the committee talking about making some of those regulatory flexibilities permanent. We think that's a great idea. We want to explore that further. But we have absolutely no bandwidth to do that at this time. And we also really need the flexibilities to go into effect and not have anything bog it down. So what we're hoping for is to get the extensions now and then put into place a stakeholder process to look at what regulatory flexibilities could be made permanent going forward. We're also along those same lines, we're also requesting that the committee seamlessly pass the telehealth recommendations from Act 21. So, you know, we want to make sure that there's no gap, and that we're able to have the regulatory flexibilities around telehealth seamlessly without any disruptions. So if you I got a little nervous when we were talking about the Act 21 recommendations going at different committees, if this needs a bigger process for those recommendations, we would ask that you take out the that temporary process for the next year and put it in this bill so that we can ensure that there's seamless regulatory flexibility for telehealth going forward. And then in terms of the Green Mountain Care Board, I'm really happy to hear that they would appreciate the extension inflexibility as well, we can talk with them about the dates and what makes sense. We're happy to do that. I the reason I propose and Jen, I'm sorry, didn't underline it. But the reason I propose new language around hospital budgets and allowing us flexibility in investing in workforce in our hospital budgets is that we are really nervous. And again, I'm speaking just for hospitals here, not the whole coalition, but we're really nervous when we hear the discussions that are happening in appropriations right now, we hear a lot of comments of, well, we really need to focus on the health care providers who get primarily Medicaid funding. This is where we should put the workforce dollars, the hospitals they can always just increase their commercial rates, they can make it up. But they don't understand that we can't make it up with the Green Mountain Care Board, we have a cap and we know that the Green Mountain Care Board does take these things into account. But we are really worried that we will be squeezed on both ends and not able to make those necessary investments into workforce. So what we're looking for is a commitment to allow hospitals to invest in workforce. If that is state dollars coming to hospitals for workforce, that is great. That will ensure that commercial rates do not go up. But if we can't get that, then we very much need that flexibility to get the workforce that we need now. The other piece that was outstanding. Can you can you say give us the your final comment on you disagree with chair mullen, or you are willing to negotiate this provision? Where where is where are the hospitals with this one? I mean, what the hospitals are looking for is the ability to freely invest in workforce so that they can serve the healthcare needs of Vermonters. And so to the extent again, whether that is accomplished through state funding, great. Otherwise, we need flexibility with the Green Mountain Care Board. And if that's the Green Mountain Care Board making a statement that they will be providing that flexibility, we just need that commitment somehow. So I'm happy to talk to the Green Mountain Care Board further. But if they're not going to budge on this issue, then I would I would like this language. Well, I think it would be very helpful for you to engage with the Green Mountain Care Board. And then follow up, I think with our ledge council, if some agreement can be made, you know, we were on a fast track here. So we Yes, I appreciate that. And I will not slow this process down. So I will talk with the Green Mountain Care Board. And we will see what we can do. Thank you. That's great. And then my last comment is the budget process is in the house. Are you talking about the BAA? I am talking about the BAA and the retention funding. Yeah. Yeah. So I just as a cautionary note to the Senate folks that the House Health Care Committee is working with their Appropriations Committee and Representative Lipper can speak to that if you would like. But that is a soul separate process going on. And ultimately, it all comes together. So right. Yeah. Yeah, I'm not going to try to speak to the specifics. But we have we are very involved. The House, the House Appropriations Committee has now received recommendations from both the House Health Care Committee and the House Human Services Committee about recruitment and retention monies. Their their deliberations are not finished, but they will be finished soon because they intend to vote today, I believe, on a their their proposed Budget Adjustment Act recommendations, which will then come to the House floor, as I understand it, assuming things keep moving forward next Thursday and Friday. Thank you. Good update. Questions? Senator Hardy. Thank you, Madam Chair and Devin. I know you have to go. So if there's somebody else, but I'm just looking at your testimony that's on our website, so could you show us specifically or tell me specifically what provision on your testimony? There's this disagreement about between. Yeah, it's hard. It's hard to find it. Yes, I agree, Senator Hardy. That's why. So it's the third bullet. And it's the sub bullet of the third bullet, where the language. Is it notwithstanding any provision? Yes, that's yeah, and that's where the Green Mountain Care Board agrees. And then the subsection B is the Fawze language. Yeah. Oh, it's on the next page. It's happening at the very top of the page. Exempt hospital investments in order to meet labor demands from the best budget to actual reconciliation that part. Okay, thank you. I'm all I'm also sensitive to the issue of rate increases from the consumer perspective. And if I completely hear you about needing to invest in workforce, and I'm hoping that we can find a solution that helps you be able to do that without increasing rates and costs for patients and consumers. And maybe the solution lies with something that is going to be in the budget adjustment as as Representative Lippert was just talking about. But that would be my concern. And I'm guessing that's part of the concern from the Green Mountain Care Board also is is we don't want to serve solve the workforce shortage by putting it on the backs of people who need to access hospital services. So during a pandemic, I agree. And it's and started to jump in there. It's our concern too. It's just if we're going to have this discussion of hospitals don't need it, because they can build commercial providers, I think we have to realize that that is the end result. You can't please don't leave us out of these retention funding policies, or, you know, there needs to be adequate funding for all of this for us to not have to make that move or we can't have these narrow lanes in place where the Green Mountain Care Board and then this also. Yeah, absolutely. I get that. And I don't think anybody, or at least I haven't heard it in this committee has said that. So I know you're sensitive to what you're hearing in other committees. But thanks for that clarification as to where the language was good. And just FYI, Senator Hardy, before you came into the meeting, Kevin Mullin of the Green Mountain Care Board did identify the cost shift issue and didn't want to see any increased expenditures putting pressure on folks who then may have to seek a higher copay or out of pocket experience with their insurance. So yeah, I heard I heard Chair Mullin, I was here for that. Okay, very, very beginning of the meeting. But and I agree, I think we need to be sensitive to the cost shift and putting it on to consumers, especially at this time, while also meeting the workforce needs. Yeah. So Representative Lepert, and then Representative Cordes has a question. Yes, I would just caution us from and I sure Devin understands this as well. But I would caution representing the House Appropriations Committee position on this as characterized by Devin Green, I don't believe that is I don't believe that could possibly be the full understanding of the House Appropriations Committee. But there are in fact differences and not wanting to open up the issue of recruitment retention issues. But there are historic disparities between payments in the hospital system and in the community system. And I think in the context of that, there may have been comments made that were that may be misconstrued as hospitals can cost shift. And therefore, there's not an issue for hospitals, but there it's a broader discussion. And one which our House Healthcare Committee has weighed in on quite strongly because the community system has been historically underfunded and has no ability to cost shift. So comments may have been made along the way. But I really doubt that that represents the House Appropriations Committee's position regarding rates and hospitals. So I just caution that we not Thank you. inadvertently represent a position that may or may not be their position. No, and correct, I do not believe that that is the position in the House Healthcare Committee. This is what I'm talking about the House Appropriations Committee or the House and the House Appropriations Committee. But there's also concern about the amount. And there has been discussion elsewhere around this ability, this perceived ability of hospitals being able to cost shift. Yes, there I think it was a broader discussion that goes to a different time and place for us to engage. Thank you. Representative Cortes. Thank you, Chair. When talking about retention, I know that short term incentives for retention are, I think that's entirely appropriate when we're triaging, actually triaging the health care system right now when we are in an emergency situation. However, I just want to make sure that we're also thinking of longer term retention in terms of wages, not just bonuses. And I'm talking specifically about community mental health services as well as hospital based services. And is that something you can broadly speak to, Devin? I think we're in favor of that for community services as well. And I think what I, because I do have to jump over to my other testimony, but I think what I can commit to is a discussion with the Green Mountain Care Board on this issue and hoping to come to an agreement with them. And I did just want to bring this to the attention of the committees. I don't want to take this bill off track. And with that, I think I, if it's okay with this committee, I'll probably leave it there and turn this over to Jess to talk about the licensure extension a little bit, if that works. And then I'll be happy to come back and answer any other questions. Representative Cortis, does that answer your question? And is does that fit with your? It's more about long term wage increases as a retention tool, but I think that's a That's a longer term discussion. Yes, it is. Good. Yes. No, we're fine. And we're looking at a lot of things that we're going to have to evaluate going forward. Good catch. And I will say the one thing that I am very pleased about over the past couple of sessions, it was putting forward the request for increased reimbursement for some of our community services and that that has been realized, but we continue to see a deficit there. And we, you know, it's an it's not hasn't ended. And so you're absolutely right about our community services as well. So thank you, Devin, and we'll turn to Jessa Barnard. Thank you. Good morning, Jessa Barnard with the Vermont Medical Society, though here with my hat, on behalf of the healthcare provider coalition, I think Devin walked through all of our overall asks and since she has to hop off, I'm happy to answer other questions. The other the only, I think other outstanding issue was the conversation you heard at the last hearing about the out of state licensed healthcare professionals who come physically into Vermont to work on the staff of a licensed facility or FQHC. We are still working to finalize a timeline on that with Lauren Hibbard and OPR, but I think generally have agreement on the concept of a definition of what it means to be in the state temporarily. We're just still we have not connected on what temporary the definition of temporary means where we're landing on that shortly, we can get back to you on that soon. But I think otherwise no other changes from what we presented to you last week. Generally, all the other provisions would be the our preference would be the March 31, 2023. So if there are any other questions, happy to help feel those. I do have a question that's going to move into Act 21. But so if you would like, I'll hold that thought, but it relates to the licensure piece. Are there any questions for Jessa? And then I'll ask my question. Okay. So in thinking about out of state practitioners in state and then the telemedicine piece, any thoughts there in terms of any regulation or lack there? So our preference, as Devon mentioned this at the beginning is that ideally all of the and David Hurley, he mentioned this framework that both of the pieces sort of the one year piece and the long term piece move forward as soon as possible. So that's the one year switch from deeming to registration. And then the the solution that would come after that is a reg registration system for certain practitioners and then a licensure system for others based on the length of time they're practicing and how many patients they're seeing. My personal preference, if I could wave my magic wand, all of that would be moving as soon as possible. And ideally going in Act six, because we want to give OPR and the Board of Medical Practice time, if you recall under the telehealth licensure piece of permanent piece of that, there will need to be some rulemaking specific to each type of profession or board because it is too hard, I think to put all of the level of detail in statute, for example, some some boards and practitioners prescribe others don't some do more urgent care type visit. Some are seeing patients for years. So that needs some nuance and that needs rulemaking. And so ideally we'd like to see that authority set up as soon as possible. So that process can start getting underway so it will be in place, you know, in a in a year. If that is not possible to get all of that in Act six, then we'd at least like to see the one year registration system, because that really need that has the hard deadline of this March of going away. So that we feel like needs to move now. And then the other piece could potentially go in another bill. We still want that to pass this session. But if it needed to go in another bill that got worked on later in the session, I think that would be acceptable, though happy to, you know, obviously I'd want you to hear from OPR and the Board of Medical Practice on that. Good. Thank you. That's helpful. Sure. Any other questions for Jessa? Thank you. This is all becoming extremely clear. And so we'll move on to Lorne Hibbert. I think you're the last one on our witness list for Act six. And then we can move on if there are any other comments on Act 21. So go ahead. Thank you. Good morning. Lorne Hibbert, Director of the Office of Professional Regulation. I don't have additional comments from my testimony last week related to the Act six provisions. The one ask this joint session gave to the witnesses last week was which of these provisions should become permanent. And for the OPR specific or the licensure specific provisions, we are not asking for any of the Act six flexibilities to become permanent law. We would just like the Act 21 language to be enacted. And I agree with Jessa's testimony, you know, the temporary provision from April 1st until July of 2023. I'm really open to that being part of the Act six extension. I just, as Jessa said, there's a lot of work setting up the telehealth registration and licenses. There's going to be multiple sets of rules. Just you all are very aware of the rulemaking process. It's burdensome for an agency to go through appropriately. But it is substantial work. And I want to make sure that we have enough of a ramp to get that work done in an effective collaborative way. Thank you. Questions. Representative Houghton has a question. Thank you, Lauren. And this is Act 21, which I know we're going to talk about in a minute, but I just want to confirm when you're talking about getting the rulemaking set up in time, this is based on the proposal that we would have that long term registration or the long term licensing process in place by July 1st of 2023. Is that correct? That is correct. So for OPR, what that means is we will need to promulgate, I think it's 16 or 17 specific rule sets related to telehealth across all of our professions. We normally do three or four sets of rules a year. I think we're one of the most active rulemaking agencies just because we have so many professions under our umbrella. Our rules are not always incredibly complicated. Other agencies obviously adopt very complicated rules. So it's not really an apples to apples comparison, but I do think these telehealth rules will be complicated because we'll want to hear from not only the professionals responsible for regulating the profession, we'll want to make sure that they're consistent with each other to an extent, and we'll want to make sure that they will work out in the field. So it's going to need probably a little bit more than what we typically do for rulemaking where we can really rely on the institutional knowledge of the board and then have two public hearings. I just am foreseeing that we'll want to engage on a wider level because inherent to like our board of nursing is not doing telehealth from another state into Vermont. So they are practitioners in Vermont. They haven't done telehealth in Vermont. They clearly have a very valid and an active perspectives on what should be required for a nurse doing telehealth into Vermont. And we will want to hear them, but we'll also need to engage with some external stakeholders. So I'm just anticipating that will be a significant amount of work and assuming that that is the policy decision that Vermont makes, which I strongly encourage that you all do, the more notice we have to get that work started, the better. Great. And if I can just follow up and and we have a BAA request that we put in our referral level to house appropriations for OPR, everything you just discussed, some of that money would be used to help get to this point that you're talking about. Yes, the subsidized network. Yes, because because we will be in a gap where that work will be will be being worked on without any fee revenue being generated. Thank you very much. Thank you. And I appreciate your help with that BAA. Okay. Terrific. Any other questions on the what theoretically, we're still on Act six, but we've been and I think we are way back before. Sorry about that. We'll know that's okay. We'll come back to 21 and go into a little more depth in a few minutes. Representative Peterson. Yes, Chair Lyons, and I have a comment more than a question and it and it relates to what you just said. We heard a lot of great testimony today. But just from my standpoint, it would be so great to take Jen Carby's list of items that show the various acts and what we've done and the duration and somehow tie in what we just heard to that list because I'm lost. I got to tell you, I'm lost. I hear a lot of stuff, but I don't know where stuff is in relation to that very comprehensive list that Jen Jen Carby provided. So this is just a process comment. I certainly would love to see us go down the list or have the person testifying say, hey, item five on page one, that's what I'm talking to so somebody can follow it. So you just said what I was going to say. So on the same wavelength, I thought it would be helpful to hear the new testimony that we have. And then we will take Jen Carby's list, the new grid, and that thankfully your committee had recommended adding the recommendations column. We will go through that now. I'm thinking that at 1015, we're going to take a break. So we can begin to go through the grid. Representative Peterson, this is this will be extremely helpful to us. We can look and see what the recommendations are, where we are with each of the proposals going forward, which one's permanent, which one's temporary, which one's not to continue. And then we'll stop at 1015. We'll come back to that. We still have folks who are waiting to testify on Act 21, and we will come back to that testimony after we've gone through the grid on Act six, because we don't want to it's difficult when you're doing both telemedicine and then everything else. So we're going to start with Act six. Jen, I hope you're there and you can share your screen. I was going to say share your webpage, share your screen with us and go through this. Thank you, Representative Peterson. Spot on. Jennifer Carby, Legislative Council. I am sharing my screen. I made the column a little bit wider over here just to give us a little bit more room. So it's I think otherwise the same as what you had provided. I also added the piece about the request from the hospital association on the budget review in that piece. So you just want to go through this. It sounds like from the top. And yes, please. And so as much clarity as we can get on what it is that is being recommended for continuation or not. I mean, mostly looking at continuation, but there are a couple of things, there's several things that are just not that are going to expire. That's it. And if I can say as we do this, if we we may, we should also note, I believe there may be a small number, but at various where we are going to need to ask for additional testimony, where we have not. We did not anticipate perhaps the full range of testimony that we needed for today. But so that's if we can do that as we go through this, I think that would be helpful. Excellent. Yeah. The first provision is the direction to the agency of human services to consider modifying existing rules or adopting emergency rules so that they can protect access to health care services, long term services and supports and other human services and to consider the importance of the financial viability of providers rely on public funding. This is currently in effect through March 31st of this year and the provider coalition has recommended extending that through March 31st of next year. And per Representative Lippert's comment, we definitely need to hear from the agency of human services on this one. Make notes that as well. The next section is the authority for the Secretary of Human Services to modify hospital provider taxes and waver matter modify other provider taxes. And that authority has expired. It was valid during the state of emergency and for six months afterward. And I added the dates and we talked about them last time, but that state of emergency ended on June 15th. So this expired on December 15th. And there has been no recommendations so so far to extend that next. Is the directive that in order to protect non health care provider up non health care professional employees from covid that all health care facilities and human service providers follow guidance from the Department of Health regarding measures to address employee safety to the extent feasible. This is currently in effect through March 31st of this year and the provider coalition recommends extending through next year. And I know there was also some discussion when we went through this the first time about perhaps adding guidance not just from the Department of Health, but maybe from the CDC or other sources. Question there. I see that. Did we hear just a coalition have an opinion on adding CDC? Did we hear that? No. OK. We should get that. I don't recall what I what I think I recall testimony from someone and whether it was a coalition or someone else was just wanting to make sure that there was enough clarity around which guidance to follow that it wouldn't be either confusing or overly burdensome to try to figure out with all the changing guidance what the most current version is in consensus across all. Or that we not fall into having a list that is seen to be extensive or exclusive and find out that there's something else that should have been. But I see Representative Cortes, who I think brought this issue forward, wishes to comment. Yes, I was just going to say I brought I don't think it was a witness. I think I brought it forward and agree that the language needs to be clear enough that it's not too extensive and broad. OK, thank you. Can we ask to the same length? Yeah, let's let's make a specific ask that if the provider coalition has any comment on that, that they bring that forward to us so that we're if there is a comment or suggestion regards. I suggest a barter has a hand up. Yes, it has her hand up. I wasn't sure if you wanted to hear that now or in writing, but we I'm happy to. Make a comment would be helpful just to make a comment. Sure, we we did discuss this informally. And I think our preference would be something general like state and federal guidance because there are instances, for example, when the state does vary from CDC guidance in certain instances, or they may not always be 100 percent aligned. But if there were a general statement about state and federal public health guidance, we would be comfortable with something more general like that. OK, that OK. Well, that that will become a discussion point. So thank you. If you can put that in writing, it would also be helpful. And we can also make a note. You're like that for future conversation. The next is the provision that allows the Secretary of Human Services to wave or permit variances from the agency's health care and human service provider rules as needed to prioritize and maximize direct patient care, support children and families receiving benefits and services through the Department for Children and Families and allow for continuation of operations with reduced workforce and flexible staffing arrangements. This provision is in effect through March 31st of this year. The provider coalition is recommending extending that through March 31st of next year. And so this one is one where DCF, AHS and the agency will have to testify and also House is going to have to reach out to human services. Yes, thank you. OK, yes. Next is section five, which allows the Green Mountain Care Board to wave and permit variances from laws, guidance and standards on hospital budget review, certificates of need, health insurance rate review and accountable care organization, certification and budget review as needed to prioritize and maximize direct patient care, safeguard health care provider stability and allow for orderly regulatory processes that are responsive to evolving COVID related needs. This provision has currently expired. It was also valid during the state of emergency and for six months afterward. The provider coalition is asking to extend that through March 31st of 2023. They also are asking for hospital but a hospital budget review exemption for workforce costs. And this was the piece that the Green Mountain Care Board recommended extending through. 2022. Yes, through the end of. Yeah, 2022. That's another that's a point of discussion and we've asked Green Mountain Care Board to work with hospitals on this and perhaps get back to you, Jen. Not just the date, but the language. Yeah, the whole thing. Yep. I see Representative Goldman has a hand. Thank you. I'm just wondering if there are examples of how the Green Mountain Care Board used this provision. How it was, you know, really operate operationalized, let's say. So that I think hopefully will be in the bullets that we've asked them to provide to us. Is there one with us still? I can't tell from my screen neither. Kevin Mullen, are you here? Put it down for me. No, yes. Yeah, yeah, but I'm not sure if he's he's probably he's not here. Yeah, just trying to get off mute. I'm sorry, Madam Chair. You are here. We're used to using teams. And so I'm not as accustomed to zoom. Oh, well, I'm I'm going to critique teams someday. Anyway, we feel the same way about teams. Let me tell you. Yeah. Come to zoom, come to zoom. Anyway, you heard that. Did you hear the question? Well, if you could repeat it, it would be helpful. Yeah, Representative Goldman, if you could repeat your question, I think I think Chair Mullen alluded to some of the more specificity would be helpful, perhaps. Yeah, I just maybe I didn't understand that context. So now I understand more about what he's referring to. But I was just looking to understand how that was used the wave and permit variance is how it was used in your process during like examples of how you use that during the pandemic. Sure, we use the language during the pandemic to change some of the delivery dates for the budget submission. We used it to reduce some of the items that had previously been required to be reported by the hospitals. And primarily, it was just to try to create less burden on the hospitals, recognizing that they had to put their focus rightly on the pandemic and to still allow for a process that reviewed their budgets carefully. So I think it worked. The hospitals may have a different opinion on that. But I think that the flexibility that was allowed under the previous legislation worked very well. And having that six months still after the state of emergency was very helpful. And just to give you an example of how it could be used in the future coming year, as opposed to what happened in the past. What we've seen is that a number of capital projects were put on hold by the hospitals as they were dealing with the pandemic. They didn't want construction workers running around and things like that until they had a handle on what was happening. So what we have now is a historical number of CONs coming into the board for capital projects and the flexibility and the CON process, which wasn't really utilized as much in the the the previous bill would be very helpful in this one. So we could, you know, truncate that process to make it a little bit speedier. And we do have the ability to truncate it somewhat. And that's been seen in the speedy processing of changes to the Miller Building certificate of need, which had placed limits on the number of beds that could be utilized. And we all saw that those beds were all utilized and had to, you know, speedily approve that so that patients weren't denied care. If I may follow up quickly, Madam Chair. All right, ahead. Thank you. So it's apparent that this expired on December 15th, which got you through your last year's budget process. And you're starting your new one, not having it in place right away will affect your upcoming budget process or how will it affect it? Well, I'm not so sure that the hospital budget process would necessarily be affected because we'll have to go through that guidance discussion, which will occur in March. But I would assume if we're at the same states of elevation that we're in now, the board wouldn't be asking the hospital for additional information except for possibly tweaking and refining some current requests that we have. So for example, we've learned a lot in the investigation of the wait times. And we had allowed flexibility so that for example, UVM in the past has presented a different measure of wait times than a number of their colleagues. And we think that really needs to be uniform. And so that change would occur. I would hope that the hospitals would agree with that given the access and wait time issues that are in front of everything, but they may have an objection to that. But I think that for the most part, just having the ability to make the process a little bit smoother for the hospitals, if we continue in the current state of affairs would be helpful to the hospitals. And no one on the board wants to create undue work when that work could be spent better elsewhere, but we do need to get important information and that's a key part of our role. Thank you. Representative Donahue. Thank you. Just wondering if you could clarify, is part of what you're saying that existing statute locks you into some things that you do not have discretion to address in the context of what you might need because of the pandemic. So you need the flexibility adjusted because you would not be able to do certain things that you think would be appropriate. Yeah, we have flexibility under the existing statute, but there are some things that are specifically in statute as far as dates. And so let's say that there was God forbid a huge uptick due to some new variant that occurred. The board might want to have the flexibility to say that the actual decisions may not have to be made by September 15th or in writing by October 1st, but that would be dependent upon the environment that we were in at the time. And there was some discussion last time about changing some of those dates, but in the end we stuck to those dates. So I think that having the flexibility is good. I think it creates a lot more pressure on the board to use that flexibility wisely, but I would hope that we would. Okay, any other questions on this one? All right, good, thank you. And thank you for the clarification on that. That was, I know you said some of that initially when you were here, but having additional conversation, I think has reinforced this for folks. Terrific. All right, Jen, why don't we move on to the seeing no more questions on that section. Let's move on to the next one, which I think is the first one. Can we return to the screen share? I think that would be helpful. Yeah, it's working on. First one on page two, is that where we are? Yes, first one on page two. Yeah. And this section requires Diva to relax the Medicaid provider enrollment requirements and DFR to direct health insurers to relax their insurance plans, provider credentialing requirements, to allow providers to deliver and be reimbursed for services across health care settings as needed to respond to evolving needs. This is in effect through March 31st of this year and the provider coalition is proposing that that be extended until March 31st of next year. So we'll all need to hear from Diva and DFR and perhaps the insurers and at least, I think Blue Cross and Blue Shield is here with us today, but I don't know if they're ready to testify on that one. And there are two questions. I don't know who's first, but representative Peterson and then representative Goldman. Yes, and Chair Lines, you may have answered the question. They need to testify on that because I just had some questions as to what they mean by relaxed Medicare provider enrollment, whether that's still this long into the pandemic still required. I just like to hear more detail, but there's probably no one here that can give that detail. That's what my question was. Hold on to it. We'll do. Representative Goldman. Thank you, Madam Chair. I'm just wondering if by relaxing credentialing requirements, there's been an increase in complaints or any problems along those lines. So that's a good question for OPR and the board, David Hurley of the board. And I don't think, Lauren, are you still here? Yes, Madam Chair, I am. And if the question could just be relaxing which requirements have led to an increase? It said we... Yeah, this says relaxed health insurance plan provider credentialing requirements. Oh, so that was for the health insurance plans. I get it. Yeah. Got it, sorry. Okay, so that one would go when Diva and DFR come in you can hold that question. That's a really good question. Or would it go to the health insurance plans themselves, sort of what their experience has been of relaxing their requirements in terms of complaints? Sure, so you'd want to hear from Blue Cross and Blue Shield or MVP or others. So they should all be in on the list, I think. And Jessica Barnard has her hand up. Do you want to weigh in on this one? I just wanted to clarify why we're asking for this one since I don't think we've talked about it yet and how it works in parallel with some of the flexibilities for the timing of licensure. So there's the licensure piece which is your credential to work in the state but then there's also getting reimbursed by the payers. And so this is, they work together and that if we're having teams come in or providers come in at the last minute to help meet surge capacity needs we also want them to be quickly enrolled to be able to be paid for that service. So that's kind of how it works in tandem with the licensure piece but certainly would welcome hearing from DFR and Diva how it's working from their perspectives. Okay. Thank you, Jessica for that clarification. I think that's helpful in trying to see how this fits together. Any other questions? All right, Jen, let's move on. We'll do one more and then we'll probably be ready for break. Yeah. Okay. So this one is section seven from Act 91 and this provision allowed the courts and the Department of Mental Health to waive financial penalties if a treating provider failed to comply with certain documentation and reporting requirements for involuntary treatment. And this provision was valid only during the COVID-19 state of emergency. So it has at this point expired and there is not a request as of yet to extend it. Yeah, we haven't heard from the state. Judicial branch either. Apparently there's not a problem that persists so we can always talk about that. If you wanna take testimony, go ahead but I think there's been no recommendation for it. Right. Okay, any questions on that? Why don't you take your screen down, Jen just to see if there are questions. Okay, so when we come back we'll be on directing DFR. And so let's take a break for until 10.25. Is that sufficient? Representative Lippert. I think that'll work. All right.