 Hey everyone, welcome back to Health Healthcare. We are moving now to H741 and act relating to health insurance coverage for colorectal cancer screening. So we had the sponsor of the bill come in before break and we had legislative council walk through the bill. So we're now going to hear from all the various stakeholders about their thoughts on it. So we're going to turn it over to Sebastian. Okay. Hello everyone. Sebastian, I'm going to go for the financial regulation. I love the new space. It's very light and heavy. Claire gets her own office. Don't get used to it. And we would not be able to see your white board here. Yes. Yes. So I am here to talk briefly about the language in H741. In general, the department supports the idea of extending coverage to diagnostic colorectal cancer test. But we just wanted to raise one concern with the particular language in the bill. So I was going to share it on Zoom. That would be great. It is in the wrong lobby. And if I'm on my phone, it's only because I'm taking notes there because my computer has died. So we didn't think I'm not paying attention. I'm enjoying the Zoom lobby. So I turn my screen. I don't think it'll work on us. It's okay. I'm good. Okay. So the language that the department is concerned about is break here, which is linking the statute with the most recently published recommendations established by the American Cancer Society. The reason that we're concerned with this language is that the Affordable Care Act has a preventative services mandate that is linked to the current recommendations of the United States Preventative Services Task Force. Our concern is that if there is ever in the future a substantial divergence in those recommendations between the ACS and US, PSTF, that those services that are indicated in the ACS recommendations could be considered a new service that is subject to state deferring. And I just wanted to show that the recommendations right now are very similar. So these are the US Preventative Services Task Force recommendations. And as you can see, tests like colonoscopies, CT colonographies, and sigmoidoscopies are every 10 years for the colonoscopies every five years for the colonography and every five years for the sigmoidoscopy. And it is the same period for the American Cancer Society guidelines, but again, our concerns just in the future, the ACS adopts new recommendations and the Preventative Services Task Force does not. The last thing that I wanted to raise, and this is mainly for the benefit of the committee, is that the law in Vermont has another category for individuals that are at higher levels of colorectal cancer that allows for coverage of tests at more frequent intervals as directed by the member's physician. So that's this language here. So I can't see that part. So can you just tell me what page four? I just probably still won't be able to see. Can you tell me page in number? Yes. So this is the language that's already in law on page three, line 11, insured to a high risk of colorectal cancer, screening exams, and laboratory tests covered as recommended by their treating physician. So with that, I will stop and take any questions from the committee. Alyssa and then Art. I don't know if you know this or not, but the U.S. Preventative Services Task Force, their A and B ratings, where do they, where do they get those from, do they get them from sort of like the medical societies? Yeah, so lag time. That's a great question. And the sources of their recommendations are in the recommendation document, which is available on the Department of Health and Human Services website. It's a whole research paper that has multiple, multiple studies cited. And I've submitted this document from the Preventative Services Task Force as part of my testimony today. Do we know when this one is from 2021? This one is from 2021. And this is the most recent recommendation from the Preventative Services Task Force. Art. Yes, could you go back? Boy, forget your name. There we go up to page three, line 11. And I apologize. I don't have my stuff. I wasn't here here. Yeah, that wording and verbiage, would that cover the intent of the bill? That verbiage there. Screening examinations and laboratory tests. My understanding is that the intent of the bill is to address a difference in billing between screening examinations and diagnostic examinations. And so the answer to your question is no. This just allows screening examinations at more frequent intervals than the Preventative Services Task Force or the American Cancer Society recommends. Which means they would be covered or that's? Yes, which means that screening examinations would be covered. But if you were to just use this language, that would exclude diagnostic examinations. And in brief, the difference between a screening examination and a diagnostic examination is when you're being screened for a condition, there's no evidence. A diagnostic exam is we have some evidence that something might be wrong and we want to see what it is. So there's no language and statute that addresses that? Right. So that is, as I understand it, the intent of this bill. Got you. Okay. I'm glad you brought that point up, because that is not how I read the intent. So can you direct me to where you're seeing that? Yeah, just to... Oh, I'm sorry. The insured, who is that? Average risk? So that would still be... So that would be considered diagnostic, not screening? I'm sorry. Yes, screening. Okay. So we're expanding screening. My apologies. I was thinking of the bill we're talking about tomorrow, too. Okay. That was... Yes. Thank you. So this is expanding screening, not by age, but by risk factor. Okay. Great. Brian? Yeah, I just want to add to make sure if I had to summarize this, we are expanding screening, coverage of screening for colorectal cancer. Yes. With no cost sharing. Yes. And right now, what is the... Right now, what is the policy? So... 50 years old. Yes. But the current policy, is it that we cover all screening with no cost sharing over 50 or is there cost sharing? Right. So the current policy, if you have commercial insurance, what is happening now is that insurers are following the U.S. Preventative Services Task Force recommendations for these screening colonoscopies to determine whether or not they're covered without member cost sharing as a preventative service. So what's happening, in effect, is that the language of the Affordable Care Act is overwriting the language that is in our statute. So under... I just want to understand the difference this would make really clearly. Yeah. Like under current policy, somebody over the age... People over the age of 50 are eligible for some kind of coverage. However, if they're underinsured, there might be a barrier. And under this policy change by eliminating cost sharing, regardless of their insurance status, their insurance plan, they would have no cost sharing? Yeah. The policy change would be to effectively lower the age in which individuals are who are not at high risk for colorectal cancer. To access those screening colonoscopies at no cost sharing. Okay. So currently, if you're above a certain age, there is no cost sharing, it would just lower... Okay. Thank you. That's what I wanted to get at. 50 and above, there's no cost sharing. Currently. All right. Thank you. That's what I wanted to clarify. So I just want to clarify. So this, the language says for an insured who is at average risk, you're equating that to an age, though, or are we looking at a risk or are we looking at both? So average risk is not defined by age. It's effectively anyone who is not high risk. And the criteria for being at high risk are in subsection C on page three, lines 60 and 320. So family medical history, prior occurrence, polyps or prior occurrence of conditions such as Crohn's disease. So for that classification, we are at high risk. You can get a screening at no cost share. Yes. Today. Today. And as often as is recommended by your physician. And if you are in an average risk, we need this language to include that group of people who is anyone other than someone in high risk. It does nothing to do with age. Right. Okay. So when you said bring it down to 45 confused by that statement. So if you look through the language on line three that is struck from the statute, the law has written limits screening for those who are at average risk to insurers aged 50 or older. We're getting rid of that. Yes. Okay. But again, that is not how insurers are processing claims because they are following the language in the affordable care act, which is better a lot. That was my question is, it doesn't matter if we have 50 in there, they have to follow the affordable care act, which is a level B. So therefore they must cover it to 45, starting at 45. Right. So do we need anything? Do I need this? Let's wait till the crossbow shield comes up. And then we go ahead. Technically, no. However, if for whatever reason, if the affordable care act were to be repealed or if the preventative services mandate were found unconstitutional, then this language would absolutely be relevant. Yep. Okay. Which we're used to that. We've done this before. Should we change though the language established by the American Cancer Society to established by the US preventative service? That would be the department's recommendation. Okay. All right. Did you have another question? Yeah. Well, we talked about no cost share. Is that in here somewhere? Yep. So it's in subsection D, which is on page four. Yeah. Okay. Not subject to any copay deductible co-insurance or other cost sharing requirements. If we aren't directly, but sure. Does that apply to everybody? Yes. Okay. All right. Great. Any other questions for Sebastian? All right. Thank you so much. So I've made the note about the change in language. I'm trying to do. Okay, go ahead. I don't know if someone else asked it though, because I'm trying to process it. So if so, I'm sorry. But if you said it already, can you just say it again simply for me, why you would recommend replacing the American Cancer Society recommendations with the other groups? Yes. So the reason is that because the Affordable Care Act Preventative Services mandate is panked the recommendations of the Preventative Services Task Force, there is the possibility, however, remote that the Cancer Society would adopt recommendations that are different than the Preventative Services Task Force, in which case there's the risk that whatever services are different may be subject to state defraud. Although they would be considered ineffective. Oh, yes. I remember you saying this earlier. Thank you. Yes, I remember that. Thank you, Sebastian. Alex, I think you're online either. I am. Good afternoon. We see your love. There you are. There we go. Ting, can you guys hear and see me all right? Yes. Thank you so much, Madam Chair for the record. My name is Alex McCracken. I'm the Director of Communications and Legislative Affairs for the Department of Vermont Health Access. I will be very brief today. Diva is very supportive of the intent behind this bill, the expansion of preventative coverage and screening for colorectal cancer is very much in line with the department's mission and priorities. We have one note that we'd like to make on the bill as drafted, and that is on the final page, the effective dates are listed as written for January 1st, 2025 for all health insurance plans issued on or after that date. The plan design for 2025 has already been completed, so we would need, we would ask this date to be pushed to January 1st, 2026 for plan design. That is really our only substantial note on the bill as written at this time. I'm happy to answer any questions or provide or run feedback back to the department for additional input, but I don't have anything else to add at this point in time. Thank you very much. Thanks, Alex. Any questions for Alex? That was fast. Thank you. Happy to help. Thank you so much. Good afternoon. I'm Sarah Tichot, government relations with Blue Cross and Blue Shield of Vermont, and with the change that DFR recommended switching from the American Cancer Society to the U.S. Preventive Services Task Force recommendations, we wholly support this bill. We already comply with this, and this is already the way that we are implementing this benefit. I can answer questions if you have any, but we're actually fine with the effective date as it is. You're fine with the effective date. Any questions? I think I do. First of all, I want to apologize that I was absent the day that you all discussed this, but I had thought the bill included something else, and maybe I'm wrong, but I wanted to know what Blue Cross Blue Shield does currently. So if somebody has a positive fecal, the ligop, colicard, you know, and then they test positive for that, and usually the recommendation is that you then move to a colonoscopy. And I had thought that there were coverage issues around then covering the colonoscopy is preventative, that it was being covered as diagnostic. What does Blue Cross do on that? Do you all cover it as preventative? Cover it as preventative. Okay. I'm not sure if every insurer does it, but that's the how we are doing it, and I thought there was something in the U.S. preventative task force about covering that. About covering that, but I would have to look again. Okay. See what it says. And then can I just, sorry, can I just clarify, you're okay with the 125 start date, or you went the point? Okay. Sorry. We're already doing it. You're already doing it. Okay. Hold on. All right. Alex, are you still there? Hi. You got saying. I'm still here. What is Diva Medicaid do for the question Alyssa just asked? As far as what we cover currently? Yeah. All right. I would need to get an answer more specifically on that front, but I believe that what we do currently is in line with the bill. Okay. All right. Go ahead. Yeah. Thanks, Alex. I'm trying to determine in my mind how this changes anything than what we do if physicians can recommend, okay, sure. Physician could recommend someone to have this anyway, right? So correct me if I'm wrong. Whoever might be around. The way the languages is today, a physician can do that for a high risk. Okay. So now we're saying that anybody, anybody, so even if you have no thought of it, but you just want to get it done, I don't know why you'd feel that way. Go ahead. If you just wanted to get it done, you could get it done. Is that what this says? Sarah, teach it with Blue Cross. I don't think that's quite accurate. Okay. So what it says is for a person who is average risk, we're going to follow the U.S. Preventative Services Task Force recommendations. All right. For someone who's high risk, their physician makes the determination. Okay. So it's two groups of people. Yeah, two groups of people. And good. Thank you. Alex. The guideline for average risk. I think it's down to 45. Yeah. Any other questions for Sarah? And so for those 45 and above at the average risk, then they could do the cold guard. And if it's needed, a colonoscopy after it's still preventative. Correct. Okay. That's how Blue Cross is reading it. She's still the cold guard has to be performed. No, I mean, no, it can go right. You and your physician shoes. Yeah, I'm trying to pick it apart. I get it. But I do want to Sebastian Erdogan again for the Department of Financial Regulation. So the cold guard isn't a conclusive test for the presence of colorectal cancer. So in 2020, when more and more people started getting the cold guard test, we updated insurance bulletin 207, which outlines the department's reading of the statute to say that follow up screenings that follow an inconclusive test are also screening colonoscopies that should process without member cost sharing. Okay. All right. Does that help? All right. Any other questions for Blue Cross through Shield or GFR? Okay. Thank you. Oh, Leslie. Sorry. Leslie, go ahead. Hi, everybody. Sorry. I'm just wondering some something like cold guard can be ordered by a non physician clinician. And throughout this bill, it only says physician. So I'm just wondering how that how that squares. I don't have the language in front of me, but I believe that. Oh, thank you, Sarah. I believe that the department has always viewed the word physician to be broad in that the physician as that term is used in the statute doesn't need to be an MD. It could be a nurse practitioner or whoever is treating that member. I'm not sure that makes sense. I mean, I get what you're saying, but I'm not sure it makes sense. So something I would like to think about to the extent that you're suggesting changing the language to buy the treating provider as opposed to the treating physician. I don't think the department would object to that. Well, clearly colonoscopies are done by physicians, but there are other screening tests ordered by non physician providers. So I'm not sure exactly where that might need to be addressed, but I'm just curious about that. Sebastian, you would be okay with what did you just say? Provider or clinician? I'm changing the word physician on page three to the member, the individual's provider or clinician or a term that would capture the whole universe of health care providers. We'll ask, we'll get with Ledge Council on that. Sarah, would you, I mean, okay, we'll put language back out. Are you good Leslie? Yes, thanks so much. Great. Thank you. Great. Thank you both. So, and I apologize. Jill's going to go, Topper's going to take over. I have a meeting I have to get to. Jill's the last one. Jill's the top attorney for medical society, and I'll just pretty briefly support legislation. We actually learned about the age being in the statute in 2022, and we thought that that didn't make a lot of sense. Just because these recommendations change a lot. And so, yeah, it had been brought to us, and we actually put language in. There's a Senate bill that we have in right now, and we have it connected to the USPST recommendations. Actually, the language we have says those recommendations or the least restrictive, just because there are a lot of different changes. And so that was what we thought it was was really changing the provision to take the age out of the statute. We think that that is meaningful and a good step. That's basically what I'm here to say, and we support more screening and more eligibility. Vermont has a very high rate of colarctal cancer, and it's the second-leading cancer depth risk for Vermonters. So. So, so what you're saying, Jill, is you want to keep age out of. Yeah. So, don't you think that's least restrictive? And we say, you know, take the age out so that you can follow the recommendations from the guidance. So USPSTF is fine with us. We think American Cancer Society is a little bit, you know, they were at age 45 before USPSTF went to that, and it took some time for the data to catch up. But for us, it's really the age out of the statute, which is important. Any questions, Jill? Just one question. How about frequency? We took age out. As I remember, it was supposed to be every 10 years. You got a colonoscopy. Yeah, that's in, yeah, that's in the statute. And that's still in there. And that's still valid. Oh, yeah. It looks like it's taken in. All right. Yeah. Yeah. Okay. Yeah. All right. Thank you. I have one question. And I apologize for asking this, because I don't think you're going to know, but I'm thinking about dueling societies. The American Association of Gastroenterologists, what are they recommending? And they support 45. Who came first, I guess, Cancer Society, Gastroenterology. Cancer Society. Okay. So how long after the Cancer Society, three years after then the Gastroenterologist said, and three years after USPTF? So at least restrictive, too, but it sounds like it's connected to the ACA and so that there is risk there. Also, yeah. Any other questions? Okay. Thank you. So that wraps it up for today. Okay. It's a wonderful job tonight. Any topper? We all agree. Or should we say legislative topper? Tomorrow, the 13th, 9 o'clock. In the committee room. In the committee room. Good. Okay.