 Good morning. It is Senate Health and Welfare Committee and it is April 9th. Today, we're going to look at two bills relating to health care affordability and accessibility working to determine how best to move forward with what some are calling health care reform and so we'll look at S132 and S120 and before we begin, I think just to digress for a second, I've asked I've been working with with Nellie and ask Ruth to put together a spreadsheet along with Nolan on some of the budget requests that we're seeing and so and so thank you very much Ruth. I think Nellie is getting you some information and information keeps coming in coming in from people requesting either ARPA funds or some base budget improvements. So we'll we're going to put all of those together and on on Tuesday we'll be able to look at that spreadsheet and the requests that have come in from various parties. Not all of them have been in committee. I want to make that clear but they are written fairly clearly and hopefully with our background and the work that we've done in the past on these organizations both with CRF and more recently we'll be able to make some establish some priorities. So I'm looking to Ruth and working with Nolan and so we'll try to get that out to everyone before the end of the weekend. Does that make sense Ruth or Monday? I'll try to get it to you Monday morning. Nolan has sent me a first list which Nolan I haven't looked at yet but I will work on it this weekend. If any of you have things that that you want to send me also we'll put it on the list. I'm going to try to color code it or organize it in some way. We can go through it easily. Perfect. Sounds terrific. So then we'll look at you can bring in what you have on Tuesday and we'll go through it. That'd be great. And Nolan thank you. This won't be easy. I know that we've got things in the budget and then we also have requests for one-time money so sorting it out sorting out our priorities our policy priorities is number one and then where the money comes from will be up to appropriations. So but we'll have to see how all that fits together. Okay so Jen Carby is here with us to go through two bills. The first bill S-132 let me just explain a little bit about what's in that bill and I would like to say right from the outset there's a lot in that bill that that is going to be as we go through the bill I or you on the committee can make some decisions about the difficulty of evaluating those and including those in any legislation at this time of the session so I'm happy to discard there are a number of things that I've already decided we might want to consider discarding. On the other hand there's a the goal for us in making healthcare more accessible and more affordable as much as possible to align the payer system that we have so and when we think about aligning a payer system then that leads to more uniform access for folks and also then allows for us to consider how to reduce co-pays and other premiums that patients right now are experiencing some really a lot of hardship and healthcare has reached a very high cost it continues to go up and then also knowing that some of the reform efforts that we have have held back and held down the increase at least the 3.5 cap I will call it a cap but 3.5 cent budget restraint for hospitals has been effective and so we want to keep looking at some of those things that are helping keep the reigns on cost without harming the system itself that's one another goal that I I see and I'm very committed to which has been a part of the ACO discussion is the relationship between provider community medical provider community and our social service community and ensuring that we have some continuity of care and that there is some case management going forward that allows for people not to get lost in this system and again that comes back to how we align our social services and our healthcare medical services together so there's a lot of thinking that we will want to do and I know that you all have been thinking about this and so I'm going to turn it over to Jen to go through S132 and then to go through 120 and our goal today is simply to to look at the bills so and then we're going to hear from DFR who's doing some work on the basic benefits is what I always call it but that's not what it is benchmark plan with respect to hearing aid assistance so I want to hear from them because that's something we might be able to continue to work on along with DFR and others so then after we've gone through those two bills we're going to come back to some primary care issues with the Green Mountain Care Board and we'll try to take a break in between so there we are so Jen thank you for being here and we'll look forward to going through those two bills I know that one is a little more a bumpier road than the other but let's let's see where it takes us great thank you good morning Jennifer Carby Legislative Council I will put the bill up on the screen okay hopefully you can see that this is S132 an act relating to healthcare reform implementation it has a number of different topics in it so I tried to use these reader assistance headings just to kind of ground you in what the topic is as we go through so the first couple of sections are on responsibility for healthcare reform efforts section one would amend the existing section that creates the position of the director of healthcare reform in the agency of administration which is currently responsible for coordination of healthcare system health care system reform efforts across the executive branch this would add then a specific requirement that the director of healthcare reform be the one to coordinate and lead all state initiatives relating to healthcare reform including innovations and healthcare system payment and delivery section two deals with the all-payer model the full name of which is the all-payer accountable care organization model and this says that upon renewal of the terms of that model agreement the all-payer model agreement with CMS the Centers for Medicare and Medicaid Services the agency of human services would assume responsibility for oversight of state efforts to achieve the agreement targets in the model as set forth in an existing statute and any similar or successor model and agency of human services would lead the state's efforts to achieve the agreement targets the state's renegotiation efforts and the stakeholder involvement processes so this is expanding on the role of the director of healthcare reform in the agency of human services and the role of the agency itself in the state's healthcare reform initiatives Jen who are wait do you want us to wait till you're all done or interrupt you as you go which is whatever it's probably easier if you just ask your questions as we go along because we'll be looking at the language okay before who has these responsibilities now uh right now the a lot of the efforts or responsibilities are split between the director of healthcare reform um the green mountain care board um those are sort of the the main ones and I think the idea here would be is to move all of that kind of reform minded effort under the director of healthcare reform and leave the regulatory duties with the green mountain care board okay thanks senator alliance is that I mean you're you're the sponsor so I can uh that that's like you speak for yourself as well yep nope that's accurate so that was the first two sections and then we move more directly into acos um section Jen before before we go back and senator alliance so can you just clarify the acos rule here I mean if we have the the director um having authority and the board having authority then what what's the role of the aco the acos involvement is really in carrying out the healthcare reform effort so the state has designed them the aco is playing a role in achieving them but isn't the one overseeing or um it's the one being overseen it's the one being regulated and um and participating in the healthcare reform initiatives okay all right thanks and then we go on and we the state also regulates acos and we're going to look at some potential changes to those requirements in these next sections section three amends the existing law where the green mountain care board is required to certify accountable care organizations and do annual budget review for accountable care organizations and so the first part of that existing statute is the certification piece um and it requires uh under existing law that uh in order to certify an aco to operate in the state the board must ensure that certain criteria are met so this is adding to those there's an existing uh criteria about the acos governance leadership and management structure this would include language that says the salaries for the acos executive officers do not exceed an amount equal to the median salary for a primary care physician participating in the aco so looking to put some some guardrails some boundaries on the salaries for the executive officers the next piece adds on to some existing language around coordination with the blueprint for health and this would specify that the aco coordinates with the blueprint's patient-centered medical homes and community health teams and acts as the link connecting patients with appropriate health care and social services including those offered by designated agencies specialized service agencies parent child centers and schools then in another existing provision around the aco's acceptance and contracting with providers to participate in the aco this allows specifically allows the aco to contract with a participating provider for a multi-year term so it doesn't just have to be a one-year contract it can be a multi-year contract so those are all in the certification piece and then in the budget review piece where existing law directs the board to review and consider certain items this would add on to the existing provision around information on the aco's administrative costs and it would say including either the annual salaries and benefits for all of the aco's employees or the same salary and other compensation information for the aco's officers directors key employees and other highly compensated employees for the previous calendar year that the aco provided to the irs on its form 990 for the most recent tax year or that the aco would have been required to perform to provide on form 990 if it was exempt from federal income tax so this is really piggybacking on the existing irs criteria around what kind of salary and compensation information has to be reported for nonprofit organizations exempt from federal income tax under 26 usc section 501 but i think at least currently the the one aco that is certified in the state is not a nonprofit under federal income tax laws so it says report the information like you would if you were tax exempt and if they are tax exempt then just provide that same form 990 information and then it finally it adds a new budget review piece for the board to review and consider and that is the extent to which the aco has met the quality measures specified in its payer contracts and if one or more of the quality measures has not been met the aco's and payers plan to remedy the deficiencies so that's all in the context of the green mountain care boards certification and review of aco budgets then this would add a new section it's section forward to add a new statutory section i want to just stop there for a second gen there is or anything currently that asks the green mountain care board to evaluate the quality metric analysis that's going on with the aco uh i'd have to i'd have to look i'm not flowing from the green mountain care board how they incorporate that but certainly it's an important aspect i do think there are some uh there i do think there are some provisions in the existing law that require the aco to have um quality measures and to be evaluating them this is looking more at the outcomes of that at the results of that so then we have a new section uh around the aco the value based payments and distribution of shared savings and this creates a role for the green mountain care board in that so it says that the green mountain care board using the results of an aco's quality analyses pursuant to a section we're going to see coming up so a new section so the green mountain care board using the results of the aco's quality analyses must establish a methodology for determining the amounts of the value based payments that the aco must make to its participating providers for delivering services to its attributed patients so the board would create a methodology for determining the amounts of the value based payments and then the board shall apply its methodology and shall notify health insurers and vermont medicaid of the value based payment amounts based on its determinations in order to inform the insurers developments of their rates for health insurance rate review the board does and to inform medicaid's development of its all inclusive population based payment arrangements that the board reviews in accordance with existing law as well so this is just to summarize this is directing the board to come up with a way to a methodology for determining the amounts of the value based payments and then tell calculating them and telling them telling the insurers and medicaid what they are so they can be built into their financial models their rate reviews and their all inclusive population based payment arrangement and currently that value based payment is determined by the aco i think it's the between the aco and the payers and the payers right so this would put the board in that role instead and then it also would have the board and said a few words but it's a big impact would have the board using again the results of the aco's quality analyses that we'll see in the next section to determine appropriate allocations of shared savings if any for distribution among the aco's participating providers so this piece is having the board figure out how much if they're shared savings how those should be distributed among the aco's participating providers and this is something that currently i believe is just the aco that's in this role section five is a new section that would go in with the aco some statutes around the aco itself so in a different chapter from the board because it's really about the aco this directs an aco to collect and analyze clinical data regarding patients age health condition or conditions health care services received and clinical outcomes in order to determine the quality of the care provided to its attributed patients implement targeted quality improvement measures and ensure proper care coordination and delivery across the continuum of care so having the aco collect and analyze data about about what's going on with its attributed lives to determine quality and figure out how to improve things and ensure proper care coordination and it requires the aco to provide the results of its quality analyses to the green man care board so to inform the board's determinations of the amounts of the aco's value-based payments to participating providers and to calculate appropriate allocations of shared savings for distribution to the participating providers so in the previous section of the statute of the of the bill that we'd looked at it would create it would create a new some new roles for the green mountain care board informed by this aco data collection and analysis and then here's the flip side of that directing the aco to do that collection data collection and analysis and provide it to the green mountain care board Jen yes in isn't paragraph a aren't they already supposed to be doing something like that I mean that seems to be what they say they're doing right I don't I'm not sure that this is a new role for them but it's not a statutory requirement so this is this is kind of putting it in the statute in part so that that information can be can be provided to the board directed to be provided to the board to inform the board's work around the value-based payments and shared savings okay thanks so sure and I'm sure the aco could tell you what they're doing in this area currently but I don't know that it was necessarily intended as a completely new role all right and then section six is some language that has also appeared in I think there's a standalone bill that may be either on the wall in this committee or in another committee that would require a certified aco to make available to the office of the auditor of accounts or the state auditor all records of the aco and any affiliated entity that the auditor and the auditor's discretion and upon request determines are needed to enable the auditor's office to audit the aco's financial statements receipt and use of federal and state funds and performance as set forth in the the statute creating and setting forth the duties of the state auditor so this again is requiring the aco to provide all the information to the auditor that the auditor thinks his office needs to audit the aco and ensure appropriate use of federal and state monies all right so then we get into a section on the green mountain care boards duties and this is really kind of I put it here as kind of a bridge section because it incorporates what we just looked at and then what comes next this adds two new duties to the green mountain care board the first being to establish the methodology for determining the amounts of an aco's value-based payments and appropriate allocate appropriate allocation of shared savings among the aco's participating providers so that was the piece that we looked at and then in the next section we'll see this new duty to review and approve proposed fee schedules and health care contracts between health plans and health care providers and so here is a new section which did you want to just a short comment on the number of contracts that are there it's probably what what we understand is that they are significant so I guess the discussion around contracts really goes to maybe goes to model contracts or some kind of evaluation of fewer contracts than all of them so it would be probably unbelievably difficult to do all of them yeah and I think we'll see as we go through and you know you've set up a process for kind of for the board to to collect a representative sample and get a sense for what they would be reviewing for so there may be modifications needed at that point. I will note as I was sort of looking through the bill preparing to do the walkthrough this morning that I appear to have used section 93.84 as a new section twice it's because we currently the statutes currently go through 93.83 here so this would be something to change going forward and it does get referred to in cross references a few times so apologies for the error and any confusion but this would add a new section in the Green Mountain Care Board statutes around review of health care contracts and fee schedules it uses some existing definitions in chapter 221 sub chapter 2 which is on claims processing and contract standards for health insurance plans and then it says that a health care contract between a health plan or other contracting entity and a health care provider shall not be effective until it has been reviewed and approved by the Green Mountain Care Board for fairness and consistency with the provisions of that sub chapter on claims processing contract standards the board's rules and other applicable laws so health care contract would not be effective until the board has reviewed and approved it and similarly a fee schedule setting forth the amounts that a health plan or other contracting entity shall reimburse a health care provider for delivering health care services shall not be effective until it has been reviewed and approved by the Green Mountain Care Board for fairness and compliance with the board's rules and other applicable laws and it directs the board to adopt rules establishing the fee schedule and health care contract review processes including the standards under which the board will review proposed fee schedules and health care contracts so there that might be an opportunity to to lay out some things that would that would be appropriate once they determine what they should be reviewing forth then there's some changes section nine makes some changes to an existing statute on fair contract standards and this is about contracts between payers and providers so the changes in here other than a just a grammatical correction um are first to eliminate language allowing contracting entities to require health care providers to execute written confidentiality agreements with respect to fee schedule and claim edit information received from contracting entities um and then putting in language requiring contracting entities to provide at least 120 days for a provider to consider a proposed contract and for negotiation of contract terms including reimbursement amounts adding language requiring that health care contracts must be for a minimum of two years and that prior to health care contract taking effect it must be reviewed and approved by the Green Mountain Care Board for fairness and consistency with the provisions of the sub chapter the board's rules and other applicable laws and then it takes out this language that says that requirements of subdivision b5 of the section do not prohibit a contracting entity from requiring a reasonable confidentiality agreement between the provider and the contracting entity about the terms of the proposed contract so taking out a couple of provisions around confidentiality section 10 requires the Green Mountain Care Board to collect and review a representative sample of health care contracts and fee schedules from health insurers including contracts and fee schedules with hospital affiliated and non-hospital affiliated health care providers in order to inform the board's development of its methodology for reviewing health care contracts and fee schedules in accordance with that new section and on or before january 15th of 2022 the board would provide information to the house health care committee this committee and the finance committee regarding the board's proposed methodology for reviewing health care contracts and fee schedules including the standards and criteria that the board intends to use for its reviews and then it says that confidential business information and trade secrets received from an insurer through those sample representative sample of contracts would be exempt from public inspection and copying under the public records act and kept confidential except the board can disclose or release information publicly in summary or aggregate form if doing so would not disclose confidential business information or trade secrets so they can kind of tell you what seems to be you know themes or particular types of sections that are provisions that are in the contracts but without disclosing business secrets all right then we're going to turn to a different topic this is on durable medical equipment let me just say this is a bill that we've had in committee um i don't even know i don't know whether we introduced it this year or not um possibly i don't think so but it is a concern uh the cost of durable medical equipment continues to be a concern across the board so uh unless you're selling it yourself the the providers the payers everyone is concerned about these costs so uh i've included it here this would add a new sub chapter in 18 vsa chapter 221 which is on healthcare administration sort of broadly on durable medical equipment and cost transparency so it starts out with a definition of durable medical equipment which means equipment such as a walker wheelchair or home oxygen equipment that meets these criteria withstand repeated use it primarily and customarily serves a medical purpose it generally is not useful to an individual without an illness or injury and is appropriate for use in the home it requires health insurers to provide clear information to patients regarding their out of pocket exposure for the purchase of items of durable medical equipment it would direct a provider of durable medical equipment to inform a patient whether it would be more cost effective for that patient to purchase a specific item of durable medical and i found another type of this morning equipment not insurance whether it be more cost effective for the patient to to purchase the specific item for cash rather than using insurance and it prohibits a health insurer from or it says a health insurer cannot prohibit or penalize a provider of durable medical equipment for disclosing to and insured the cash price for an item or for providing information to an insured about the insurance cost sharing amount for the item of durable medical equipment so for some of you this may sound somewhat familiar it's similar to the prohibitions on gag clauses as they've been called for in pharmacies for prescription drug prices that you passed a few years ago so it's sort of a similar similar type of information to the consumer and prohibition on limiting what the the seller can or the provider can inform the patient about then we get into as senator lions mentioned before we started the health insurance coverage for hearing aids this is a bill that is either on your wall or in the finance committee um i i don't know i guess it's in the house this but this time it's in the house it was in finance last year we i don't think it's senator comings you're muted you don't think you have it this year yeah no i don't think we have it this year no it didn't make it out last year right and it went great and we had a similar bill in health and welfare at one point and then it got um moved over to you and finance but again and then this is the cost yeah so dfr is working with other interested parties on this issue so we'll hear from them right and they're not necessarily working specifically no are they on the hearing aid part piece but yes so so i think some of it will make more sense as we go through this would add a new section to the statutes on hearing aids um and what's important for this is the definition of health insurance plan because it's really defined in a way that um does not include the individual and small group plans sold both in and outside the exchange or the reflective plans so this means it defines it as a group health insurance policy or health benefit plan uh offered by a health insurer and includes Medicaid so it does include a Medicaid and any other plan offered or administered by the state or a subdivision or instrumentality of the state so that pulls in the state employees plan and the plans offered to teachers but it does not include a qualified health benefit plan or reflective health benefit plan offered in accordance with those statutes or a policy or plan providing coverage for a specified disease or other limited benefit coverage so i'll take a pause here to explain why it's written this way and this is some of what you'll start to get into with dfr as well there is a requirement under the affordable care act and we may have talked about this before um that the state defray the state pay the cost of any new health insurance mandate enacted after 2011 um so for the qualified health plans for the individuals for vermont individual and small group market plans if you were to enact a requirement that health those plans cover hearing aids the state would have to pay all of the additional premium attributable to that new mandate that's what's called state defrayal so this is written to take kind of an incremental approach so that the mandate would apply to the large group and to the governmental self-funded plans which we can regulate it would apply to them now or starting in 2022 and then set up a process for trying to for looking at changing the state's benchmark plan um to include hearing aid coverage but you'll hear from dfr more about um the benchmark plan and and what's involved in that it's not as simple as um just adding a benefit um you have to make other changes as well so that's why health insurance plan is defined to really be large group including state employees and teachers and also Medicaid for this purpose so then it defines hearing aid as any small wearable electronic instrument or device designed and intended for the ear for the purpose of aiding or compensating for impaired human hearing and any parts attachments or accessories including ear molds and associated remote microphones that pair with hearing aids to improve prove word comprehension in difficult listening situations in live or telecommunication settings the term does not include batteries cords large audience assisted listening devices such as those designed for auditoriums or standalone assisted listening devices that can function without a hearing aid hearing aid professional services is the practice of fitting selecting dispensing selling or servicing hearing aids or a combination including evaluation for hearing aid fitting programming hearing aid repairs follow-up adjustments servicing and maintenance of a hearing aid ear mold impressions and auditory rehabilitation and training hearing aid professional is an audiologist or hearing aid dispenser licensed under the professional licensing statutes physician so an osteopathic physician or a medical doctor a physician assistant or an advanced practice registered nurse so then it requires a health insurance plan to cover the cost of a hearing aid for each ear and the associated hearing aid professional services when the hearing aid or aids are prescribed fitted and dispensed by a hearing care professional the coverage provided by a health plan for hearing aids and associated services shall be limited only by medical necessity but a covered individual can select a hearing aid that's an excess of what's medically necessary and pay the additional cost the coverage required by the section shall not be subject to a deductible co-payment or co-insurance requirement that is less favorable to the covered individual than those that would apply generally to other non-primary care items and services under the plan and then it specifies that a covered individual who has exhausted all applicable internal review procedures provided by the health insurance plan shall have the right to an independent external review as set forth in statute except for Medicaid a Medicaid beneficiaries grievance would be redressed by the Human Services Board as set forth in 3VSA section 3091 so that's health insurance coverage in that large large group and Medicaid and then section 13 would direct in the timeline looked a lot more manageable in January but honor before May 7th 2021 the agency of human services in consultation with DFR or you're going to hear from and the Green Mountain Care Board must apply to CMS to modify the essential health benefits and Vermont's benchmark plan to include coverage of hearing aids and related services at a minimum standard of medical necessity beginning in plan year 2023 and so that the reason for this date is that that is the deadline um under the federal requirements to apply to change your benchmark plan for plan year 2023 so if you did something after that it would be for a later plan year it directs the agency to contract for actuarial services to the extent necessary to prepare the actual actuarial certification and report required as part of the application process it would have had the agency provide a draft by April 1st of 2021 so obviously we have to relook at the dates the agency provide a draft of its completed application materials including the actuarial certification and report to the Medicaid and exchange advisory committee and the office of the health care advocate and make them available on its website it would require the agency to accept public comment on the application materials to respond to all public comments and to incorporate the public comments into the final application materials when practicable and it would require the agency to provide periodic updates on the disposition of its application to the house health care committee this committee the finance committee the Medicaid and exchange advisory committee and the office of the health care advocate section 14 would direct the agency of human services to seek approval from CMS to provide coverage of hearing aids for individuals enrolled in Medicaid as set forth in that earlier section that actually spelled out the coverage because that is in excess of the existing coverage requirements in Medicaid so we're getting close to the end section 15 is a change to the state health improvement plan which is an existing requirement for the secretary of human services or designee this would specify that it would be in fact the commissioner of health not the secretary or designee in consultation with others who would adopt the state health improvement plan and amend it as appropriate then we get into some reports section 16 would have the green man care board by January 15th 2022 provide to the house health care this committee and finance an analysis of the increases in health insurers administrative expenses over the most recent five-year period for which information is available and a comparison of those increases with increases in the consumer price index so look at increases in health insurers administrative expenses with increases in the consumer price index section 17 directs the director of health care reform in the agency of human services to provide information by January 15th of 2022 to this committee and the house health care committee regarding the manner in which specialty care will be incorporated appropriately into the all-payer model and when that incorporation would occur section 18 directs each accountable care organization certified by our existing processes to to provide information by January 15th 2022 to this committee and house health care provided description of the ACO's initiatives to connect primary care practices with social service providers including the specific individuals or position titles responsible for carrying out these care coordination efforts so report on exactly what it is that they're doing to connect primary care practices with social service providers including whose job it is to do that section 19 has some reports on on what it would look like to have two at least two primary care visits per year without cost sharing so the first part requires diva in consultation with dfr health insurers and other interested stakeholders to provide an analysis by January 15 2022 to house health care this committee and finance this analysis would be of the likely impacts on qualified health plans patients providers health insurance premiums and population health of requiring individual and small group health insurance plans to provide each insured with at least two primary care visits per year with no cost sharing requirements and then a separate report from the green mountain care board in consultation with dfr and the department of and dhr of human resources to report oh and i'm sorry health insurers and other interested stakeholders to report by January 15 2022 with analysis of the likely impacts on patients providers health insurance premiums and population health so the same criteria of requiring large group health insurance plans including plans offered to state employees and to school employees to provide each insured with at least two primary care visits per year with no cost sharing requirements and then finally we get into the effective dates which i can we can go through or we can hold those for another time whatever you prefer we can hold those unless someone okay we're good okay just know they're there questions for Jen okay so there are a number of things i think in the bill that require analysis and study so and some of those including the last sections on primary care are things that we might want to fold into into a single there are a number of things in the bill including the primary care that we may want to fold into a single analysis or set of analyses so and then one comment on the health improvement plan that is was traditionally done in the in the department of health that plan i think we should ask to have updated by a date certain if we can do that and i don't know what the requirements are in statute in terms of a annual update or do you remember i think the language was uh to update as the commissioner or as the secretary designee deems appropriate yeah okay let me just pull up the some of that is in the bill yeah i know i get i just think it might be helpful to have it updated because it it can be the data that's collected by the health department is important in informing the green mountain care board around the health resource allocation plan which is then used for c o n and other distribution of services so that's the reason that that's in there and we haven't talked about it in a long time we can get someone in to talk about that if people are interested i'm interested but okay all right so you're all set to vote it out it sounds like uh sorry go ahead there's just a lot in there and it's um and a lot of it's sort of i mean it's obviously all related but it's it's there's a lot not directly related and the the sort of regulatory changes it's hard for me to sort of figure out what impact they would have um yeah so i you know and i i completely agree with you i think that this it was meant to uh stimulate some conversation and i think as we hear testimony and as you heard yesterday from ina back as some of the recommendations that they're going to be making about the all-payer model next gen to to ask for some changes some of what's in this bill a may not need to be done but b also might uh as i said before fit into some kind of analysis either uh with an independent consultant or within the grematt and care board or a hs so we there are some choices there or you know whether we even want to pursue some of those at this time based on what we're hearing from folks so not there's there's no uh i'm not committed to moving this senator comings no i'm just struggling with timing we worked on hearing aids and again you know i see that you're pretty much limiting it to state employees but at the present time we're struggling over whether or not we can afford state employee pensions and to be increasing healthcare coverage at the same time is a lot um so i think you're right there's a lot here but the goal is actually to improve access also affordability so in and we know how critical hearing aids are to sort of mitigating the effects of aging all timers or so are dentures so just assume that dentures are coming next oh yeah um they may as well uh yeah but who pays for retired employees healthcare i know we pay for teachers who pays if you're retiring at 60 who pays your health insurance well you you go to medicare remember that not until 65 yes i do think that there is so i think that some of the other post employment benefits is not my area but um but i think i mean are we adding my question is are we adding to the pension cost we definitely would be adding to the cost of teachers retirement i don't so i don't know that the language as written applies to retired employees but i think i'll be healthcare for retired teachers yes but that's not the language that's it talks about school employees not retirees um but you need to you i think would need to hear because the bulk of people i hear from from hearing aids are retired and that's so but that that's where the also then if it's an early onset hearing loss that could be that's one thing significantly more important in terms of living one's life with a quality with quality outcomes does medicare cover hearing aids gen no no not at all senator hooker i i you know like everyone else has said there's a lot here and i was just um wondering about medicare and how that fits in because i know it doesn't cover hearing aids uh you know what what other implications does this have for medicare nothing you can't affect medicare i mean you could create a state only benefit that you provide to people who are on medicare on medicare um you know we you've done that with in prescription drugs with v farm you've done a wrap um but that would be all state dollars yeah and that is a significant portion of the population and it's growing every day uh you know what i'm going to suggest because we're in this conversation uh and it's moved uh to hearing aids i suggest that we hear from jill rickard and emily brown who are here um from dfr and jill thank you for being here why don't we why don't we hear hear what you have to say about what you're doing at this point and that would be very helpful maybe inform us about what we can do within the legislative process to facilitate some outcomes sure thank you madam chair my name is jill rickard i'm the director of policy for dfr we um we are current we have applied for a two-year grant from the centers for medicaid and medicare services to perform analysis related to our market um and part of that analysis is actually the largest part of the grant is is going to be focused on reviewing and analyzing our benchmark plan and whether to change the benefits around or to add new benefits such as hearing aid coverage um that is something we're interested in looking at of course it takes um actuarial analysis because when you increase the benefits in one place you have to decrease the benefits in another place and so we're engaging in actuary which is a pretty expensive process to do that um which is why the timing in this bill is un not workable if we wanted to us to look at that and during that process because there are state deferral costs if you increase new if you add new benefit mandates so what we would propose is to give us time to take advantage of this really generous grant that we're expecting to receive any day now from cms um to explore the benchmark plan is if you would push out the dates all by one year such that we have because it is a long process a to do the actuarial analysis then we'll have to propose the new benefit mandates those have to be approved by the green mountain care board and then ahs would need to um propose those to cms that then would have to approve them so that would take a year or more um we could get it done in a year and that if you moved those dates out all by one year um but then once they're approved by cms they would need to be effective for the 2024 plan year well whatever day is to work for you i think uh thank you i'm sorry did someone else want to say something did i interrupt but um if i think you you did send along a note about this um so uh and i don't know if you included gen in that uh communication but if if you could do that and we could maybe modify the language somewhat so it conforms with the work that you're doing and so that we we understand the the work that you're doing and the report that's coming back and whether or not the you're successful with the grant um that would be that would be very helpful to two other comments um madam chair if you don't mind that it you know it this doesn't speak directly to the state employee plans or Medicaid of course this is only going to our benchmark for the exchange plans um but it may make sense if the committee decides to also push that out to 2024 so that it is informed by the analysis that we're performing on our benchmark um and the other thing is i do believe that Vermont Medicaid does currently cover hearing aids so you may want to hear from diva on that aspect because that may not be necessary i think just to clarify i think they do cover but not to the extent necessarily to the extent contemplated by the bill go ahead ruth senator hardy think you know no worries um uh could uh jill thank you madam chair jill could i this grant that you're getting sounds great um and wondering if there are some specific topics that you are planning on asking and looking into um about in this analysis it sounds like hearing aids is on your list are there other areas that are on your list do you mean other other new benefit mandates that we could look at yeah other things i mean i'll just throw another one out there that i'm interested in hearing learning more about there's no bill on it but i am working on something for next session about fertility coverage and i know that's super expensive so i would love to get more information on that um and i'm sure we all could come up with other things so i'm wondering if you have a list and and given the timing it seems to me that we might want to hold back on implementing new mandates even without effective dates out into the future and wait to hear what your analysis says and then sort of decide what is reasonable and possible that's my thinking but i would like to know what's on your list to look at so thank you for that question that is that is what we would propose as well i think that's a great idea we would invite the legislature to you know if there are things that you're interested in us looking at we'd be happy to look at them and add them to i don't think we have a specific list at this point um but again i can add i think my colleague elit emily um is leading the grant process so she can maybe speak to that a little better okay thank you um so to to your question senator hardy um part of this whole benchmark updating process while i think you know a lot of the cost and the analysis will go towards the cms application and that for real analysis there before that even happens the state has outlined kind of uh the state's internal process of how we're going to go about updating the benchmark plan and that um i believe it's on diva's website and if you're interested i can put that along but that process um we're envisioning it as being a stakeholder engagement so you know having the uh issuers involved in that the health care advocate any other interested parties where i think that will be uh an opportunity to kind of talk about policy objectives as well and what benefits are people or what needs are people seeing in the market that aren't being addressed and then have that be more of a collaborative effort to say okay these are the areas we think we should focus on um and then move kind of have it be definitely a you know a collaborative and kind of um participatory process instead of it just being like okay we're just going to focus on these benefits we want to we want to be able to make sure we're understanding um and studying the market rather than assuming that we know you know where the needs are and and what needs to be added so um other states uh for examples other states have done this um i know illinois is one state that has updated their benchmark plan and they wanted to focus on um mental health and substance use disorder um to try to tackle the opioid issues um so they were focused on that and up their benchmark plan accordingly so i think it just depends on you know what comes out of our our stakeholder engagement um what we find maybe that other states are doing that we we could see could benefit vermont so i don't think i'm trying not to go into this process assuming that i know you know what things should be added or shouldn't be added i think it really just needs to be like a collaborative process and um you know with with many stakeholders to try to to try to work through this but i also would say it would be very welcome um if the legislature had issues or or policy objectives that we should consider i think that would be great and and maybe provide that a more of a direction for this process in some pointed areas that that um you all would like us to look at that would thank you emily that that would be great i think that rather than trying to push forward something even with extended dates just providing some a list or guidance about what we're interested in hearing about and certainly you know hearing aids is one of them for sure and i'm sure others we could come up with a nice list and that wouldn't mandate anything but would help you with your thinking and would be easier for us to tackle at this point in the session i think as well i'm thank you senator hardy that's well said um and i think uh by hearing aids for me are at that the top of many lists but so and why don't we do this uh send your comments please you jill and emily you've heard the conversation you can help us uh modify this language wherever it goes we don't know where it's going to go uh but so if you could can do that and then in the meantime we'll also be thinking about those um changes that might help from our perspective on the benchmark plan you've already heard two i don't know how dentures fits in this and but we've heard that one and i know we hear it over and again particularly with a increased age of our population um and then and you brought up mental health and substance use disorder treatment and that's been an ongoing concern uh from the both with private insurers and our medicaid folks about the extent to which uh folks can be treated how many counseling sessions for example it's always been difficult to determine and uh so i would i would welcome that one on the list as well or those two senator hooker and i've also heard from home health agencies that they would like to see more follow-up for people who are really dismissed from hospitals so that you know they don't have to return to the hospital because they haven't had enough care in follow-up and i don't know how that would fit in but certainly something that i think needs attention yeah i know that that that fits in a lot of different places including the coordinated community service issue that we've been looking at so okay this is very helpful jill thank you for reaching out in the first place really appreciate it and i think something good might come of this i think the good you're doing is certainly going to come of it uh so and as you know legislators are not apt to be available all the time to give input in a stakeholder process but we certainly can add our thoughts at this point and help things along senator hardy thanks madam chair i was just thinking of strategy about vehicles um for this type of thing and also potentially for this the next bill that we're going to go over and one bill that we have from the house that might work i don't know jan i would obviously defer to you is the the h430 i think it is the dr dinosaur bill because that's about expanding coverage under medicaid and it we might be able to make that argument that this is about looking at other areas that we could potentially expand coverage um and s120 is also that so there might be some provisions in this bill and the next bill that could fit in that if we can make that that's going to be our that's going to be our ongoing discussion and challenge that's good that was just a thought i had last night and it looking at the bill it seems like something might possible might be possible if you want to get that gen and see what you think i think you probably want to talk to secretary bloomer because it's going to be up to him whether something is germane or not so we're so we'll we'll have a broader conversation about that um after we've completed some of the work on our on the bills okay um jill and emily is there anything else that we need to hear um and we need to know at this point i don't believe so the other excuse me i'm just going to sneeze there the other sections under durable medical equipment and the studies about two primary care visits we we are fine with those as well just to put it okay that's good to hear all right yeah no i and how those studies end up and where they end up i think will be important the primary care visits have always been kind of the barrier if you have to lay out a copay you may not go when you when you should for prevention and that's one of our goals but thank you for that testimony thank you for the opportunity all right okay so committee any other discussion on 132 i think there are some sections that i'm willing to um forgo we'll certainly hear from other people as we go forward on the bills next week but um i think as we identify things that are that resonate with others and can happen without a lot of debate we'll keep moving those forward okay so jennifer carby is here on s120 thank you sure i will put that one up now just moving it over senator hooker you're the lead sponsor do you want to add anything just that i'm here just said i think that this is important that we start you know that we look at um ways to certainly um increase access and affordability this is one way to do it we're hoping that this bill will help us to position ourselves as a state when things start happening at the federal level and you know it's a step forward i think so and maybe senator hardy would like to weigh in on it as the other lead sponsor sure i i think that there uh is a potential opportunity for as senator hooker said to expand access and affordability um with a new administration in dc and we just wanted to make sure that we had the ability to lay the groundwork for for that on the off session and also to build capacity among legislators for um understanding and leading on this issue next session if there is an opportunity for such a thing um specifically expanding down the age eligibility for medicaid and or medicare and maybe expanding up the eligibility the age eligibility for dr dinosaur and finding um creative ways to work with the federal government on this and also looking at our own system so it's similar to what we are frankly just talking about but um ways to expand coverage with with also uh maintaining affordability which is a really tough thing to do so um this is just off session work to try to get at that um and um in a focused way so okay so and i'm going to suggest that as we go through the bill and then when we go back through 132 there may be some things that we want to combine because we've been we'll talk about all this stuff and we we throw it all in the hopper and out will come something that's all in it there out will come something okay so we'll get made okay Jen carby thank you all right there we go this is s 120 uh and as you know it it was introduced by three members of this committee senators hooker hardy and Cummings it is an act relating to the joint legislative health care affordability study committee it starts out with findings so it has general assembly finds that the COVID-19 pandemic has caused significant job losses with women especially impacted likely causing a significant negative impact on the number of remanters without health insurance and placing greater financial strains on those who are underinsured second many remanters who have health insurance are still exposed to high out-of-pocket costs through their plans co-payment co-insurance and deductible requirements in addition to ever increasing premium rates currently a family of four earning more than $105,000 per year who are enrolled in a silver plan through the Vermont health benefit exchange may pay as much as $44,000 per year for health care between their health insurance premiums and out-of-pocket costs in some instances an individual or family may have health insurance but not be able to afford to receive necessary health care services because of the out-of-pocket costs associated with their plan others who lack coverage or who are underinsured and receive necessary health care services find themselves saddled with substantial medical debt third employers across the state including local municipalities and school districts small businesses and community organizations face significant and persistent budget pressures due to the increasing cost of health care coverage for their employees fourth hundreds of remanters lack access to any health insurance coverage due to their citizenship or immigration status and many younger adults cannot afford to purchase adequate health insurance coverage fifth Vermont is facing a significant shortage of health care providers especially primary care physicians and nursing professionals in many areas of the state and finally the biden administration has indicated interest in using its demonstration and waiver authorities to partner with states to pursue certain reforms that cannot be accomplished through congress the administration has signaled that it may be open to working with interested states to test strategies such as an expanded public option for health coverage so those are the findings and then it creates this committee in section two so there is created the joint legislative health care affordability study committee to explore opportunities to make health care more affordable from Vermont residents and employers the committee would be composed of the following six members three current members of the house of representatives not all from the same party who shall be appointed by the speaker of the house and three current members of the senate not all from the same party would be appointed by the committee on committees the committee is directed to explore opportunities to make health care more affordable for Vermont residents and employers including identifying potential opportunities to leverage federal flexibility and financing and to expand existing health care programs the committee shall consider the following the long-term trends in out of pocket costs in Vermont an individual and small group health insurance plans and in large group health insurance plans the efficacy of Vermont's all-payer accountable care organization model and the changes to the model that would be necessary to make health care more affordable for Vermonters or whether an alternative model may be more effective the extent to which Vermont's uninsured rate may have increased during the COVID-19 pandemic and the specific causes of any such increase opportunities to decrease health care disparities especially those highlighted by the COVID-19 pandemic and those attributable to a lack of access to affordable health care services and opportunities made available by the Biden administration to expand access to affordable health care through existing public health care programs or through the expand the creation of new or expanded public option programs including the potential for 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 to align with the young adult coverage under the Affordable Care Act in order to gain a fuller understanding of the impact of health care affordability issues on Vermont residents the committee would be required to solicit input from a wide range of stakeholders including health care providers health care administrators Vermonters who lack health insurance or who have inadequate health coverage employers labor unions members of the new american and black indigenous and people of color communities Vermonters with low income and older Vermonters um beginning on or before September 15th 2021 hold not less than eight public hearings each in a different Vermont county to gather information from stakeholders and other members of the public public hearings may be held in person or by remote means and each public hearing would begin with a panel discussion involving committee members and local stakeholders selected by the committee and include an opportunity for public testimony and a summary of the findings from the field hearings would be included as an appendix to the committee's report the committee through the joint fiscal office would hire a consultant to coordinate the committee's work in addition the committee would have the administrative technical and legal assistance of the office of legislative operations the office of legislative council and the joint fiscal office honor before January 15th 2022 the committee would would present to the general assembly its findings and recommendations regarding the most cost effective ways to expand access to affordable health care for Vermonters without health insurance and those facing high health care costs and the various options available to implement these recommendations the first meeting of the committee must occur by July 1st of this year the committee would select house and senate co-chairs from among its members at its first meeting and the co-chairs would alternate acting as chair at committee meetings a majority of the committee's membership would constitute a quorum and the committee would cease to exist on January 15th 2022 which is when its report is due then there's the compensation and reimbursement so for attendance at meetings during adjournment of the general assembly the members of the committee because they're all legislators would be entitled to prudium compensation and reimbursement of expenses under 2vsa section 23 for not more than 12 meetings these payments would come from monies appropriated to the general assembly and the bill would appropriate 175 thousand dollars to the joint fiscal office from the general fund in FY 22 for a consultant to coordinate the activities of the committee and to cover related costs of actuarial analyses research meetings and the prudium compensation and reimbursement of expenses for members of the committee any act would take effect on passage okay why don't we take it down questions so it sounds like the actuary analysis will be done on the expansion of things like dr dinosaur and then but the but the bulk of the work is to go out and listen to the public and gather data from the public am i is that accurate uh yeah go ahead Cheryl did you want to say yes i think so yeah certainly you know dr dinosaur and medicare expansion are two of the possibilities i think you know if we find that there are other ways to um affect this access and affordability then you know those two will be considered but that's what you know the intent is so far would you okay okay and so if so as i'm i'm looking at it there your interest is in having uh the legislators go out in the field listening and setting up meetings across the state and then while at the same time there will be a consultant analyzing information that is directed in the bill so i'm i'm trying to i'm i'm trying to put those two things together if there is there any is it was there any thought about taking the data or information that you get from the um what might be gotten from the testimony and trying to analyze that so it seems like there are two separate things here one is a group going out and listening and gathering information and collating that information but the other is a consultant analyzing two very specific things one medicare the other dr dinosaur yeah i think you're right that there there should be a connection between the two of those and um that there's i don't know it may be not you know they you know could be value in both right you know there's wanting to hear from the public particularly in this post pandemic hopefully post pandemic end of pandemic um about um access and affordability of health care coverage and what what people are experiencing on the ground and um and also um sort of thinking about that in the context of the goal of our state which is universal coverage for and universal health care for everyone and you know is that happening and if not how can we make it happen and those two ideas are in the bill but there may be other ideas that we hear and also ideas that come to us from the feds and this is really in connection with the other work that's going on in terms of our global commitment and the all the payment talk discussion we've been having to because i think that that you know is obviously those are part of the puzzle okay so and and just before we go to josh uh senator taren z then one of the findings is about the uninsured in our state and we do have data on that so it'd probably be important to understand what that means all right senator taren zene thank you senator lines i um my question probably piggybacks which you just said i was wondering do we know um from the pandemic how many people are uninsured as a direct effect of the of the pandemic i see no one saying no we don't know that directly we let no one answer oh go ahead no one i think senator hardy can answer too i think we just we don't know you know that's right we do we do an annual we do a survey every two or three years and that's the day that we have my understanding is that the health department will be doing the survey again it's called the vermont household health insurance survey it's my understanding they'll be doing it again this fall so it's required every three years by step yeah and senator alliance i think anecdotally we've heard that people you know who have lost their jobs have lost their health insurance and so anecdotally at least it seems as if uninsured or under insured or um you know the numbers have been rising senator comings no one have we seen an uptick in medicaid because that's usually the process if you lose your job and lose your health insurance your next step is medicaid yeah so the problem with that is because of the cares act um f-map increase okay they don't mo you or uh we have a moratorium on determinations and so in suric there's no churn people can come on but they don't come off right now so it's hard to determine if there's new people that wouldn't have stayed on like you know if the overall so the numbers are clouded and it's hard to know i think the answer is probably yes but we don't we can't tell from the data because it's too much noise in it okay other questions so i my one of my questions was going to be why not look have the health reform oversight committee and and by the way i'm very interested in changing the name of that committee but why not have that group be involved in this process with the the group of folks who have a foot in the door of finance and appropriations as well as healthcare uh but it sounds like you're more interested in having uh folks going across the state and gathering information from uh interested parties rather than having the group make uh specific decisions and recommendations except for as completed by the consultant i'm trying to sort out the thinking behind the that yeah um sorry i had sharyl i don't want to keep stepping on you if you're i would say that um that's a great idea to have that health reform oversight or whatever it's called or whatever new name you would like to have um involved or consultant that actually hadn't occurred to me so i think that that's a good idea um i think that you know one of the things that in in talking about this bill that sharyl and i or senator hooker and i have talked about is when we all go out and campaign what we hear from our constituents as the number one problem the number one concern they have is healthcare and you know i heard that time and time again both times that i was out campaigning especially the first time when i was knocking on thousands of doors and it doesn't feel like what we talk about here is necessarily connected to what we're hearing out in the field all the time and so a lot of this is what what do what what are people in our community saying about the type of access they have how expensive is it and what is it sort of like real vermonters on the ground what are they experiencing and how can we learn from that as legislators when we're not campaigning that it's you know part of our job not a part of our politics if you know what i mean and um and then taking that and using it to create policy with the help of a consultant who has some expertise while also building um the capacity to do this work next session sort of hit the ground running and it's super connected to some of the things in your bill and other bills that we're talking about and i think you know combining efforts is a great idea okay i got it thank you anything else all right okay all right so we will pick up some testimony on the bill and we'll we'll try to sort out the best way to go forward what to add what to subtract what to perhaps modify and then what to do with it which is the last question maybe it should be the first we got to figure out how to how to move it along and we will do that and part of it may end up um being incorporated into the budget we don't know that frequently happens to some of our bills at the end of the session all right