 and so forth, so it was for a lot of people who were interested. So I'm going to get started. Is it you or Bobby? It's not me. Bobby, you're ringing. No, it's not me. It's your broker. You're broke. He's not broke. Don't worry. If he's broke, the rest of us are in deep trouble. Why enjoying? All right. So I pray. So we're going to get started. And we have just a budget adjustment from Dale. So Mr. is here to brief us on her request. When we get done, I need to talk to you about a different issue. So happy new year everybody. Thank you. I'm going to be working with the Department of Disability's agent of independent living. And with me today as always is Bill Kelly, our chief financial officer. And actually, new this committee is leading to an award. Who is our new deputy commissioner, Kimbryle George, who will be audacity to retire at the end of December. What she was thinking about, luckily, we had me get the department for a very long time. I think this is for clearance issues. Great tradition. And he's here for the first time. Okay. Since it's a budget adjustment, you don't need to go through the description of the conference and so on. And you are. So if you want to jump to that, as always, Bill compares the kind of a narrative version of the ups and downs, just because it seems simpler to walk through. So if you want to just jump to the third page of that document, I can just walk through the numbers. So that first section, that first, the Dale overview, is a summary of everything that I'm going to talk about. And I'll do that by appropriation. But just to give you a kind of a sense of the overall, the total net increase in terms of gross numbers for the budget adjustment, Dale, is the 6.1, 613140. All funds. All funds. All funds. I almost wish you were closer. I think you're not. No, it says so all here. Because obviously you've got Medicaid involved. So is there a general fund? I'm sure there is on a different paper, but it's not here in terms of general, what it translates to in terms of general funds. Just bragging quickly, there are almost all global commitment funds except for the 1.7 money falls person, which is 100% federal, just to spending authority adjustment. Okay. All right. So I'll just jump into the in-go appropriation by appropriation. And again, this summary document that Bill does matches to the ups and downs if you wanted to toggle back and forth. But in terms of the Dale administration appropriation, there are no requests for budget adjustment for that appropriation. The next one down is the Dale grants, which is specific to our adult services division. And just a couple of changes there. My point is that 541-947 is moving the spending authority for the one-time funds for scratch. You recall that that was a three-year commitment that the legislature made last year. This is the first year of that. And it's just moving the spending authority from the agency to Dale. And you'll see that for the next three years. Okay. So that was just... Just... That's an AHS neutral. Exactly, exactly. And then the second item is an adjustment in the attendance services and Medicaid program. So you recall there are two different attendance services program. One is pure demo plan and one is Medicaid. And this is once again just an adjustment that we're able to do as we continue to see a trend of unutilization in that attendance services Medicaid program. This isn't all of the underutilization, but it is kind of a clear trend that we've been watching. So we just continue to try to adjust to make sure that we are managing the budget as closely as we can to what we need. Okay, so the 317 gross is an adjustment. What's the total for Medicaid attendance services? 1.6 million, approximately. Okay. So the next appropriation down is the division for the blind admission repair and there are no adjustments requested of the budget adjustment procedure. If you go to page 4 you start with what you have and again there are no adjustments requested of what you have. I think we're... No, that's the last page here. Okay. Yes. Thank you. The next appropriation down is developmental services. There are a few things in there to talk about. The first is just an adjustment between the department of the ship between the Department of Mental Health and Dale. When the legislature appropriate or approved a rate increase for the designated agencies and the specialized service agencies we always have to sort of screw up so that's a net neutral adjustment just moving the dollars from the major to Dale. The next item down is a little bit more underutilization in our non-home and community based services program and developmental services. So the bulk of developmental services are those HCBS dollars, those home and community based service dollars. But we have a few programs that are funded with non-HCBS dollars and we have seen again in terms of underutilization in those programs. So those programs include our target police management the bridges program specialized services which are services for individual developmental disabilities that are approved to be in nursing homes and also a family managed respite. So both of the underutilizations in those specialized services. So if you have a developmental disability and you are going into the nursing home in the state of Vermont and you've moved through the department through the division to make sure that people with developmental disabilities are not being inappropriately institutionalized and so there's a pass on approval that has to happen. In addition to the approval to be in nursing home we're able to provide specialized services for those individuals with developmental disabilities while they're in a nursing home to enhance the experience it may really tailor to them while they're in a nursing home and we're just seeing continued underutilization in that arena. Probably because we work really hard to keep individuals with developmental disabilities out of nursing homes and because most of that is more rehab state than it is long-term care. So the specialized services are just strengthening and utilized. And then the next item down as you all know very well we have a collective bargaining agreement with our independent support workers and there's some underutilization in the dollars that were allocated for the second year of the collective bargaining agreement. And why is that? We just estimate it wrong? It's essentially it's a point in time estimate and you do that based on the number of employees and the hours that you're seeing at that point in time estimate and it's just a little bit less than what we need and so we're again we're just trying to keep this very close to the best in terms of managing the dollars that they're actually using. The next appropriation down is the traumatic brain injury program. Again, a little bit of underutilization and we continue to just try to make sure we're leveling all of our appropriations appropriately. And I think we've talked about this before but with long-term needs in that traumatic brain injury program we shift people into the places for care program so we continue to do that for the active needs so the TBR program is really specific to that approach so we continue to manage that. I feel like I'm going very fast. If anyone has questions but I don't... And then the last appropriation is our process for care appropriation. The first is the carry forward from 9th state this way here in 19 into 20 as required legislatively. It's the one percent reserve that they can get stuck even forward into the next year and it also includes a little bit of money that was over that one percent that we didn't invest as we are required to do but that 2.0 the 2082781 So this choices for care is really up here embedded in all of this offset by the savings. Yes. You're looking puzzled Bill? A little bit. So for example the bottom number. So it's here but then you've got where you're getting savings from other areas. So this shows 6.1 and the choices for care is 6.7 but the 6.7 is offset by all of it down. Now you'll say okay. Is he not in now? I have the advantage of being able to see him. To see him I have. So these are the numbers that we're already seeing over here. Yes. The case mix. Actually we had case mix one dental health was in yesterday was on the PNMI piece the Q&A of care. The same thing is happening in nursing homes. This is basically the normal rate review and case mix adjustment based on the acuity. I would assume that with all the emphasis on keeping people at home and in their communities by the time they go into a nursing home their acuity level is very severe. I think that's absolutely right. I think that the people that are in nursing homes are more medically complex. The case rate mix is based on a number of different factors the staffing required to that person the amount of therapies that they need and are receiving it. So that all of those factors go into a case rate mix. So that's exactly right. Questions? Since it is my budget could you just get an email to me put this in the context of total appropriations and the shifts that are made on total appropriations and because most of this is dropping caseload for a huge piece of all of this total caseload on how much we were off and a little background for each in an email. One thing that people always get concerns when they see something going down are you deliberately doing something to reduce spending are you somehow doing it at the expense of services or case plans and I think that is always the concern that people say as opposed to no we're doing everything the way it is currently level but either we've got a few fewer than we estimated or the service mixes somehow. And if there was some comment made why you think we were down and we were off. We have some training we have all the information on all of that so you can send me that as well. If that would be great then if we get a question about this it's not that I really have much concern but the likelihood most likely thing is people would ask questions about why is this happening and what's the numbers. I think I'm really asking more or less I'm not clear on how much of this is for example money that's just not being spent or money that's being spent differently in house. You're paying a little less here and more over there. How close is this to a zero sum game. I think it's as close as we can get it. Certainly it's not in the areas that I talked about the different programs it's money and Bill as you all know is pretty conservative so he won't usually think like this even after consideration if he can't see that there's been a pretty consistent trend over time. For the most part you're putting it someplace else rather than just giving it back. It's helping to fund that overall adjustment of over 6 million. We are definitely working really hard to do that management we're watching the overall Traces for Care program which is where all of these particular programs that we're talking about with underutilization other than development of services they typically focus to Traces for Care program so we're certainly watching that program closely and seeing very consistent usage there. Absolutely we have a pressure in the nursing home and we have to figure out how to fund that to make this level of management. There are numbers going down as well. This is pretty consistent and a lower rate but certainly the acuity level for people that are in nursing homes is getting higher. And that's also a work for the key centers. We're trying, that's the goal in doing this. It's a very much a balancing act. Well the other thing is people need to remember when you're doing these estimates both caseload on service plans as well as on the salaries under the bargaining you're doing this almost 18 months ago. And so this is with a case rate it makes the same idea it was months ago that we may be estimating and then you took some of the actual research so that goes both ways for sure. What this is doing is obviously there's some significant ups here relative to the money follows the person, the federal funds. It's not because we've got more, can you explain? I can. I mean that's nice, almost 1.8 million there. So we, again I know we talked about the program, we spent time talking to you about ramping down the money follows the person program. We didn't anticipate having that program in place in the FY20 budget it was the demonstration ramp was ending but the federal government continues to sort of, every year not sort of, every year they say oh we have a little bit more, we can do this for another year and so this is them giving us one more year of funding. And candidly and I talked about this with house appropriations as well candidly there's always the calculation whether it's worth ramping a program back up for just one more year because the federal government tends to there's bipartisan support from the person which is a concentrated target program to move people out of nursing homes into lower levels of care and Vermont we used it as well to get people out of hospital settings into lower levels of care but the federal government has been their budgeting has been there's been a little bit of people there and so they have only been able to move them along one year at a time and the message to us is that if you are not in the mix in those one year at a time you won't be in the mix if we ever consider funding it as a program indefinitely and fully and so we continue to sort of stay in the mix even though it creates a little chaos for us that's what you're seeing here is that federal piece of it building some of that a little bit more I think it's just to your point 18 months ago when the budget was built we didn't anticipate needing spending authority for the grant because there was no confirmation that that money would be available other questions my goodness you're off the hook very easily one question a couple years ago we talked about programs that were up and whatever and that's a state funded program for people who don't qualify for Medicaid what is the current status of that so we I know we did a report that we issued last year that really walked through literally individual by individual as much information as we could get it continues to exist and we used to sort of slowly a trick to lock itself down as much as we can have people to shift often to Medicaid as they become eligible to do so but we don't require that we are paying attention to it we do look at them annually but we can't force them to make the shift because I think that we talked about it as a group and as a legislature we didn't want people to have to make that decision if they didn't want to do that it's a slow, gradual wind down but it's still in existence and how many individuals in this party 30 35 or 40 I have to look back but it's going down each year as people move the program but that's pretty much that's pretty close to what it was last year there are some people that are eligible to move but the decision was last year we weren't going to make anybody do that because we paid the spouse it's because you can pay the spouse and choices for care but you can't pay the spouse for instrumental activities of doing this but that was part of it and it's a program that doesn't there's people that don't qualify for Medicaid on that program and it's valuable to dismiss it at all it's a very valuable program but we've always struggled with it being if you had to pick what was core we tend to focus on Medicaid eligibility as core but it is a big program no anytime there's a proposal you get into this well then you're saying it's not valuable or it doesn't help and that's not that's black and white okay other questions otherwise it's Friday afternoon and people can it's not snowing like it was get ready to head home and we will let you get back to the office I did want to trust you if I could so we're done thank you