 And the average premiums was expected to be minus 0.3 percent in response to questions from the board's contracted actuaries. Blue Cross discovered an error in its development of the administrative charge. And after correcting for this error, the expected average premium impact fell to minus 1.3 percent. And on June 1st, 2021, the board approved the filing. And just to note, as with experience-raided large group plans, the actual premium change experienced by an association health plan may differ from that minus 1.3 percent. And that's it. Thank you, Mike. The next item on the agenda are the minutes of Wednesday, May 26. Do I have a motion? So moved. Second. It's been moved by Marine and seconded by Tom to approve the minutes of Wednesday, May 26 without any additions, deletions, or corrections. Is there any discussion? Hearing none, all those in favor of the motion signify by saying aye. Aye. Aye. Aye. Aye. Aye. Aye. Aye. Aye. Aye. Aye. Aye. Aye. Aye. Aye. Aye. Okay. So we do. Now I will move into an update federal policy changes. And we have quite a distinguished in large panel. We have Adeline Stromelow. We have Sean Sheehan, Dana Helahan, Emily Brown, and Ena Backus. So Addy, whenever you're ready to take it away, I don't know who's going first. is Dana are you running the slides. Actually Sean was going to drive are you on Sean. I am I just can folks see the slides I have. We can yes. Okay great. Great. So we've divided our presentation up into two parts and I think the first part will be kicked off by Ina. So I'll go ahead and hand it to her. Thank you Addie. I'll provide some introduction and context for the remainder of the presentation and then turn it over to the to the rest of the team to share the materials with you for today. Vermont's essential health benefits benchmark plan hasn't been changed since since it was established for the 2014 plan year and it was established at that time consistent with CMS's original rules. The current rules did not require that states revisit their benchmark plan selection. However states can reevaluate their selections and make changes in accordance with three options as specified by CMS and those three options will be discussed later in this presentation. Because Vermont's plan has not been reevaluated since 2014 this group those of us presenting today along with staff from the board and input from the board staff. We have established a process and timeline for periodic review of the plan so that there would be a defined mechanism for this review to occur now as well as in the future. The current plan review now dovetails also with legislative direction to reevaluate the essential health benefits plan. You can find the established EHB benchmark plan process at a link that we've provided and is now posted with the materials that we're presenting today in this meeting. As you're very familiar the Green Mountain Care Board does have jurisdiction to review and approve the benefit packages for qualified health plans with recommendations from the Department of Health Access. And the Department of Financial Regulation has regulatory responsibility for the provision of the benefit packages. The Director of Health Reform whose role includes coordinating health care reform across departments and agencies and with the GMCB specifically is responsible for coordinating this essential health benefit benchmark plan review. We're pleased that we can be talking with you today about this inaugural plan review process and to update you on the effort and ensure coordination throughout this process. I'll hand it over to Emily now. Hi everyone thank you Ina. So my name is Emily Brown. I'm the Director of Rates and Forms at the Department of Financial Regulation and I'm just going to be talking about the essential health benefit benchmark plan process. I am going to kind of go a little bit out of order. I'm then going to talk about the timeline and then I'll address and talk about the way that we are going to fund this work. So in 2019 the federal government started to allow states to make changes to their essential health benefit benchmark plans. And this and like Ina said since 2014 Vermont has not updated its benchmark plan. So this is providing an opportunity for states to kind of look at their benefit plan and to see if there are any changes that are needed to address any policy goals the state may have and or to address any you know population needs that may not be currently being served by the benefit package. So in 2019 the CMS laid out three options for states to update their benchmark plan. The first one was to actually just adopt another states benchmark plan in whole parts. So you could look at another state and say we really like how they're doing it and take their whole plan in place of yours. Another option is that you can look at different categories of the essential health benefits and decide for instance if you liked the ambulatory benefit of another state you could substitute that out. So that's another option. And I think the option we're going to kind of be looking at performing in Vermont or selecting in Vermont is to actually be looking at a set of benefits or looking at certain benefits and seeing if they will fit into our current benefit plan and seeing how we can work them in and hopefully apply for CMS approval and adapt our benefit plan to maybe address benefits that aren't currently available in Vermont or maybe change benefits so that they are better suited to address the population that are buying these plans in Vermont. And so as Ina said you know even if we get CMS approval in Vermont we have an approval process built into our statutes for plan changes and so the Green Mountain Care Board has jurisdiction to review and approve those benefit plans and kind of with support from Diva from the Department of Vermont Health Access and DFR and our role is to implement those benefit packages. Next slide. All right so there's a few options that states have used and can use to initiate the benchmark plan selection process. One of those can be just having a periodic review of the plan. Another can be a legislative mandate to review your EHP plan or it can also be just a policy goal the state would like to to address. And so in Vermont as some of you may know there was recent legislation this past second which directed the Department of Financial Regulation in conjunction with other state agencies to look at our benchmark plan and actually look at a few specific benefits that are currently not included in the in the benefit package or they may be included but to look at them to see if they can be improved. So that will be one way that we'll be approaching this benefit package change. But I think we're also looking at you know with stakeholder involvement any state initiatives to address any emerging health care reform priorities in our state. So those number two and three are kind of the approach that Vermont is taking to to analyzing our benchmark plan. And then again even if you know we'll have to go through this work this the as I'll talk about and kind of the next slide the timeline for this is is very extensive and it does take a lot of stakeholder engagement as well as actuarial analysis. And so once we submit our changes our proposed changes to CMS then they will have to approve it. And so an example of kind of the extended timeline we're dealing with here is that if we submitted our proposal for new benefits next May it would be expected that those would be implemented the soonest January 1, 2024. Next slide. So this is the part of the timeline that Ina had mentioned the benchmark process document that I think was a link was provided on the Green Mountain Careboards website along with this presentation. And this is the timeline I pulled from that document and just to give you an idea of where we are now and where we have to go. So already we have decided we're going to do this work and analyze the plan. I'll talk about a little bit about the budget and how we're going to finance this work this work because of the actuarial work can run into the hundreds of thousands of dollars. So we think we have a way to to fund this which I'll talk about in a minute. And then so the next step and what we're kind of rolling into right now is is conducting stakeholder meetings. So for further background we are the Department of Financial Regulation is working on an RFP right now to contract with an actuary and then we will start conducting stakeholder meetings and we are hoping to do that before the fall of this year and hopefully start sometime this summer. And as you can see then once we have those stakeholder engagements and have the actuarial work we'll have to then get that plan design approved by the Green Mountain Care Board before we submit it to CMS. There is a required public comment period not only at the state level but then also at the federal level for CMS approval that we'll have to conduct before we submit to CMS. And do you mind next slide Sean. Thank you. And then so you'll see so we're hoping that if we can start this work in the summer and work on this throughout the fall we'll be in a good place next April-May to then submit to CMS which then their review takes about six months. And once we hear back from them we'll then again approach the Green Mountain Care Board for approval if there was something that they changed or some adjustments that needed to be made were accounting for for that time to be needed and then it will then have implementation then the following spring with the the form filing which which comes to DFR. All right next slide. All right so I mentioned before about funding this this can be a very expensive undertaking and fortunately CMS has an opportunity available now for states to apply for grant funding to conduct this work so the grant that we've currently applied to is called the State Flexibility to Stabilize the Market Cycle II Grant Program really rolls off the tongue and that is a grant which DFR has applied to. We are expecting to hear back in April and I think due to all of the kind of money that's falling out of the federal government right now they've prioritized other projects that they're trying to to fund but we do anticipate in the next hopefully in the next month hearing back from CMS on this grant. And I think you know another thing I want to mention is that the grant isn't only for this benchmark work while I think we will be prioritizing that I did want to bring up a few other projects that we will be looking at and hopefully using this funding for. So obviously one the first one is the benchmark plan review which will be probably in year one so that will be assessing the benchmark plan will probably be analyzing other States benchmark plans to see you know if there are different ways to provide benefits and then also looking at our current current benefits to see if there needs to be any modifications. Other projects the department plans to undertake are looking at network adequacy. I think this past year with COVID we've seen a lot of changes to how networks work and how people are receiving their care so we're hoping to take a look at that to see if there needs to be updates to our regulation or if we need to look at enhancing any of our regulations to address any deficiencies that are currently in in networks in Vermont. And then the last will be the last project we'll work on is an enhanced form review where the focus on looking at prescription drug formularies. And so we're estimating the funding we'll receive will be about $660,000 and I think we have budgeted about $230,000 currently for the benchmark plan review and that's I think that's my last slide Sean. Thank you. So do you want to take questions after each presenter or how did you want to do this. I think it would make sense to pause for questions related to the essential health benefits now before we move on to the other topics. Perfect. Going to start with Robin Lunge. Thank you. Hi Emily thanks for joining us. This is a great update. I had a couple of I had more one comment and then one question. The other thing that I think would actually be helpful in the timeline to include even though it's not directly related to the approval of the benchmark plan is that then once they're in place we would be seeing the impact of that benchmark plan change in rates as well. So there could be some there will definitely be an interaction with the premium approval process and it just might be nice to note that so that people are understanding that there is a financial component to this that would come a little bit later in terms of the actual impact. So that was the comment and then I I also just wanted to say I think the approach that you outlined of looking at sort of our own special kind of plan makes sense to me because we still have a bunch of legislatively mandated benefits and statute which quite frankly drove some of the benchmark plan components in the initial implementation. So that's another component that you would need to look at when you're if you were looking at other states is how they're what they have interacts with their state mandate. So I was just wondering if you thought of that kind of interaction and and how you would see that playing out. Yeah I had it and I think you know what we were going. So yes I think Vermont is unique in that we we do have a lot of state mandated benefits which makes our benchmark plan really great and valuable. I think what we would be focusing on is and I hope this is getting to your point is more of the benefits that we do have control over that wouldn't take a legislative change right. So you know of the 10 categories in the EHBs which ones would we have the ability to kind of move around and then potential new benefits or new you know new designs of how we're approaching you know health care insurance. So but that's that's a good point and I think we can take that back to consider when we're doing this work. That's great and I think you probably could if you haven't already find the initial analysis that sort of compared the EHB. Yep I have that. Cool all right great I love reusing work we already paid. Yeah exactly thank you that was it for me. Thank you Rob and other members of the board. Yeah I have a good question. Oh go ahead Tom. I'm going to recognize Tom first. Oh sorry a couple of questions I'm just curious about the timeline here and I'm sure it's a fully loaded timeline but five years seems quite a long timeline to me. I did spend some time on CMS's website looking at other states that have gone through this process and you know again these this rule change happened in 2019. I think five states have already gone through this process and their plans have been adopted by CMS that includes Illinois South Dakota Michigan New Mexico and Oregon all five of those selected option three the same option that we're basically looking looking at and so I'm just wondering if I think changes to the benchmark plan are important I think for example you know why are they important well diabetes is one of our top chronic diseases in our health reform health prevention population health benefits but our benchmark plan doesn't support pre diabetes programs for example the like the blueprints CDC program that they run so so that doesn't make sense to me that you know we're not investing in prevention but we're we're paying you know for for for benefits for people once they contracted these and I'm sure possibly that there are other situations like that in our benchmark plan so so so I have my first question is do you think that the timeline can be can you know contracted a little bit yeah but yep I think that those are all really good points so I think you know and I yes a lot of other a few other states have gone through this process and gotten approval I think what our timeline outlines is the until the consumer feels the impact of the changes so if you think about where we are now we're so we're in year two right so I we applied to the to the grant we started thinking about this I think last year as far as you know okay you know there had been a lot of talk in the legislature at the Green Mountain care board about looking at the benchmark plan so that was what I view is kind of the year one lead up to where we are now in year two but the actual process for getting the approval right so if we submit so we have our state process right which which takes you have the stakeholder engagement the actuarial analysis and then the Green Mountain care board approval so right there you have you know a six plus months but the actual CMS approval is only about you know I think it it can be four to six months so that is actually not what's taking the time I think what is really taking the time is our our state steps that we have to go through to actually get to the point where a consumer is is benefiting from those changes which just due to you know when the forms are filed plans not being able to be changed mid-year I think it's a big one that's I think why it it does seem like a lengthy timeline but it's it's I think really the quickest that that it could be implemented based on you know the steps that we have to go through and I think the biggest of those being is the fact that you know once you start a plan year you can't make those those changes mid-year so if we got approval from CMS in fall 2022 we we couldn't just automatically implement those changes we'd have to get the board's approval and then also have those form files with the DFR as Robin said the rates would need to be adjusted if necessary and all that you're right take that additional you know you add six months here six months there and before you know it you're you know your timeline is extended and I think you know at this point if 2022 to 2024 would be when we hope they would be actually able to benefit from Otter so but to answer your question I don't think there would be a shorter way to do it at this point and maybe one of my colleagues has a has a different opinion on that but I think that's essentially just where we are and it would be interesting to kind of maybe look to see if other states were able to to implement the changes faster I would imagine they would have a similar issue with plan design changes you know needing to be on a calendar year versus you know a mid-year change but so I understand we're sometimes hoisted on our own partards but I think that's a phrase I hope another question I have is relating to the language that is in the appropriations bill pertaining to this directly and I'll just read a little bit of it it mentions all of the players the Vermont Health Access Folks Director of Health Care Green Mountain Care Board and then it says shall review Vermont's benchmark plan establishing the state's essential health benefits to assess whether the benchmark plan is appropriately aligned with Vermont's health care reform goals regarding population health and prevention as set forth in the Vermont all pair accountable care organization model agreement and the Department of Health State Health Improvement Plan 2019 2023 and to determine whether to recommend requesting approval for the for the Centers for from the Centers for Medicare and Medicaid services to modify the benchmark plan. So that paragraph then is followed by the request on the or the demand on the legislature for reviewing certain benefit increases and that there's five of them there. So my question then is let me come back over here. My question then is and there's a deadline on that review which is January 15th 2022. So it's near I mean it's a very very tight effort and I'm just wondering what your thoughts are on how to have the clinical analysis done that looks at our state plan and that the all pair of model and basically looks at it from a population health and prevention point of view and says here are the better ways to align our benchmark plan which goes back to 2014 and precedes the all pair of model and the current state health plan. Here are the areas that need a realignment. How how would how do you see that unfolding. That's a really good question and I think I might defer to my colleague Ina Bacchus for that question just because I'm not as educated on the accountable care organization or the state health improvement plan. So Ina do you have any comments on that. I I agree that that's a that's a very good question. We did anticipate doing the review with the assistance of the contractor that Emily described that we would be RFP'ing you know going out to bid to select a contractor to assist with the actuarial and other plan review. When it comes your your recommending that there be a clinical review in terms of what the essential health benefit plan offers and whether or not those clinical services align with the with the goals of the all pair model and the state health improvement plan I think that that's another that's a that's a different that's a different point of view on the assessment than I think we understood through the legislative conversation about it. But one that we can take back and consider how we would how we would think about that. We were certainly looking at determining that through that actuarial lens in particular. Yeah but I I I ask that because I think you know looking at this four or five benefits that the legislature wanted you to look at some you know three or four of them came in the Senate and a couple are added in the House and you know for example like oral health I think was one of them hearing aids was one of them and that seems to me reasonably clean actuarial work it's very focused and and you know a lot of work but it's but looking looking at and catching things like for example where the plan our current plan supports diabetes treatment but it doesn't support pre diabetes prevention that's a harder thing to find and so it's having people that are are I think you know well versed in preventive health kind of looking at at our at our goals which I think are well established in Vermont but also looking at the you know the connectivity between the plan and and and and these prevention benefits so that's a concern of mine is is that a I think that adds time to the process but I think it's a good a good thing to do the only other thing I would note this is putting my old hat on in kind of thinking about the money for this I did note that DFR in the 2020 budget submission uh committed uh submitted um or transferred 37.1 million dollars uh of DFR funds to the general fund in direct applications so these are the excess funds that accrue to DFR during the fiscal year that they are aren't necessary to support DFR programs and so those move over to the general fund so I think given that and the fact that we have some long-term planning between now and the budget adjustment for example the 2020 two budget adjustment that they're wearing my old hat if the governor walked down the hall and said I need 600,000 dollars or 200,000 dollars for this um I'd know where to go to find it and uh so good luck with that thank you thank you okay Jess my question was actually just quick and it was about the funding and whether it was contingent upon getting the grant and and what the probability of getting that grant is and if you had a smaller grant than what you proposed how would you prioritize those three buckets yeah that's a good so I think we're about 99 percent sure that we're going to get the grant um this is money that CMS has to spend um and have to distribute to the state so I don't think there's a lot of doubt and we've had indications from CMS that it's not there it's not like there's a hang up with our application it's just more about them having the time to to do that part of the process so I feel pretty confident about getting the grant but as far as prioritization I think I put them the way I put them in order on the slides is the way I prioritize them so it would be the benchmark plan would be the first thing I would prioritize and then it would be the network adequacy review and then you know more support for our form review process here at the department great thank you that was my only question any other questions or comments from the board hearing none it probably makes sense to also take public comment on this section by section because otherwise we'll be going all over the map so at this point I'll open it up to any public comment on um the benefit plans question go ahead I have two questions one having to do with the benefits themselves uh Tom mentioned and I think somebody else did too about diabetes I know like vision is covered in diabetes um they will cover one pair of glasses and I think that's after surgery for glaucoma or but the point is they have a they recognize the need for vision care I would be curious to know because there are other medical conditions like stroke that literally takes your vision from you if it could be added as a benefit because that's just as severe in consequences as diabetes to vision to add the benefit that glasses get covered for certain conditions so that was one of my questions the other one is in terms of the plans themselves and how it affects the premium um because of the dynamics of covid and how this can affect subsidies and I don't have all the answers to these questions so that subsidy help will change over time um is is there any way of including if money to help consumers pay for premiums changes drastically how do you include that in your plan design or can you so that you don't get sticker shock two years from now when suddenly covid money goes away if it's impacting the cost to consumers what the premium will be um I just want to put that out there because this is so complex I'm worried that that is going to happen and it would be a concern to me thank you okay um I think I starting with your first question um about the vision benefit so in in the legislation that was passed this year um and that um was mentioned earlier vision care is one of the categories that we will be looking at and I think what we're hoping to do with each of these categories is to go through and figure out okay what is the current benefit what could the benefit look like um something I didn't talk about was the tests or the requirements that cms has put on states when they want to change a benchmark plan and those are those are essentially a min and a max of a benefit package so and I don't want to go too into the technical details but the idea is to keep the the value of the plan very similar to what it is currently but you're kind of taking pieces out and maybe putting other other pieces in or putting benefits in and taking benefits out so it's it's more of moving things around and adjusting things rather than just adding things on because one of one of the tests that cms requires you to do is to say okay is this plan you can't make the plan overly generous and there's a few standards that you have to look at when you're when you're doing that analysis so you know it the the looking at you know when you're looking at these benefits and these coverages we're also going to then be looking at okay how if you added vision care like you said for you know after you have a stroke what how is that going to impact the value of the plan would that satisfy cms's requirements for the for the tests that they require states to comply with when they're changing their benchmark plan and then i think that does kind of lead into your second question about premium so there is kind of a difference when you're thinking about adding benefits and taking away benefits versus cost there so cost there is what you know in premium is what it costs someone um when you're going to the doctor or when you are paying your premium what we're really doing with the benchmark analysis is saying okay is there is there a different benefit design here we're not talking about should we um offer you know a certain benefit at zero cost there that's handled in a different a different way at the state level and there are other requirements for that what we're talking about is okay what what are the benefits that we currently have is there a way that we can you know is there a benefit out there that people aren't using that doesn't really have a lot of value to people or um like board member pellum said is there is there a benefit that we could offer that might actually you know prevent something or prevent you know another benefit from having to be utilized in a higher manner so it's kind of doing that analysis to say is is there a way just to to make our plan better to address health needs in a better way rather than saying oh we're just going to add all these benefits and an increased premium for people across the board I don't think that's the intention of the plan changes and I don't think it would be approved by CMS if we did that and then to sorry then to your further question of I can't answer really about what's going to happen with the federal subsidies and what's being offered now but so that's kind of an unknown but I don't think I don't think I think there might be a premium shift with you know the benchmark plan changes but it it hopefully wouldn't be to the point where you'd be adding you know a significant amount of cost that that's not the goal okay are there other comments from the public hey Kevin go ahead Walter thanks Kevin just wanted to ask Emily when she said CMS doesn't want to see a plan that's too generous exactly what is too generous yeah and thanks and there's another question and thanks to Tom for the prediabetes mentioned as someone who just was diagnosed as prediabetic that was a surprise to me I can just imagine the claim denials coming in from the supplement programs that I'm on because I'm on medicare so this leads into a question of is this just plans on the exchange or is this medicare supplement plans too because these things deny claims just as regularly as the ACA claims stuff and the regular insurance and three as I notice you're talking about all these plans but they don't seem all connected you know there's no it's like separate okay we'll add this to this plan that to that plans like this but the problem with healthcare is everything is so interconnected that's picking up on what Dale said okay I'll stop badgering you from now so I think I'll I'll take your easy question first so this will only impact exchange plans so this is only going to affect people who buy their plans on Vermont or buy a plan that's offered through Vermont Health Connect it won't impact your medicare supplement plan or any other kind of other health insurance plan it won't impact large group plans that are fully insured and then to your to your third question about what plans can you explain your question a little bit more are you like what you're what you mean by all the plans oh it's just you know everything's always so you know this plan has that that plan has this you know if you buy you know you have to pay a premium for one plan and then deduct those but it doesn't cover that or it's another own you know yeah it's gonna yeah because I get that so much yeah so this analysis and this work will not impact your cost a cost fair or deductible it's not going to change that we're the benchmark analysis is just talking about the benefits within the plan so I think what you're referring to is if you bought a premium or a platinum level plan you know you might have less cost fair less out of pocket cost than if you bought a bronze plan and that's this analysis will not be impacting that what we're just talking about is maybe there's a benefit that's not currently included one you know an example that would be adult dental and is there a way that or a benefit design that could add that in that might have you know a benefit that would off or you know a youth that would offset then maybe the need for a different benefit so that's all that's what we're doing here with this work and then sorry could you repeat your first question I I had written it down and then I all I wrote I didn't write a good enough note oh you asked about the test the generosity test yeah what what is too generous because yes yes okay that's our healthcare is never generous right right so um so there's CMS has laid out two tests and one creates the floor and one creates the ceiling and when I talk about the generosity test I'm talking about the ceiling and the way that they phrase it is that the the value of the benchmark plan cannot be more generous than whatever plans were available to the state when they chose their benchmark plan so in 2014 when the state was looking at which benchmark plan to choose we had an assortment of plans we could choose from and those are all laid out in federal federal law so an example would be you could choose a federal health plan you could choose um a small group plan with the largest enrollment there are all these options so what we're going to do with this analysis is once we decide or once we say okay we really want this benefit or we want this change we then have to do kind of a comparative analysis with these other plan options that the state has has and had and say okay are those exceeding are those exceeding the benefit generosity of these other other plans and if they do we will not pass the the CMS test so that's kind of like when I was talking about you know premium and it this isn't just an exercise of adding benefits this is just going to have to be more of a we're going to have to look at the whole package of benefits and see you know what what do we think should be added is there's something that we can take away and and then on top of that then doing this kind of cross comparison analysis with these other plans um and that is the way that CMS has laid out the process for for the benchmark plan changes okay is there other public comment yes go ahead Dale just a follow-up that explanation she just gave brings me to another area of concern I'm worried about medical inflation and where does that fit into this if if you're maintaining something over five or six years and medical inflation especially we know what pharmacy is done you're aren't actually maintaining the same value and the benefits they are going to reduce if you're trying to maintain the same analytics which also means you're actually diminishing the quality of care um am I misunderstanding something I mean the way this is being described I see us losing value intrinsic value not gaining thank you this is Dana maybe I could jump in with a quick comment in response to that is that at the end of the process to evaluate and you know most likely make some changes to our benchmark plan we have to keep in mind that we're still in the framework of them prescribed by the ACA with the metal levels for each type of plan for example a gold plan is 80 percent the actual value meaning that the insurance covers 80 percent and the enrollee covers the other 20 percent that will not go away so understanding that cost go up it's still that relative you know where where the cost covered will will maintain you know be the same going forward so I think hopefully that's helpful to keep in mind okay other public comment hearing none we want to thank you Emily and we'll move on to the the second half of the presentation thank you thanks everyone hi this is adi stromello deputy commissioner at diva so for the second half of our presentation we're going to move from what was largely a state initiative to some of the federal activity that we've seen over the last few months and how that impacts vermont um you know we were here I think four months ago presenting on the standard plan designs as we do every year and those recommendations are often dependent on federal guidance that's outstanding this year there was even more uncertainty than usual because of the transition with the federal administration so we've divided this portion of the agenda into two sets of updates the first will be about the federal guidance that impacts plan designs and Dana will walk us through that just for context you'll recall that this guidance generally comes through an annual rule and the AV actuarial value calculator that's updated annually the rule is promulgated by CMS and it's known as the notice of benefit and payment parameters or the payment notice the trump administration proposed the payment notice in late 2020 and that's what the plan designs were based on that we reviewed together this winter that that team kind of rushed to finalize portions of that rule before they left office in january but they omitted kind of finalizing the plan design parameters that are in there so just recently in may the biden administration finalized those other portions of the rule and in doing so made some changes to the design parameters including the maximum out of pocket and again Dana will walk through all of those changes for you after that we'll move over to kind of the major health care initiative of the biden administration which is the american rescue plan act and its subsidies this became law in march and diva has been working very hard on implementing aspects of it and shawn our policy and implementation specialist we'll walk through where we are with that and what it means for the marketplace hi everyone so this is dana hooligan and nice to see you or be with you all so there are really just a few changes in the final payment notice that i want to review with you thank you for that context adi because there were there was a lot of you know in the transition this year there was a lot of uncertainty and we were in an unusual situation where between the proposed amounts and the final amounts in both examples are reductions in the cost share for consumers so i'm here to just review those with you so the first one here first i'll list them and then i will review with you the summary which essentially takes us back to what we presented and got approval from the board back in january so the first thing is that there's an annual or a maximum out of pocket was reduced from $9,100 the from the draft amount that was an increase of about $450 from last year and it was reduced in the final amount to $8,700 and i'll show you i'll show you what that amount actually refers to because it's all within the high deductible health plans and it's kind of a complex benefit structure that i'd like to give you a little bit more detail on in the next slide in a minute number two is just informational the this one is a floor of $1,400 as the deductible in a high deductible plan all of our plan designs are currently compliant with this this does not require a change i just think it's noteworthy that this was left unchanged since 2020 and then number three again is another parameter that is set by the irs not cms is an individual for an individual plan what is the maximum out of pocket within a high deductible health plan that was reduced from the anticipated amount from the draft or you know based on prior years we can barely accurately anticipate what the increase will be and the the final allowed increase was less than anticipated so i'll show you what that is about and then as we presented in january the actuarial value calculator for 2022 again as adi mentioned that's updated each year for the first time was actually brought out with a zero percent trend so meaning that no changes were actually required of in benefits that they would all have the same actuarial value from 2021 into 2022 vermont made the decision to do modest benefit cost share changes as you saw just an anticipation of rate relief it's it was you know the directional impact of rating is something that we are always concerned about and want to minimize that so that if we do a small increase in one year we will hopefully avoid a larger required increase in a subsequent year we could move to the next slide sean please so this is a an edited final summary slide taken from our presentation in january so really all i need to show you are the changes in the high deductible plans at the bottom of this page so again looking at if we look at the bronze plans first the the rose shaded in yellow that maximum out-of-pocket amount that we had proposed changing from 6900 to 7100 the final irs amount was brought back to 7050 so we will do that what that refers to is the maximum out-of-pocket amount for a an individual level bronze plan so a single person in that plan with their maximum out-of-pocket amount will be 7,050 not 7100 the embedded amount was reduced from 8550 and we were proposing increasing it to 9100 the final payment notice reduced that to 8700 which is 400 less these plans having what that embedded single amount means is that there's a there's a maximum out-of-pocket for a single level and a family level so for example 6900 is the maximum out-of-pocket for a for a single in 2021 the family amount is twice that 13800 they allow a larger embedded single maximum out-of-pocket amount within a family plan that's what's complex kind of complex to explain so instead of that being 9100 in 2022 it will be 8700 and that's the same in the silver plan silver-handed out-of-pocket so that's all as I said they're they're both reductions to the out-of-pocket amounts for consumers which is a good thing and so we are just bringing them back to the maximum allowed amount so that's really it in terms of the final kind of contents of the payment notice and the IRS guidance that affect plan design for 2022 so I'll turn to Sean at this point if there are no other questions excellent so going to talk about the American Rescue Plan Act and it will feed into what it means for the 2022 rates I know there are a lot of questions about the increase in subsidies and what they'll mean relative to the proposed rate increases and so I think it'll be helpful talking about what the American Rescue Plan Act does and understanding how subsidies are calculated and I think that'll flow nicely into the 2022 outlook one one piece to flag is that there are several components here of the American Rescue Plan Act that that impact health insurance marketplace and the first is more generous premium tax credits so the people that you all know people up to 400 percent of the federal poverty level that have been eligible for premium tax credits in past years they'll get even more premium tax credits for this year and next year secondly people who were over that income cliff and didn't qualify for tax credits before they may now qualify again for this year and and next year that cliff has been replaced by a by a phase out third there was a particular benefit given to anybody that was eligible for unemployment compensation in in 2021 so that's just just for this this year that one doesn't apply to this year and next year those three components all require system updates and as we'll talk about in the next slide on the timeline that they're going to be going into effect and leave into the system the end of the end of next week so it's coming up very very soon and the two pieces that that don't require the system system updates one that was relevant last month when people filed their their taxes is that if they ended up taking more premium tax credit in 2020 then they then they qualified for in other words if they ended up having a higher income in 2020 then they anticipated having when they implied for their coverage at the end of 2019 or or during 2020 normally you'd have to repay that when you file your federal taxes they were granted a reprieve from that and people who paid it before the American Rescue Plan Act went into effect will be getting a refund for the for the IRS they don't have to do anything or refile taxes or or anything else the last component is the feds are paying employers to fully cover 100 percent or 102 percent of of cobra reimbursement so people that have cobra continuing coverage from April 1st through this coming September 30th get get free free cobra when we talk about the marketplace side our timeline of what we're looking at for this year it's been a pretty pretty busy year and will continue to to be so starting in February we had a special enrollment period normally people can only apply for for coverage in the in the fall during the open enrollment period November and December or if they have a special very discreet life event that would would qualify them to to enroll because of because of the COVID special enrollment period it's been open since February originally slated to end in May and now with these additional subsidies and benefits really being a game changer was extended through October 1st of this year so people will be able to come into the through the summer and in early early fall and that will also allow those folks we talked about who are getting the free cobra through September to not have to be then stuck with paying for very expensive cobra coverage for October November so so forth for the rest of their 18-month period or dropping off during open enrollment they'll be able to come over right in right in September and enroll for coverage starting in October. We've also been working with people who are directly enrolled with the insurance carriers with Blue Cross, Blue Shield, Vermont and MVP Healthcare about 7500 people who as as you know over the past few years particularly since since silver loading when the previous administration stopped paying for for cautionary reductions and then we loaded the silver plans but allowed people who weren't getting subsidies to get reflective silver plans and just people who weren't getting subsidies to have the the ease of enrolling directly with the insurance issuers now being a game changer and that most of those folks may now qualify for for subsidies and but they have to come back through the marketplace to do so. So we've been working with Blue Cross, Diva has been working with with Blue Cross and with MVP to help them in the outreach they're doing to to their members to let them know about this this opportunity I'm assuring them that if they come over and and stay with the same issuer they'll still have the same plan anything they've already paid towards the deductible or not a pocket limit will transfer with that plan and that's that's already should we anticipate you know continuing throughout the throughout the year and through through open enrollment to continue reaching out to those those folks. In June as we talked about now we we are in June so this this month system updates will be be deployed to cover those those three new provisions that I mentioned on the on the last slide. After that deployment goes into effect people will have a new eligibility determination showing what their new levels of premium tax credits are and if they qualify for or enhance silver plans with cost sharing reductions will then be sending out notices to to all the members to to let them know what their new eligibility amounts are they'll have two options the same two options they they have at open enrollment or any other time of of year they can take they can take that subsidy they're the premium tax credits they qualify for and they can choose to apply it all for their upcoming monthly bills as a discount on their their future bills or they can choose to to wait and take it when they file their taxes next year or they can do a mix of of the both if they if they qualify for $900 a month they could choose to apply 700 or 800 and take the rest as tax credits the the same way you might do if you when you when you have your your page act and the number of exemptions you you claim and at this time too people will also have the opportunity to change change plans normally you can only change plans mid-year if you have a again a very discrete set of life circumstances but this this year because it is going to be such a game changer and that the amount of subsidies that people will be getting really could impact what plan they they choose to enroll in and not not changing plans could mean could mean leaving money on the on the table or having higher out of out of pocket costs this opportunity is being open to everybody who's who's currently enrolled they'll be given 60 days which is the amount of time people are normally given for for qualifying events so they'll have from from mid-June through through August 15th to decide to change plans in support of their their decision or and to help them evaluate what plan would make the most sense for their their medical needs in their budget we have an online plan comparison tool that's always very popular at open enrollment time we've worked with the vendor to have that updated I think that was the very end of April that we had this post-american rescue plan version posted so people can can go online now and see what subsidies they'll qualify for and in what what plan will likely have the lowest total costs adding together their subsidized premium with their anticipated out of pocket costs based on their household members ages and and health statuses if they want to give more more details finally we'll be rolling right in it's not too far away this time of year we're already starting to plan for for open enrollment that will be be happening as as well and one the one wrinkle for this year for next year for 2022 is the premium processing project and shift that we're working on meaning that people will no longer be paying their their bills to to the marketplace to Vermont Health Connect they'll be paying Blue Cross and MVP directly so we have both the the testing for that work underway on our side and and with the issuers and outreach we'll pick up on on that front in the in the fall as well one one thing to think about really you know talking very broadly about those three vision three provisions of the American Rescue Plan Act some ways it's helpful to think in more see them in more concrete terms and and really in thinking about them it's helpful to remember there's a few a few narratives that I think have kind of gained steam and in the Vermont Health Insurance landscape over the past you know decade or or more certainly the past eight years or so with under the Affordable Care Act in the marketplaces and one of those is that if you're under the 400% you know federal poverty level you're you're really you know protected but if you're if you're over that you're you're really exposed and could could pay very high premiums and I think the some of the American Rescue Plan Act narratives that are they're changing is that even a family of three with $150,000 clearly well well over the subsidy threshold before you know would in the past have paid way more than the than the national national average but again for this benchmark plan it's saying that everybody if you're eligible for subsidies you can't pay more than eight and a half percent so for somebody or household earning $150,000 eight and a half percent of that income is $1,063 per per month so that's what the benchmark plan that second lowest cost silver plan would be and it's important to remember though the way the premium tax credits are calculated is you take this second lowest cost silver plan and you determine what the difference is so you know the difference nationally is less than a couple hundred bucks difference here in Vermont is $818 per month so that same family earning the $150,000 they don't have to enroll in it in that second lowest cost silver plan they can take their $818 tax credit and apply to any plan so if they're you know a young couple with a kid and are are healthy and you know want to take a lowest cost bronze plan they could apply that $818 to the bronze plan this is where it becomes kind of interesting is that even though Vermont is kind of known for having the maybe higher premium certainly for younger people they would actually be able to get a bronze plan for significantly less than the national average even though they're a relatively pretty high income household so that's that's one narrative that's changing at least for under the American Rescue Plan Act. Another narrative has been that folks who are you know with Vermont not being one of only a couple states not to have any age rating it's a good deal for for older Vermonters not so good a deal for for younger Vermonters and if you if you look indeed a 60 year old individual who had been over that 400 subsidy cliff threshold at the beginning of the year indeed they'd be paying several hundred $500 less than an average 60 year old in the U.S. in a gold a gold plan looking at the gold gold plans folks in the 60s might be more likely to need medical coverage might be looking more at a gold gold plan and you know the way it's changing too in that flip side just like we talked about with the high cost on the other side meaning bigger subsidies really nationally that the big the big winners are older Americans under the American Rescue Plan Act indeed they'll come way down and certainly even in in Vermont you know a 60 year old here would would be paying only $394 a month compared to that 674 they were before so they're paying a few hundred dollars less and they're still paying a little bit less than than the average American a 60 year old but it's much it's much closer part where it gets really interesting is you look at a 27 year old who before with that same income $55,000 over the subsidy cliff before being unsubsidized in that lowest cost bronze plan paying the same amount that the the 60 year old was obviously because we don't have have age rating but for them that that would be you know more than $200 more than the the average 27 year old out there in in the country again you know here because they're getting that benefit nationally nationally there isn't really a subsidy cliff for for young people the subsidy cliff is big for for older Americans under under age rating in Vermont we have the subsidy cliff for everybody because we we don't have age age rating but that actually turns out to be a benefit under ARPA for these folks who are just over the the subsidy cliff meaning that now a 27 year old in in Vermont would pay less than half but they would have paid for before for that bronze plan and would pay even less than the national average that's a pretty exciting opportunity when we look at according to the household health insurance survey you know folks in their in their 20s and early 30s have by far the highest uninsured rate of any of any of the age groups in in Vermont so this really could be a could be a game changer for them the the piece to kind of roll from here right into thinking about how those subsidies are calculated came the question of okay who will be protected how much in 2022 and we were asked to look at this normally we don't really look at the proposed rates until until after they're they're finalized because that's when we we put them into our plan comparison tool and start getting ready for for open enrollment we were asked to do so for this presentation wanted to just underscore that we're just using the proposed rates for illustrative purposes we we know that it's the board's job as part of your your job to do the full full analysis of what those rate increases should be and that they may well not be what was proposed but for the simplicity of an analysis we used the the proposed rates and it actually is a relatively simple you say relatively because nothing about that all these subsidies is too too simple but compared to most years it was a relatively simple exercise for a few reasons number one usually the applicable percentages in other words what somebody at a given income level would have to contribute toward that second lowest cost silver plan bounces around from from year to year it might be 9.5 percent one year then you know 8.33 percent and or 9.83 percent I'm sorry and then but but with the American Rescue Plan Act they said for people who are 400 and over it's just eight and a half percent both both years 2021 and 2022 the same thing under 400 percent it's a lower percentage than that eight and a half percent but it's the same percentage for both this year and and next year so that takes out one one variable and looking at what people will actually pay from this year to next year secondly inflation can impact it a little bit because the the federal federal poverty level increases each so depending on whether you're saying a percentage of the actual dollar income versus percentage of federal poverty level that can change from year to year and that does change from 2021 to 2022 we always use the previous years federal poverty levels so in 2021 we're using 2020 2020 um federal poverty levels for 2022 plans we're using 2021 federal poverty levels we already know those there were it was very low inflation lower inflation than normal last year obviously it's picking up so 2023 may be different but at least I'm looking at 2022 it simplifies that a lot and so really it can come down to as simple as knowing as we talked about in those last slides that the premium tax credit is going to increase what people get by the same amount that the second lowest cost silver plan increases that you that if you have a plan increases by more than that second lowest cost silver plan increases um then the subsidized member would expect to pay more next year than this year if that plan where the premium was going to increase less than that second lowest cost increase then the subsidized member would expect to pay less in 2022 than 2021 um based on the same the same income um for those purposes it's it's helpful to start again with with that second lowest cost silver plan which in the case of um 2021 is mvp's silver high deductible health plan and based on the proposed rates at least um that's mvp's silver high deductible health plan would still be the second lowest cost silver silver plan um so you can see kind of on this graph across the income levels that blue line showed what people were paying at the start of of 2021 prior to the american rescue plan with the american rescue plan people all the way across the board up for an individual up to $95,000 uh income $94,500 income or for a family up to $265,000 income qualified for subsidies um and then and paid across uh the the green the green line and you can't it's hard to see the green line because underneath the gray line um it's actually gray dots i'm not sure why it's showing up as a green line when i go to presentation mode apologize for that but essentially it means that people all the way down from um you know no income up to the $94,500 are paying substantially less under the american rescue plan act when they were paying before it and in 2022 they can expect to pay virtually the same for this second lowest cost silver plan as they paid uh as as they're paying for the rest of 2021 um and then people who are above that $94,500 income level um they're they're partially protected up to an extent and that they're getting they still would be getting some premium tax credits to ensure they don't pay more than eight and a half percent of their their income under the proposed rates that would go up to about 108 um dollars uh i'm 108,000 dollars uh would get some some premium tax credits and then people over 108,000 dollars um would be paying full full price um and you know not be not be protected at all not get any premium tax credits another example and this was something that kind of came up in the i thought a lot of the the press coverage of of the initial rate proposals complicated matters a little more than i think they actually were needed to be and it they talked about um you know the rate increases by the issuers and you know based on income maybe it'd be a lion's share that would be paid but it wasn't clear how much would be paid again it really comes down to what's the difference between what that second lowest cost silver plan goes up versus what another plan goes up so at least based on proposed rates MVPs proposing that second lowest cost silver plan go up by 108 dollars per month for an individual blue cross um at their standard silver plans proposing that that go up by by 53 dollars so um people who are subsidized would get a subsidy increase of 108 dollars to get a gross premium increase of 53 dollars they'd be paying about 55 dollars less if they if they were in the so standard silver plan and stay in that standard silver plan based on the proposed rates and um what it what it means i mean to look at an example an individual earning 20 000 dollars um they would have paid 123 dollars a month for that standard silver plan when they when they enrolled during open enrollment period last year under the american rescue plan um they'll be qualifying to pay just 53 dollars per month and i should mention they'll be able they'll have they have the option to apply that that extra 70 dollars that they have if they were enrolled in paying 123 for january through through june so they could effectively be paying zero um you know for the last several months of of the year but averaged over the year they would be paying 53 dollars for that plan um because they'd be paying 55 dollars less for this plan in 2022 that person earning 20 000 dollars enrolled in a standard silver blue cross plan um you know could get that plan for zero zero premium um in in 2022 um and and i think so i think the question there of you know what people pay or what the percent increase you see the percent increases there that are proposed um obviously that he's pointed along that line that paying 55 dollars less is a different you know a different percentage but for a single person earning up to 67 000 dollars you know that 55 dollar decrease would amount to a double digit decrease in their in their net premium each month and just one last example to give there would be if somebody um enrolled in blue crosses lowest cost bronze plan the lowest overall bronze plan would still be an MVP plan although under proposed rates they're only a couple dollars away from each other um in this case somebody in blue crosses lowest cost bronze plan i think it's a different plan that under blue cross would be the lowest in in 2022 but if they choose what's blue crosses lowest bronze plan that would be a 38 dollar increase over the 2021 lowest cost bronze again they get 108 dollar increase in their subsidy they get a 38 dollar increase in their in their gross premium so they would pay 70 dollars less um per per month and that would be a double digit decrease for all currently subsidized members um to give that in a summary of where the plans go um of the there's 20 plans that increase they have a proposed increase that is less than the proposed increase for the second lowest cost silver plan so effectively that means that subsidized people in all 13 of blue cross blue shields uh plan designs as well as all five of mvp's bronze plans and two of mvp's silver plans would pay less in 2022 than they've been they're paying under the american rescue plan in 2021 as we discussed people in the second lowest cost plan that's the benchmark they essentially pay the same there's five plans that increase by more than the second lowest cost silver plan um and so in those five plans all from mvp people could expect to pay more the most significant increase being the platinum plan that um is proposed increase by 46 dollars more than the um this is the benchmark plan in the subsidy the other uh the other four plans three three gold and one silver increased by more than a by by about a dollar to 16 dollars depending on which of those which of those four plans um so that's those are who would be fully protected I mentioned the higher people with higher incomes um that don't get subsidies now people are between 94 thousand dollars and about 110 thousand dollars uh in an individual plan or 265 thousand dollars up to 308 thousand dollars under proposed uh premium increases those people um would would qualify for some tax credits so they wouldn't be bearing the the full increase but they would be paying more than they're paying in 2021 and then people who are unsubsidized would um would bear the full the full cost of that that premium increase and so the last slide here is just kind of important underscore who we're talking about when we're saying people who who pay um the full the full premium I think that the people that's easy to think about are sort of obvious from from those graphs are people on the the high side of those of those graphs um which we don't believe to be too many too many people when we look at people who we currently have income information um on there's there's very few who are over for an individual that's about over 700 percent of the federal poverty level is what 94 500 is and for a for a family 265 thousand dollars that obviously bounces around depending on the size of the of the family but for a family of you know three or four that's um you know well over a thousand uh percent of of f fpl and um we only we only have less than less than 200 households that have um higher than 700 percent fpl I believe now we're trying to get information from people we don't have um financial and um and come on as I mentioned we're doing the outreach with the issuers to get people to to apply and and we're also reaching out to people that have applied um and and bought coverage through the marketplace but haven't given their financial information we've sent out multiple notices to them and we'll continue to to conduct outreach to them and we anticipate more people with higher incomes will come in but at least as of now the vast majority of people we have income information on and I think it aligns with when you look at the state as a as a whole through census data or tax department data um there's a start um you know not a lot of people making um two three hundred thousand dollars in in the state particularly that we need need insurance through us the second group is people who don't qualify for premium tax credits for for reasons other than financial eligibility um and the upside here for for 2022 is that one of the most common reasons is the failure to reconcile the previous year's premium tax credits as I mentioned before the the feds gave that one-year holiday um for people that if they if they had um owed their uh taken too much premium tax credit in in 2020 normally would have to pay that back if they don't file their taxes or don't reconcile their taxes normally they would be getting a code when we when we determine eligibility with the federal hub um that would say you know from the IRS say not to not to give those folks premium tax credits because of um not needing to reconcile um you know that won't be an issue here for that group so there'll be there'll be some other people people that have um citizenship um kind of various other reasons they might might not qualify but typically a big one is not not reconciling and that that should be mitigated here another reason that's gotten a lot of discussion is the you know the quote quote family glitch um or people that have an offer of affordable minimum essential coverage and when I say um affordable maybe um you know along the lines of the same the same question that that Walter asked of of uh of Emily on what's what's seen as too um too generous uh affordable minimum essential coverage isn't a judgment on on our part it's a federal definition of um what it takes for people to qualify for subsidies and that is if they have another offer of miss minimum essential coverage typically employer sponsored insurance that would cost um an enrollee uh less than 9.83 percent of household income for a single person coverage then that coverage is deemed affordable and even if the other members of the family that were offered coverage it would cost them a lot more than that amount that's the that's the federal test and so there's been some rumblings that the that the feds might address that family glitch um if they do it would help help these folks out if they don't it would be an impact here over the course of a year we have about a thousand people maybe more than a thousand people that come come through that applied for coverage um and and are found to be impacted by that by the glitch to be not not eligible for subsidies because a member of their household has um employer sponsored insurance that's deemed affordable many of those don't enroll at any given time maybe have 100 to 200 who are who are enrolled so it's hard for us to say whether the rest of them are are uninsured or whether they end up enrolling through their employer sponsored insurance or whether things have changed over the course of of the year but as far as folks who are enrolled and would be auto-enrolling that's a you know it's a it is a batch of people but not a not a huge batch um and then finally there's the direct enrollees that we've talked about who um are enrolled directly with Blue Cross and with with MVP and uh you know conducting outreach we anticipate some of them already have come over I think about 600 individuals have started the process of transferring their their coverage we're continuing the issuers are continuing to do outreach to those members we anticipate that when we have these new subsidies going to effect later this month there'll be an opportunity another another wave of of people might come over maybe particularly the the reflective silver enrollees who maybe didn't want to come over and pay for a full cost silver-loaded plan but maybe would come over and switch to a gold that they can you know take subsidies for um and you know it'd be different for for each group of people but we anticipate another wave then um and the issuers doing outreach to those folks at that time again at open enrollment time will be another opportunity to reach out to to these direct enrollees certainly if they get the sticker shock of of um of opening up their their premium unsubsidized premium increase um that might help drive some more some more over um but of course those who who don't transfer over um would also be subject to the premium increases and some of them again of course maybe because they don't don't qualify they fall into those top a couple buckets um those were the slides I had of course I'd be happy to take any any questions on the pieces I've talked about and I I know Dana would be happy to talk about uh his slides as well great thank you this is uh incredibly valuable information to anyone that's buying product on the exchange and this is the second time that I've seen this I saw it when you did it to the legislature um you know just as I wish that uh every um high school student in the state of Vermont had to take a personal finance class I wish that all 72,000 members that are buying product through the exchange um had to sit down and look at these slides but that's not going to happen and you talked about um outreach from the the carriers can you go into that in a little bit more depth on what you're hearing their outreach will be and what efforts the state of Vermont is going to do to try to get information to people so that they can make valuable decisions you know seems like a huge opportunity for some people to get much better insurance at a more affordable price and I just want to know um how they're going to know that these options are available to them yep absolutely happy to happy to talk about that and yeah I think your point on personal finance in the in the schools that's something I've I've talked to uh to Dylan Jean Bautista about in the in the treasurer's office he had pulled together a lot of the financial literacy education work but they but they do and we've been uh aged human services in the past we've worked with with their outfit on on that because you're right it comes right down to uh financial literacy and I think you know it's often times more fun to think about uh being financially literate when you're buying a house or buying a car or buying something fun and tangible and healthcare is less less fun and insurance in general is a product that you buy hoping never to you know never to use um except maybe in the case of healthcare we obviously encourage people to use their their preventive care and those those annual visits and and so forth but uh you're right it's a tougher tougher sell not as not as fun as far as the outreach we're we're doing we're really looking at dividing into a few a few audiences and a lot of the audiences that we work with are um are very discreet audiences people who are directly enrolled through the marketplace for one we we have them we're sending out the notices of decision I mentioned they'll talk about their eligibility and we'll we'll encourage them to check out the plan comparison tool to make sure they're in the right plan that's something we do regularly we reach out through through social media and other means as well we also will do direct um we have email outreach that we've we've done so we can look at people who might be in a bronze plan um if they're in a bronze plan and they they chose that plan because it was um you know free which was kind of one of the other narratives I didn't talk about but certainly that's been a tough the other narrative that you if people who are relatively low income have had that choice of either getting a premium free bronze plan that has those really high out-of-pocket costs that um that Dana talked about if people need to use coverage or getting an enhanced silver plan with with cost-sharing reductions but if that meant paying the existing example I had in there if someone earning $20,000 paying $123 per you know per month at $123 um there might be a small slice of what the what the gross premium is but it's still a significant amount if you're on a tight tight budget and so you've had to really choose do I want to pony up maybe more money than I can afford for a plan that will have very low out-of-pocket costs if I need to use coverage or do I just take that plan that's premium free and um yeah maybe you know it has high out-of-pocket costs but certainly those out-of-pocket costs are better than you know six figure out-of-pocket costs if I if I get cancer get hit by a bus um the nice part of that narrative changing is that now you know people don't have to make that choice at least at least under the American Rescue Plan this year or next year they can afford very low premiums or zero premium plans and in many cases that still have that cost sharing reductions and so that's a piece we're going to be doing outreach out we do we do email each open enrollment time and direct directly reach out to people who would be in a bronze plan but would qualify for a free or very low cost silver plan to help them understand um you know what an enhanced silver plan would look like help them go to the Plank and Paris and tool to see for themselves we also do that direct outreach to people who might be enrolled in a a gold or platinum plan but would qualify for those more generous levels of cost sharing reductions who are actually paying a higher premium and getting you know more higher out-of-pocket costs because they're they're having more cost sharing in a gold plan than they than they would in say a enhanced silver or 87 or enhanced silver 94 so we directly reach out to to those folks we're working with the department of of labor to reach out to people who are on that who have gotten unemployment compensation and that's a that's a whole lot of people this this year because it's not just the standard unemployment compensation it's the pandemic that's all the acronyms the PUA and the PUC all the other acronyms that folks that labor can get no no pattern of the pandemic unemployment assistance and so so forth I mean you're talking about not even including the PUA I understand it to be over 40 000 remodders have have gotten those other forms of coverage and again just qualifying for just one week of of this year if you don't have um you know employer-sponsored insurance or other other insurance right now you would you would qualify to get that most benefit most most generous level which is you know it didn't get into it here but it's being deemed to have your income not be higher than 133 percent the federal poverty level somebody who's just over Medicaid so what that means in terms here is that for 2021 um if you got any unemployment benefit you could get any one of MVPs for enhanced silver 94 plans which can have very low out-of-pocket costs for zero zero premium or you could get one of Blue Cross's four enhanced silver 94 plans again very low out-of-pocket costs not for zero premium but for for a very low you know premium you know 20 34 depending on which of those four plans you're you're looking at per per month so that's a that's a huge benefit for those folks and to the extent that again we don't know exactly the last household health insurance survey was 2018 feels like eons ago anything before last march feels like eons ago but it was you know fewer than 20 000 uninsured for monsters then it may have bounced around but we anticipate that certainly some some segment of that you know 40 000 or more for monitors who have qualified for unemployment insurance may be maybe uninsured and the extent that we can work with labor will be emailing all those folks that have gotten that benefit letting them know about this this benefit anybody who applies new labor sends out an emailing on a daily daily basis to people who apply new so people who aren't caught in this initial outreach we do to them will be working in a flyer to their to their daily mail mailing to people who apply to unemployment compensation where we'll be looking at kicking up some paid advertising which we haven't haven't done in a in a few years just typically because there's so few uninsured people in vermont and people have kind of looked at the the coverage we haven't haven't done that but we'll be kicking that back up in next month as well as getting out through radio through front porch forum through other other means because really the message here is there's a lot of people that may have looked at the marketplace you know looked at vermont health connect in past years say okay i qualify for a subsidy but that subsidy is not good enough you know i'm not doesn't make sense to to enroll and these these subsidies are such you know such game changes you're talking about somebody who's at 300 percent of the federal poverty level which is about the median as i understand it and in the in the state are pretty close to it could could enroll in a zero premium bronze plan again you know we're not advocating for bronze plans necessarily they have this high out of pocket costs but if it comes down to you making the decision of thinking i'm you know i'm healthy i'm going to roll the dice and not get any coverage at all versus having a zero premium you know plan would much rather people jump jump into that and so by getting the word out of you think you've looked at the subsidies before you know it's you haven't you haven't looked at them now give it another look and and that's something we're going to be doing weening heavily on the plan comparison tool for people to see for themselves and getting getting the word out also through all of our sister organizations and other other promotional partners both both other state agencies you know beyond i mentioned DOL but kind of others others as well and our sister organizations will be getting getting the word out talk a little bit about the the issuers what we did with the issuers in the initial mailing we wanted to get out to people right away in in April to the extent because again it's every month that you're enrolled you qualify for this for this benefit so people who are enrolled starting in january as i mentioned they you know they may have a plan that requires them to pay 50 or 60 dollars um a month but they can take what they accrue for the first half of the year and apply it to the second half of the year and have have zero premiums so to the extent that somebody who was direct enrolled or not insured was willing to come over and pay full price for you know last month for this month we get these the implementation in effect later this month you know they will then have those months under their belt that they could apply later in the year so we put together some worksheets some material some flyers for for both Blue Cross and for for MVP underscoring kind of what these income levels are that we're we're talking about because i think a lot of times people somebody's making six figures and you hear that there's some subsidy out there you probably aren't gonna aren't gonna look so we want to get those numbers right right out there so i know if you're in a you're in a family plan and you're you're earning uh you know a quarter million dollars you're you know you can there's subsidies here for you if you're enrolled through the marketplace um and then number two really getting the plan comparison tool up so people can get for them see for themselves the initial mailings we did we put some worksheets in there because we didn't have the plan comparison tool up we didn't get it up to the end am i the only one that lost shawn no sorry i just got a uh just popped up on my screen and someone someone to remove me from the meeting i was like i don't know if i'm being too long-winded here so when you yanked me off the stage right and i've never gotten that message before my teams but um yeah so so we put together a bunch of bunch of materials that were worksheets were very kind of paper heavy in that first round that both blue cross and mvp sent out and so the and really came up with a worksheet that much more looked like a worksheet so people particularly on silver plans could see okay this is how much more i'm paying this is what my premium tax credits um would be to see if it makes sense to um to shuttle over sooner or later to understand kind of what their flat cash flow was it was a more complicated decision so now that the implementation is going up blue cross is looking at doing another mailing that week of you know week after next to all of their members who haven't transferred over yet you know it'll be a simpler you know simpler math equation for them so you can go right over you can call the marketplace today you call anytime before the end of june you can have your coverage starting you know july 1 for people who are transferring coverage and find out what their you know what their subsidy would be so be a simpler message in the next round of outreach and we'll just continue working with them i know they've also both blue cross and mvp have done some spot phone calls to members who didn't transfer plans just to find out um you know if people a open to their mail b if they didn't open their mail like if they did open their mail you know did they understand it was there something that could be communicated more clearly so it'll be an iterative process we'll continue working with both the issuers we have calls every thursday um with folks from diva and both issuers to see how this uh process of outreach to direct enrollees is going and how we can improve it um we will we'll continue to do those weekly calls as we go terrific and you know maybe uh in addition to paid advertising you might want to just put out an informative press release that newspapers could pick up on radio stations uh television we know that not everybody reads their emails or their mail but if they're trapped in the car going someplace and they're listening to the radio they may catch the information so it's just one of those things yeah absolutely that's a great piece that i was i yeah i neglected to mention that but certainly the earned earned media is a great component as well we've done a couple um press releases and we've kind of held off on doing too many when we're in this point where there could be confusion you start publicizing you know there's a discrepancy between people seeing what's what's up there but certainly our our intent is to do do more of that um as we once we get the system up so absolutely okay members of the board yeah i think i would just add that's to me that's uh echoing there that um i totally agree with the educational piece you know both from getting to transfer over you know the special enrollment group and you know i think also somewhere in there i under you know i do support right getting somebody on a bronze plan who maybe isn't covered but having them in the past but having them understand you know what their out-of-pocket could be and what percentage that could be of their income as well so you know there almost could be some charts with you know if you're a silver plan and here's what your premium would be here's what your maximum could be with your out-of-pocket and then the same with the bronze we don't want to scare people away but we also want to make sure they kind of understand if they're going to be utilizing their insurance and they have a high deductible you know that that could could be an issue um and then another thing and i don't know how we think about this or how this gets communicated but you know with the fact that the insurance markets are split this year with the small group and the individual and the submissions are higher for individual than they are for small group that's not what's approved but the submissions are higher and it was almost like well the higher on the individual market they're going to get covered by the subsidy most the people will this year but i wonder you know those subsidies ever claw back or anything if we have this you know market going opposite ways and we may not be able to talk about that here but but that you know i think some of the soundbites that come out in the paper are going to be what potential increases we saw what the requests were from the issuers for the individual market some being fairly high which will be offset with the subsidies i don't know what the soundbites will be so it's really going to be having that education so people understand that you know they're not going to pick the brunt of that but i do worry about the future if subsidy continues to continue what that could mean now if they go away so that you can comment on that but it's just something we have to be aware of in the future yeah i know i yeah i think in that point not a lot to say other than it's certainly right i think at the forefront of everyone's minds and should be it certainly was at the forefront i know of the legislators legislature's discussion as as they were emerging the market and the administrations as well and specifically looking at you know doing it for a year and keeping an eye on what happens with these with these subsidies i think to your point on the bronze that's certainly at the forefront of our thought too we've we've had what we've i think back from the beginning what we've called kind of the the cigarette cigarette label warning it felt like warning these bronze plans can you know can come with with high you know high costs side pocket costs and that can go ahead and we need a lot of education right and the playing comparison tool i think doesn't like that yeah yeah so but um thank you it's a great presentation yeah absolutely no comments from the board i have a couple questions and first i want to thank you shon for the work that you helped in terms of profiling the uh the benefits cliff that agatha and i worked on you know the last couple years i don't think we ever met but i i knew that you were the the man behind the curtain getting it all done in that situation and i just appreciated that you know those documents my two questions are the first is um i noticed i think i saw on some of your charts that people at 300 of property or below are also benefiting um from these uh this new you know this new federal approach and is that true it is yeah yeah everybody i think i can go back to so okay so so so why why i asked that is that is how does that integrate with the state's premium assistance program you know that supports people at 300 percent of poverty or less um yeah so that is still still in effect um the i'm putting it up up here um so people in the 300 percent is actually this little mini mini cliff here let me see my my mouse on there and uh that mini cliff is because of the um the vermont premium assistance so people up to 300 percent qualify for one and a half percent of their of their income um as a as a monthly subsidy so once people go over 300 you know they would they would lose that one and a half um percent income and that's the little bump up there you can see that uh people all the way down have um are significantly below that line of what they've been been paying earlier in 2021 and the way that works is people people up here on the over 400 percent of the federal poverty level they're tied to eight and a half percent of their of their income uh is is capped that's their their maximum contribution for that second lowest cost silver plan for people down down here underneath 400 percent it's a lower percentage and all the way down to people at um believe it's 150 percent and lower would have a zero percent federal contribution and so what what that would mean is you could get that second lowest cost silver plan for zero for zero dollars if you were at 150 percent of the federal poverty level in addition you would still qualify for the one and a half percent vermont premium assistance so if you were in a bronze plan or the lowest cost silver plan or second lowest cost silver plan the the federal premium tax credit would completely cover your premium and you wouldn't get any vermont premium assistance but if you were in one of mvp's more expensive silver plans or a blue cross silver plan in addition to getting that full tax tax credit um you would you would also get one and a half percent of your of your income that you'd be able to apply as vpa to make that more expensive silver plan even less expensive um or as we mentioned if you were in a gold or platinum plan we we hope you're not busy because you'd be getting lower out of pocket costs with the with the silver plan but again if you were you'd be able to apply that full cost of this of the second lowest cost silver plan so so so let me ask ask the question a different way um i just looked a while back at the for 2022 the premium assistance program is budgeted at five point six million dollars all things being equal not changing uh you know program uh you know the guidelines for that that program will there be a savings to the department in the premium assistance program because of these new federal subsidies yeah that's that's a great it's a great question and it's actually sounds like a simple question and it's it's probably a long one the likely for 2022 it is likely that less vermont premium assistance will be paid out um then was paid in and past past years um for as far as the savings to the department sounds like the same question it's actually a very different question um and the reason comes down to the the administrative costs and as far as the cost allocation works so right right now the the department's costs of running the marketplace which is everything from the you know the computer system to the the folks at maximus our contractor that handles the the phones when people when people call in those all get um those costs are attributed based on um how many people are in qualified health plans that that aren't aren't subsidized versus uh how many people are in Medicaid and obviously most of the department's members are our Medicaid so a big portion gets it gets uh gets allocated toward Medicaid costs which are paid at the global under the global commitment waiver with the feds picking up a little over half 55 percent or more of of those those costs um in state dollars general fund paying for the for the rest people who get vermont premium assistance because vermont premium assistance is under the global commitment waiver they actually get attributed to the Medicaid population so it benefits the the state more federal dollars get get picked up on the administrative costs when people are in vermont premium assistance so to the extent that we have people who go off of vermont premium assistance because the feds are picking up all of their premium it would mean fewer federal fewer vermont premium assistance dollars going out the door but it would mean the administrative costs at least the general front portion of administrative costs would be likely to increase and how all that washes out is um you know a good good question that i think will need more analysis sometimes we can go through the we can go through the detail of it i was just looking for some money for emily's work on the benchmark plan so um there might be something there as my second question is with um vermont health fact moving to blue cross blue shield in terms of administering and and collecting premiums are the premium collection discipline at blue cross blue shield comparable to the one that is at vermont health connect under diva in in in their rate review presentations blue cross blue shields presents that they have a fairly aggressive or effective waste fraud and abuse approach and i'm just wondering if there's going to be any shock uh at all between the experience of folks with at vermont health connect as it's in diva versus the collection of premiums as it will be under the the the newer arrangement i don't know if adi or anyone else on the call wants to wants to take that i'll um i'll beg out in the sense that i i uh i left diva for for a couple years to go work for the tax structure commission just came back a couple months ago and got my head right into arpa but i'm rusty a lot of a lot of other pieces so even this premium processing if adi or anyone else has anything i'll defer to them yeah you're sure and i'd welcome dana to chime in i so what's happening is that the issuers will now be sending out bills for their customers whether they're enrolled through vermont health connect or not so it's something they already do for their direct enrollees and now they they will also be sending the bills instead of our premium processing contractor at diva doing that i don't think we anticipate kind of a shock i i do think it will it's a behavioral change that will have to happen and we're going to watch that closely and make sure people get to the right place and aren't kind of caught in the middle and having late payments but i don't think that that would be prompted by something in particular around blue crosses kind of mechanism for issuing the bills yeah but the reason i asked the question is i recall um an article a while back where the auditor haw for audited the dr dinosaur program and found um the enforcement of premium payments and the issue of benefits going out the door to people that haven't paid their premiums was was loose and from you know in in terms of his presentation and i'm just and you know i'm just wondering you should we anticipate if blue cross blue shield has a more disciplined approach should we anticipate some noise in that regard that's that's my question yeah i mean just to follow up on the doctor the dr d issues that were addressed in that audit um we don't have those same issues with respect to the qualified health plan bills so the the you know notices for late payment go out the and the processes around termination for non-payment are intact so um if anything i think it's possible that the issuers might be more lenient than we are allowed to be under federal rules with respect to grace periods um new so but we'll we'll certainly be watching the transition closely great thank you okay other questions or comments from the board i have a couple um a lot of echo today um addy just one follow-up around the premium processing what is the savings to the state from shifting the premium processing to the carriers it depends how you look at that um but we're we are a current contract for the vendor is around three million dollars and once it we are only doing dr d billing it goes down to around i think 600 000 thanks um uh Sean i had a i was looking for the diva health coverage map for 2021 i the last version i found online was september 2020 is there do you happen to know if there's an update of that for 2021 yeah there there is one um and i was actually it should be it should be posted and i just actually noticed this morning that it wasn't either um i could i'll follow up um today to make sure that it's posted by by end of end of day great thank you or or i can send you the pdf directly right now too if you if you'd like that would be awesome um that's great i was so it looked like at least as of september 2020 there are about 7500 people directly enrolled as individuals as opposed to small businesses with the carriers do you think that it's about the same in 2021 i'm just trying to get a denominator for the how many potentially could switch over correct yes as of january it was right around 7500 individuals so yeah so we've been we've been tracking that um and as of um last week about eight percent of um of those folks have initiated a transfer um pretty similar we're tracking it both across and um and and with mvp with with the individual things yeah a lot of work to do there um yeah the other question i had is for people who come in to do a plan change and switch plans after they understand the impact of the new subsidies will any deductible and out of pocket also transfer like uh the direct enrollees i know that can be trickier if people switch carriers yep yeah i see yeah they can't as long as they stay with the same carrier um both carriers have agreed to um to honor people changing changing plans um having their their deductible move move with them and that yeah that's that's something that certainly helps a whole lot that's something people would be concerned with and it would be an extra monkey wrench that i'm talking about getting in the financial literacy class that would be more than the high school level financial literacy you need to have the the grad school level of right if you're in a if you're in the bronze plan and now you can get your premium silver but you've already sunk a grand until you're out of pocket cost doesn't don't make that so thankfully we don't have to go there um you know the message out there is it's going to be very very clear if you have to stay with you know the same issuer to have those plans go over but then you can you can change change plans the issuers will will honor that that's great um those are the two questions thank you thanks robin other members of the board any questions or comments no i just want to thank you that was a really helpful presentation and actually my questions are already asked and answered so thank you you're very welcome great to be here so at this point i'm going to open it up to the public for any public comment does any member of the public wish to offer a public comment ham davis thank you kevin um i just like to ask shawn i missed this can can you give me the latest number again on the number of of uninsured in the in the state now can i get that again and then secondly if you you you didn't wasn't in your presentation but how could you just if if you know how does that number compare historically and is that very low is it medium etc thank you sure absolutely thanks thanks ham um yeah so the most recent number we we have is from the 2018 household health insurance survey i know that state's looking to field another one department health will be be fielding another one later later this year but the best figure we have right now is is from 2018 the figure there was just under 20 000 vermonters were um were uninsured i believe 19 800 was the estimate which was the second lowest um in the in the country after after massachusetts um again 2018 in many ways feels like feels like eons ago um you know we know there's more people in medicaid people aren't being disenrolled from medicaid we see the other numbers around a lot of vermont's population is our biggest age group is in the 60s a lot of people are are aging into um into medicare um so there's sort of a lot of certain a lot of certainly a lot of reason to um expect that it would still be still be low but that's our that's our most recent figure um in the second second part of your question what i was just going on is whether over the sweep of reform to the extent that you know i've never heard a number as low as as low as 20 000 but i don't know i mean is it how does that compare yeah yep no you're you're right yeah thanks for thanks for flagging that yeah it is it is the lowest um lowest number and yeah if you go um look in the vermont household health insurance survey i think in the back and the appendices they do have i think the rate and the absolute number over the years that they've been doing um that that survey which i think is going back to about 2000 or or so um and it is it is the lowest thank you absolutely okay walter carpenter uh thanks devin um picking up on hand statement let's not forget the under insured as well um we don't know about those and then picking up on statements um about education i think definitely we need a phd program in this stuff because there's no way that a common person outside of the this realm can understand any of this so i think we should put a phd program in the vermont state universities i like jessica smile on that idea yeah i think that's true you know i think along those lines the um we looked at a lot of different tools and we certainly look and have a lot of conversations with other other states you know this is the this is the system we have and the marketplaces are the you know systems that are that are out there with the other state-based marketplaces and and the feds we look at how they communicate about these complex issues and where we can can learn from from others um we looked several years ago when we were looking at at tools we had subsidy calculators we liked this tool the plank comparison tool we saw saw out there we contracted to get that in in place that had some video helps people understand not just anchoring around a premium not just anchoring around a a subsidy or a max out of pocket or deductible but really looking at what those likely total out of pocket costs um would be and being able to have those different columns where you can look and and you can sort by what your expected out of pocket cost would be or what the out of pocket cost would be in a in a good low usage year what it would be in that worst case scenario year um you know see the see the probabilities for somebody your age i mean once you start flipping in and digging deeper there and seeing probabilities i understand you're you're no longer at the fourth grade reading level or fourth grade math level but at least at that first yeah at least at that first level of seeing the numbers and being able to sort at least it gets you going in a you know in a good direction towards a metal level or toward plan that might make sense for you it's also another argument for a single payer plan because you can least understand that yeah i think for you know for for arguments like i said we're working in the in the system we have but but certainly the arguments of the different the different systems with the with the single player it's almost right the difference of almost retirement benefits right again like the pension you get paid versus money to people to go put in put in the market right and if you want to really put in a lot of a lot of time you're going to have that information differential where you can do better and where you can do worse so working in the system we are we try to strike that line of making it as easy as possible for people who don't want to put a line a lot of line in don't time and don't want to get a phd but even putting two or three minutes in um you know can be useful with the plan comparison tool and then if you want to put hours in we try to say look you know if you were gonna you were going to buy a $20,000 car you're going to buy a couple hundred thousand dollar um you know house it's been more than a a couple minutes comparison shopping heck you probably spend more than a couple minutes comparison shopping on your your two dollars boxes of cereal at the grocery store right so actually I do not grab and go that's what it is more power to you we want to yeah we want to we want to be able to help people along the way if they want to dig deep we want to help them dig deep and do those comparisons if they wanted this the high level we want to do that I should mention actually on that too one of the other pieces I neglected to say on the education I was also working with those um those industries and those employers in in Vermont that tend to have folks that would be more likely to come through um the marketplace so we've worked a lot with retailers in the in the past with you know with grocers um just a couple weeks ago we did some presentations with um with let's grow kids and and the early uh educators uh folks that work work with them to help folks that are you know working um as early educators and often may already be enrolled in our in our plans or gone without insurance because they couldn't afford it to do some uh you know some webinars and conference calls with them make sure they're aware of these changes that are coming to help them get enrolled and to help them have these tools to decide the right plan for them we certainly want to continue doing that with other other sectors that can reach their employees and and Vermonters and collaborate with them to make this information as as understandable as possible okay other public comment question go ahead Dale actually want to follow up on Walter's question that's always was a really good question um can you give me a little more specifics what are the people you find that really understand the healthcare system what what level grade level are they reading are they high school grads are they college grads what kind of degree do they have if it's more college level who's the people that seem to really understand the healthcare system and navigate it well yeah that's a that's a great question as far as understanding the healthcare you know system and navigating the system a bit of that's beyond us i mean i probably look back i think look probably look back to the household health insurance survey as far as the most comprehensive survey of really looking at what people understand and i think to walters point two of like where people are underinsured i think the questions in the household health insurance survey of really getting at the questions of what percentage of people wanted to see a doctor they had to forego coverage or needed prescriptions and all those all those pieces i think are things that the survey has delved into and it's continuing to to look at you know and see see which of those metrics we've i think back to ham's question not just on the uninsured but where we've made progress and where we haven't made progress as far as you know people having to forego coverage people being able to use you know you get the services when they need them and so forth that that survey has really been the best tool best insight we've had at that level okay other public comment seeing and hearing none i want to thank the whole team of presenters this afternoon this is really useful information hopefully the people that need the information get it and you know i hope that the news media does their job to get the information out there as well because i think we all have an obligation to try to to help people pay as little as possible and and unfortunately like walter i'm kind of a grab-and-go shopper but we all know people who are incredible shoppers that really can do some incredible savings because they put the time and effort into it and unfortunately this is one of those cases where if you really want to get the best deal you're going to have to put some time and effort into it so with that thank you all and we're going to move on to the next item on our agenda and that is old business last week i promise that under old business we would take up the proposal that mike fischer had put forward and i'm just curious if board members have had a chance to think about what mike has proposed which is really trying to put together a committee that would include providers consumers etc to be kind of a gateway for the the um i don't really want to call it law hanging fruit but those situations that arise that could be fixed and should be fixed so board members have you had a chance to give some thought to to mike's proposal i can chime in i thought i've thought about it a little bit um and i suppose it couldn't hurt i just wonder uh it seems like it's really the work of quality improvement and so depending on what the issue is and so i i wonder if there's not already existing sort of processes for that quality improvement or quality improvement efforts um that that could help with that because really what you're talking about is individual provider decision making with their patients in some instances but you know so i i hadn't i didn't actually have a ton of time to think about it in the last week but that was sort of my initial wonderings um is making sure that we weren't sort of duplicating efforts that might be happening elsewhere and whether or not a committee could solve this kind of issue that seems to me is really about provider decision making but i think it's someone got into a little bit more than just provider decision making but um i i definitely get your point robin um is mike on the the meeting today um i don't see him on the list kevin um i guess i'll just chime in here i don't see any harm in it and to the degree that you know there's a group of people providers consumers maybe some folks from uh the carriers that want to spend some time thinking about that low hanging fruit i mean that's information that could be beneficial that maybe we could identify some small solutions for workarounds for so i if there are volunteers willing to do this um i don't see the harm in it it would be helpful i think to robin's point to see if there's any other we don't want to duplicate other you know um groups trying to achieve this but i don't see the harm i i see on the upside if it if there are people willing to do it and it's really essential that we have some commitment from people like a hospital administrator a provider a consumer and maybe if people who are listening i don't see mort wassen on today's call but i know that he um spoke strongly in favor of what mike had suggested and you know i don't know if a doctor like mort would be willing to volunteer some time i know that uh walter had talked about the need for a consumer on there i don't know if he's willing to volunteer some time but maybe we could just leave today's conversation with just asking people if they are interested in serving on such a committee if they could either email or give myself or mike a call and we can try to see if there's interest out there and if there's interest then you know it'd be good to have that committee to look at these things as they pop up and so that's not what happens at a coply doesn't get recreated at bennington and and a year later at another hospital things like that so i guess it's really going to be if people find that it's worth their time to serve on that type of committee so any other thoughts from anyone including the public so i'm not hearing any so again i'll just put it out there if you have an interest um drop either uh mike or myself a line um and uh let's see uh if there's the interest to serve in that capacity and we'll move forward from there so with that is there any other old business to come before the board is there any new business to come before the board is there a motion to adjourn so moved second second it's been moved by uh jessica and seconded by robin to adjourn all those in favor of the motion signify by saying aye those opposed signify by saying nay thank you everyone have a great rest of the day