 Okay, we are reconvening as the health health health care committee. It's about 140 p.m. on Wednesday, April 21st, and we are convening this afternoon to hear from our legislative council Jennifer Carvey about some and this is in anticipation of possible language changes to a bill that we passed out and is now in the Senate. And is in the jurisdiction of the Senate Health and Welfare Committee, but at the request of their chair, Senator Lyons, we are reviewing language in anticipation of possible changes that they may make at the recommendation of our legislative council. So with that, and this is with regard to House Bill 430. With that, I'm going to turn it over to legislative council Jen Carvey. Great. Thank you. Good afternoon, everyone. So we are looking at some new potential language for H430, which is what we'd call the Doctor Dinosaur Expansion Bill. And just by way of a little bit of background, so Diva had asked to work on some new language, I'd work on this language with them. They were concerned that the way the bill had been written to kind of tie into the Doctor Dinosaur, existing Doctor Dinosaur program, would require them to make eligibility, Medicaid eligibility determinations for all of these individuals, then find them ineligible based on their immigration status, and then find them eligible for this coverage. And so knowing that the committee had wanted to make things, make it a more streamlined process for people who were not eligible, even though they were financially eligible, were not eligible for Doctor Dinosaur because of their immigration status to have an easier path into the program. So that is the language that I have worked with them on for H430. It's a new first section and then some conforming changes throughout. I did do a walkthrough of this language with the Senate Health and Welfare Committee this morning, and they had a couple of additional provisions they were interested in. I'm still working those out with Diva, but I will tell you what they are when we get there. So I will put the language up. And I would just remind members that, again, we were operating under the pressure of crossover. So we were aware that there might be something that should be looked at further but it was important to move the bill forward, and I appreciate Jen you engaging with Diva in the interim. So thank you. They were great. You're very welcome. The first thing this so this would replace the existing section one and the first thing that it would do it actually codify it elsewhere in the statutes to take it out of the Medicaid sub chapter and put it in its own sub chapter in the same overall chapter in title 33 so it had a new section called coverage for additional populations, but it was a good sort of neutral heading that we could potentially put other things in in the future if it seemed appropriate planning ahead. So this would add a new section 2091 just a different section number. I think that Dr dinosaur like coverage for certain Vermont residents. It's maybe not the most elegant but I wanted to keep that idea of Dr dinosaur that I think had been important to this committee and to Vermonters who understand what the programs are, even though we can't really offer them exactly Dr dinosaur because of its connection to Medicaid and S chip the federal programs. So and then I move away from using that term for the rest of it. But we have as used in this section and this is our new term instead of undocumented immigrants we have Vermont residents who have an immigration status for which Medicaid coverage is unavailable. So as used in this section that term also includes and you'd had this in your language migrant workers who are employed in seasonal occupations in this state. It directs the agency of human services instead of saying provide coverage under Dr dinosaur, or even like Dr dinosaur it calls out the types of services that Dr dinosaur provides shall provide hospital medical dental and prescription drug coverage to the following categories of Vermont residents who have an immigration status for which Medicaid coverage is not available, and who are otherwise uninsured. This would be children under 19 years of age whose household income does not exceed 317% of the federal poverty level and pregnant individuals whose household income does not exceed 213% of the federal poverty level for coverage during their pregnancy and for 60 days postpartum. I'll stop here for a moment to say children under 19 years of age with household income up to 312% of the federal poverty level, plus a 5% disregard income disregard is the eligibility criteria for children under Dr dinosaur so that's what we're capturing here with the 312 plus 5% is the 317% and pregnant individuals with household income that does not exceed 208% of the federal poverty level plus a 5% disregard so that's where we have this 213% for coverage during their pregnancy and for 60 days postpartum. This is what is covered currently for people whose immigration status makes them eligible for the doctor dinosaur program. And then it would have allowed the doc the agency of human services to adopt rules to carry out the purposes of the section which we had before, and I'll talk about some new potential language for this after we walk through the rest. Section two still has that 1.4 million in one time funds to the agency of human services for grants or reimbursements or both to healthcare providers for delivering healthcare services during FY 22 to children and pregnant individuals who have an immigration status for which Medicaid coverage is not available. So you'll see here I've shown in the yellow and you know highlighting just what the changes are from the language that was in the bill that passed that came out of this committee and the past the house. So that's the language change there also grants to Vermont organizations that work with members of Vermont's undocumented immigrant community that language still seemed like it fit to describe the community who people who these organizations work with. Or with members of the healthcare provider community to provide outreach and information regarding opportunities for children and pregnant individuals in Vermont, who have an immigration status for which Medicaid coverage is not available to access healthcare services at low at low or low cost in FY 22 and thereafter, and I'll pause here just because it's in context. The Health and Welfare Committee was interested in adding language right here in between provide and outreach that would say culturally and linguistically appropriate outreach and information so that's what is likely going in the version that they're working on. The third use of that 1.4 million for implementing the technological and operational processes necessary for diva to administer. And again we're describing this as the coverage for Vermont residents who have an immigration status for which Medicaid coverage is not available as set forth in this newly recodified section beginning on July 1, 2022. In version three we have agency of human services, Dr dinosaur like coverage this is just a session law provision around the FY 23 estimate. It has a chess provide information on the estimated FY 23 costs of providing coverage to Vermont residents who have an immigration status for which Medicaid coverage is not available pursuant to that section beginning on July 1, 22 as part of the agency's FY 23 budget presentation to the relevant committees. And then in section four we have the effective dates so subsection a does not change subsection be again I've changed the language to include the agency of human services, making coverage available to Vermont residents who have an immigration status for which Medicaid coverage is not available in accordance with section one, and that renumbered section beginning on July 1, 22, subject to FY 23 appropriations for this purpose. And then finally I suggested a name change and it was pointed out in Senate Health and Welfare today that it really shouldn't be expanding eligibility issue just be an act relating to eligibility for Dr dinosaur like coverage for all income eligible individuals regardless of immigration status so my kind of working new version has that language in it. Do you want me to stop there do you want me to talk about the other potential change that that is kind of in process right now. I'm going to suggest you talk about all the changes. Well, the other concern that was raised in the Senate Health and Welfare committee was around the confidentiality of information that was provided by applicants and enrollees and potential concerns about how that information might be used. And so I'm working on coming up with some language what I have right now and what I've sent to diva for their comment but have not heard back. So I want to make sure we're not again muddying the waters with the Medicaid language I'm hoping to kind of piggyback on the existing Medicaid confidentiality pieces by saying something like the agency human services shall adhere to the same confidentiality provisions regarding applications and records as at fourth and section 1902 a of this chapter, except that the agency shall not make any information regarding applicants or enrollees available to the US government. And then putting something sort of related to that over here in the outreach and information about opportunities for accessing this coverage and the confidentiality confidentiality of all information regarding applicants and enrollees so that potentially part of that outreach and information would be here's this, this coverage is going to be available to you, and you don't need to worry about the confidentiality of that information. And on that point. Am I correct that this is similar to what was done when we created the stimulus funding to somewhat similar population to try to preserve, preserve confidentiality and lack and reduce the fear that it would lead to some type of immigration consequence. And that is what I have been told I have not had an opportunity to review that language I've been focused on the kind of AHS specific Medicaid enrollee confidentiality language but I think that the idea is the same and that parallel was brought up and sent out the welfare as part of this. Yeah, I think it might just encourage you to perhaps at least take a look at that. Looking at that right now. There were some of those same concerns raised, of course, in that initiative earlier. Open up for questions then. Yes, do I mean to take the language down or leave it up what's most helpful. Well let's see that's the question and see whether languages helpful or not. So I have a couple of questions. Thanks Jen. So, what happens if the federal poverty level changes for Dr. dinosaur. This change with it. This wouldn't change with the absent legislative action. The, the doctor dinosaur levels eligibility levels I don't believe are currently in statute although language linking premiums to certain eligibility or income categories is in statute. So we can't just put the income levels. Concurrent with current. The federal government is not going to change the law or eligibility. The strong recommendation was really to separate this from an existing Medicaid financed program. Okay, and well, and the other thing in that same vein is the 60 days. And coming up here. Don't we have federal. Rules that that 60 days postpartum will be changing. The states to pursue that I, as I'm remembering I think it doesn't actually become an option that we can take advantage of until 2022 and then it's five potential for five years. So we may need to do something to address this population. If that's the direction that things go. So, I understand Diva wants this but just changing the language to say all of these things consistent with with current programs is not appropriate so that we don't have to keep changing it. I guess I'd prefer to have Diva weigh in on that I didn't that was not a specific question that I asked them so I don't know what their response would be. I just step in. Could we ask that you at least raise that question that specific question with Diva. It seems that if there's a way if that's not too much of a linkage for that that would address the questions that represented black is raising. I'm thrilled about the addition of culturally appropriate and language because if you like if you all, if you all remember, we had that in the original. And then I believe when appropriations did their breakdown, they removed that so I'm glad that we'll be going back in. And the other thing I was thinking about is, isn't there currently like driver's privileges cards that are given and wouldn't the. Isn't there something in there also existing language that so confidentiality regarding federal. That was another thing. That was certainly take a look at that. I was just thinking maybe that would be a copy and paste. I'm not sure. That was it. I think it looks, I think it looks good though. Okay. Representative down here and represent Peterson. Thanks yeah I have another linkage question but but maybe there's a different way to address it by language without lengthy went when we talk about the agency of human services shall provide hospital medical dental and prescription drug coverage. To these categories, but we're no longer linked to Dr. dinosaur, and there's no modifiers there, which could be read to be much more expansive than anything that Dr. covers. It just comes to my like dental I know is not an unlimited dental benefit. I think there may be some other things. So is there some way we can identify that we're intending to align it with the benefits that, you know that we can't say that Dr dinosaur provides but there's no way to, to create that assumption without reproducing all of the without saying I mean it's easy to say the income we can't list all of the specific inclusions of Dr dinosaur in rule or whatever but I think we need something to link that. Again, I will ask. Eva, for their thoughts on that. Peterson. Yes, thank you. I just want to ask about the confidentiality part of it. And it's something I really don't understand in terms of the folks that are here, and what their privileges allow them to do and to be in this country. I assume you would. Anything we do let's put this way anything we do would be in conformance to federal and state law I assume, correct. I, you know, I don't understand. You're just operating in a different sphere you're not you're not addressing. You're addressing immigration only to the, in the sense that you're identifying particular individuals who may or categories of individuals who are not eligible for Medicaid because of their immigration status but otherwise you are dealing with with paying for health benefits you're not taking a particular position on on what they can and can't do. As far as their immigration status. Right, right. I guess my my concern is I, I don't want to hide some folks are not supposed to be here I guess that's that the bottom line for me, I, you know, and I don't know. I don't know much about it but I, you know, we should be conforming conforming to the federal law anyway I assume we're making our own law here which is fine but I'm not up in here and I'm not going to be as fully articulate probably as needed but art. One of the issues that has come up over the years as we've extended drivers. What were they called it. They're not drivers licenses but drivers privilege cards or some privilege cards. And we'll use that as a as a good example. One of the instances and so the concern was. Okay, how do we, how do we, how do we navigate this territory where we believe they're we Vermont decide believe there should have the ability to have a driver's identification card, or a driver's identification card because it gives them an identification, but there were instances in which the there may there may be, and likely are some kind of federal rule or regulation saying that information should be provided to the immigration for anybody who might not be a documented citizen and the policy decision is that Vermont is not going to participate in that for this purpose, because otherwise, no one would come forward to get the driver's privilege card. In fact, there have been instances where the Department of Motor Vehicles has adopted a policy, but individual members of the Department of Motor Vehicles actually participated in notifying immigration and some people ended up being deported, which was completely contrary to what the policy of the state was. And I think the concern is similar here. I mean there is, there is a tacit, I mean I don't even know if I should say it's on the record but there's a tacit understanding that there are workers here who are working in our particularly in our dairy industry. And that we're kind of separating this, okay there's immigration issues that involve the INS, and there are Vermont policy issues that in this instance, and for the stimulus payments we wanted to extend that to them, and we want to extend this health benefit. But in fact, if you, if you don't, if you make a completely tight linkage, it basically puts everyone in the position of I can't seek any of these services because in fact if my information is provided, knowing we are inadvertently in an instance where someone may very well have a status that does not allow them to be quote legally in Vermont, but we in fact know they're here and know they're working that no one will understandably avail themselves of any of the services. So it is a paradox, and it's a dilemma. And I think the governor has agreed and the attorney general, I may be stepping beyond what I should say, but that this is a narrow way of navigating between the the federal government regulations and what the state intends to do for people who we believe are here and should not have to live in fear of not accessing a service we believe they deserve. It's difficult. There's no question about it. And I hear your question. And there are probably others who can help articulate it better than I just did. Can I give one example real quick? I'm sorry. Can I give one example real quick, which is truly, don't forget like these children, they're in our schools. So, you know, they're, they're already in school. So they have to have this, this confidence that by bringing your child to school, you're not going to report them to the feds. So we already have these things in place. Okay. You know, I get all that, but, you know, we have laws in this country, we have rules in this country, and we continually step around them. That's all I'll say. I mean, I get it. You may not find the level of comfort sufficient to support this art. I reckon I just, I will acknowledge that there are those who do not. But it has been the policy of the legislature and of the executive branch to provide certain access, provide access to certain services while trying to preserve that barrier from automatic provision of information that would jeopardize someone's ability to continue to work in Vermont. It's, it's, it's, there's, there's nothing easy about it. Okay. Thank you. Ian, I represent down here. Oh, I'm sorry that was an old hand. Okay. Sorry, it's, they don't show up anymore when we're on. I would never call you an old hand. Someone with great, great knowledge and years of experience, but not an old hand. Okay. I have one of the question, Jen, and I'm trying to check the time because I want to respect your. I can't see the time limit. It's two or six. I think we're good still. You, you need to make sure you let us know when, because you have a hard stuff I know and there's now snow on the ground. Oh, and I'm looking outside and it's coming down more and more. Okay. I was, there were, you mentioned two different suggestions that I know, I think Senator Hardy had at one point shared something and said she was looking at possible some changes and you mentioned to them. There was a third and, and it actually touches on what an issue that is implicated and part of what I was just talking about. And maybe you can tell us if they looked at it or if they did not but in the sense that it wasn't necessary and determined it wasn't necessary. So that the issue was around. Right. Agricultural workers who are not seasonal who are around, like dairy farm workers who is responsibilities or year round. And lack of understanding about whether that, or she hadn't realized that that already fit within this main language of Vermont residents who have an immigration status for which Medicaid coverage is not available. The migrant worker piece was a clarification that somebody who might not otherwise typically be considered a Vermont resident would be included in that term but that year round agricultural workers were easily covered already by that language. And that that's a helpful clarification because I when I first heard it I when I first saw it I would I thought oh yes that's an important thing to include but you're right. The includes is not the definition of the what's in quotes but it's an additional clarification is that is that what you're saying. Right. Okay. So agricultural workers would be included in the, in the quote Vermont residents who have an immigration status for which Medicaid coverage is not available. All within that category. Exactly. Because some do and some don't. Right. Okay. That's helpful. Thank you represent page. Yes, Jen. Quick question, the verbiage that we have here. The verbiage that we have here. Is it similar, the laws here, similar to surrounding states that allow this to occur. Is it basically the same. I don't. Are you talking about the benefit itself or the language. The benefit and the language because we talked about this before, you know, we didn't want to have other individuals coming into Vermont and using this service. Because, well, because it would probably hurt our own systems here. Didn't we, didn't we determine that some of these benefits were already being granted in neighboring right, right. Yes, that's what I'm getting at. That's my recollection. I'm trying to look and look at my notes to and I'm just wondering whether you know our verbiage here is similar to what other states are doing. That I don't know I know that diva had looked at some other states and then suggested this language. When somebody like representative Peterson asked a question, you know about legality issues, you know state issues versus federal issues. Is it pretty much the same with other states surrounding Vermont. I don't think I can answer that without some research. So I don't know what the language looks like. Okay, well it doesn't matter just curious. I guess what I'm saying is, what we have here is no different than what other states are what we're doing here is no different than what other states are doing actually some other states. Right and I don't I don't know that I can answer that definitively one way or the other or how the benefits compare to those offered in other states even to to non immigration disqualified families I mean I think there are different benefits in different states. Thank you. Can I say one thing. Yes, please. So, if you remember. If you are pregnant. Under chip, you are eligible to be covered. There is a federal federal CMS allows you allows coverage. So the states that have expanded to include that coverage cover under just their regular programs. If diva had said that they were not going to do that, because the administrative burden to be able to apply for that federal match. They thought would be more onerous than just covering them under state only dollars. That's why you know that's why I think they want this language children children are different. That's only state only. I know New York covers children and they cut and they say they cover them under their whatever their term for their child state health coverages I can't remember the name of it be New York's version of Dr dinosaur. But then also I won't. Don't forget we have Vermont residents. So you can't live in New Hampshire drive over the border and get this coverage. You, you still have to be a resident in our language. Okay. Other questions or comments. This is language that's actually under consideration the Senate Health and Welfare Committee. We do not have jurisdiction of the bill yet. And they are, they are in the midst of their deliberations. But I guess what I'm looking for and we'll hear other questions or comments, but I think Senator Lyons is looking for a general sense from our committee as to whether this conforms to what we had in mind. And I'm looking for a general sense of the Senate representative page. Yes, I just just a quick comment. I was just thinking what representative black said about diva, not wanting to just include this language because they figured it would be too onerous to submit the paperwork if I understand this properly. But it just seems to me. Hey folks, you know, why can't you submit the paperwork and and and do the necessary work to cover this, it just. That's all I have to say is, so I do think the coverage is more limited in what we could. You can get federal chip funding to provide prenatal care but I think it's limited specifically to the pregnancy related care and not to. So this provides health care generally to pregnant individual and postpartum it's not specific to prenatal care only. Well, look, I'm for this I'm just, I'm just making the comment that. Hey, you've got probably dozens and dozens of personnel working in that office, you know, and people should be, you know, I'll just leave it at that, you know. I hope I get my point across I just feel that there are things that our state government workers workforce should be doing our departments should be doing and and even if it is onerous too damn bad, you know, go ahead. I am going to step in here represent page because in fact, it has been communicated to me that in fact, given all the changes that are happening at the federal level in terms of the new premium assistance, etc, that that in fact, the staff at diva are and and all that has been having to be done during the period of the pandemic because they've also been engaged in providing extended coverage that in fact I think we may not appreciate the level of extended work that has been required and is being required, so I'll just. Okay, thank you. May I make it may I make a clarifying comment as well I think it was not that they did not want to do the paperwork or put in the effort but rather that it would be potentially or likely less expensive overall for the state to pursue this option to provide the coverage with state only dollars, then it would be to administer the program and get federal matching funds so it was actually more cost effective to go this route than to file the paperwork or whatever the administrative work was to get potentially a lesser benefit. Okay, well then I take back my ranting and raving that I said early. Yeah, right. Can I can I clarify something that Jen had said also that I had forgotten about the federal, the federal match is because they are recognizing that they're covering only the unborn child, which is why it's only for prenatal care so if a pregnant woman was to get sick and needed to go to the doctor. There's no coverage for that. So, I, in, in, you know, diva wanted to expand it just so that they didn't have issues around like that. I think they are actively working as partners and trying to make this happen. I think that was my question, which was better for the population of people we were talking about which process and my impression was the diva was working for them, you know, for our, the people who were trying to help so that was my understanding I just want to verify that that that was the motivation. Yes. And I think that's important. I think it's very important. Yeah. Okay. Any other questions. So can you take down the, can you take down the language just so I can have us all on screen. So, I'm not going to ask us to do a straw poll or vote at this point because we don't really have anything in front of us to do that with but I do. I guess I'm generally wanting to get a sense of the committee as to to communicate with our Senate counterparts that. Okay, I guess what I'm, let me put it out this way. I do not see anything in front of us that would suggest that this flies in the face of our intent or our desire to move forward with this. What was an important bill and which are, which are committee supported very strongly. Is that fair to say is that I'm looking across the screen. This is consistent with our intent and that we appreciate that the language being changed in the Senate. Moves in the direction that we wish we wish to go. Okay, seeing a lot of nodding on the screen, I'm going to convey that informally or formally whatever manner to set center lines and I would Jen, I would ask you to that you feel free to convey that as well in your interactions with the Senate Health and Health Committee that we appreciate and I want to say, particularly to you and the folks at diva that I greatly appreciate the hard work to try to make this happen. Because this in fact is one more thing that we're asking their staff to take on that is in addition to the work they're already undertaking on our behalf. So, and if you'd communicate with center lines I'd appreciate and I will as well. Good, I think we've gotten a gotten recovered some good ground here this afternoon and I anticipate we'll see a language hopefully coming back from the Senate that's somewhat similar and perhaps modified slightly but then we'll review it again. This will not be our last attempt to our last opportunity to look at this. Again just in terms of process for those who. This is your first time through the Senate Health and Welfare Committee will make a recommendation. We'll go out some new language, though amend what we've done. It'll go to the Senate floor. There's always the potential for an amendment there as well and when it leaves the Senate floor will come back and be referred to the House because it is different from what we sent to them. And that will be the opportunity then for our committee to weigh in to look at their final modified language. And for us to determine whether there's any further amendment that we wish to make or whether we concur with their amendment. And I think that you put us in the position of perhaps being much closer to being able to concur with an amendment from the Senate because we've already had a chance to understand it. Okay. Excellent. I think that's, this is a good use of our time. Jen. Thank you for making yourself available to us. I think we can thank you. We can leave you free to meet your other commitment. And I think with that, I'm going to suggest that we conclude for the day as a committee. I'm going to, and Mari, maybe you and I could touch base about what we talked about this morning. And I think there's some other things that people need to do to prepare for testimony tomorrow morning, which will begin at nine o'clock. Okay.