 Good morning. It is Friday, September 11th. This is a joint meeting with Senate Health and Welfare and House Health Care. And so we're joined today by Chairman Bill Lippert and his committee. And so and all members of our, our committee, some will be here a little bit late. So thank you all for being here that we're going to be doing this again next week where we're talking about another issue and I think it's really helpful to have both committees together. So the first item, the agenda item that we're working on is from the Department of Financial Regulation. And I think, Bill, why don't we just allow Jill to go ahead with her presentation so we can understand the issue. Great. Yes, good morning. And Senator Lyons, it's, I think it's good when we're able to be as efficient as possible given everything that's on our plates right now. So I appreciate being able to do this jointly and look forward to doing a joint session again next week. I think the materials have all been sent out, although I understand there were some revisions at the last in the last day or so. So, Jill, when you present, it would be good for us to both understand the language as well as the rationale and and may perhaps help us understand what what changes were made. So, I agree that's proceed. Yeah, go ahead, Joe go ahead and I are you going to put the language up. I don't have the ability to share my screen but Nellie or Demis. Oh, I am. I could try. I have never done this if it's just the one page of the of the language it might be easier if if Nellie have it to throw it up on the screen. Nellie or Demis can you put up the that's got red and blue in the middle paragraph number one. It's the second one. Yeah, give me one second I can I'll pull it up. Sure. It's the second on the under Jill's name. Well, she's doing that I can start. Thank you. Thank you. Chair Lyons and chair Lippert for having me and committee members. My name is Jill Richard and I'm the director of policy for the Department of Financial Regulation. Let me just make sure yep that's the revised one. And we appreciate the opportunity to present our proposal to. I don't want to say expand but sort of clarify our emergency rulemaking authority with respect to COVID-19 treatment testing and prevention. We are proposing to expand the language in that is already in was an act 91 and then it was revised slightly enact number 140. And so we already have this as you know, ability to adopt emergency rules. We had proposed just to make the changes that are set forth and item one here to expand to direct health insurers to basically to wave to waiver wave cost sharing requirements directly related to the diagnosis of COVID-19. And this is the revised language that we're proposing it. We had previously said related to the diagnosis of COVID-19 influenza pneumonia or other respiratory viruses. We had some conversations with the insurers who were, you know, concerned that 85% of what providers see in the fall in the wintertime obviously is respiratory illness related. And so they wanted to make sure that we were saying we're only requiring the waiver of cost sharing when it's related to COVID-19 and that was absolutely our intent. We just moved the language around to clarify that we're requiring the waiver of cost sharing when it's related to the diagnosis of COVID-19, including tests for flu pneumonia and other respiratory viruses that are performed in connection with making a COVID-19 diagnosis. So basically, and I'll start with this one before I move on to treatment. Basically, we are aware that the symptoms of flu and pneumonia and certain other respiratory viruses are nearly identical to the symptoms of COVID-19. And so a provider in making a diagnosis of COVID-19 may or sort of most likely will order a flu test to rule out COVID-19 either before ordering a COVID-19 test or at the same time concurrently with ordering a COVID-19 test. And so we are trying to avoid the situation where an individual would go to their doctor, the doctor suspects COVID-19, the COVID-19 test is covered but their office visit and or their flu test they then have to pay for. So we believe in our intent in our original rules was that all would be covered at no cost share and this is just a clarification of that. I will also note that the federal cares act does require this to be covered at no cost share. And they have issued guidance to specify that flu tests and other respiratory tests that are performed, you know, in the work up to diagnosing COVID-19 should be covered at no cost share. So we really view this as just a clarification and not an expansion of our rule making authority. So I'll stop there in case there are questions. Oh, you know what? Sorry, I forgot to mention we're also aware that there is a new combined COVID-19 slash influenza test that will be introduced this fall. So this also is to make sure that that test is covered, even though it's not just specifically COVID-19 it's a combined test. So again, I'll stop there if there are any questions about the diagnosis piece. Committees. Go ahead, Bill. Yeah, I don't know if I can raise my hand. Okay, just I won't see it. I mean, the if you have a question I think either from either committee please just speak up. I'll we'll try and keep you in order, but I'm I'll let me see if I can grab participants out of this. Yep, I can see you. Okay, so Jill, I'm, I do feel like I need a little bit more of an understanding of this. So if does this mean that if I were to go to my physician or my medical provider feel it not feeling well, not sure, you know, perhaps worried that I had COVID-19 but or the flu or whatever reason. If my provider made, if my provider tested me for flu, they say, Well, we need we need to do tests that work. So we're test you for flu. And if that comes back negative, we'll test you for COVID-19. But it comes back positive for flu. What, how does this apply that if they have not yet tested for COVID-19. Does this only cover this, if in fact, they test for COVID-19 first. So that's a good or that it becomes a COVID-19 secondary diagnosis or first I mean does there have to actually be a diagnosis for COVID-19 for this to be covered. There does not. So this is this is in. So it really this comes down to provider education about coding. And so we would, we would expect to. Yeah, we have been talking about this and we've been talking about it with the insurers and internally and I think when if we from if we adopt rules for this which you know we we may be using this by bulletin, just to clarify what we mean here but if we do do the rules, or we do a bulletin we would expect to include coding guidance in the role or the bulletin to educate providers and just make sure they're aware that if they suspect COVID-19. If they're trying to use the COVID-19 code, even if they're just doing a flu test first, but they do suspect COVID-19. If they code it, we're trying to figure out if you have COVID-19 that should be covered at no cost share. That that and the flu test. That's a good flu test. Right if they're if they're attempting to diagnose COVID-19 and that is what suspected. And they code it that way, then doing a flu test first should be covered. It's if it if it's a suspicion of pneumonia or COVID-19. Right same thing. And the diagnosis for pneumonia often as I understood as I recall from some experience with family involves not necessarily at a Tesla swab or anything but sometimes x-ray or chest screen, you know some some kind of screening. Is that what's covered here? Well, sometimes they do. And x-ray is a good question and and I if you don't mind I'll have to go back and talk to our attorney about that I think we were thinking. I mean how did they diagnose pneumonia. Well, sometimes they have breathing tests. Do you know when you have to breathe into the tube. I don't know if you've had one of those but. But most often what I'm familiar with is that most often it involves something beyond that to diagnose pneumonia. My understanding is if the provider were to put the COVID-19 code on the lab test or the x-ray form that submitted because they're suspected COVID I'm not sure why they would do an x-ray. If they do an x-ray first if they're actually suspecting COVID-19 I would think they would do a COVID-19 test first but. They might do it all simultaneously. If they do it simultaneously sure if they put the code on there that should be covered as well. My suspicion would be that if you come in and you're feeling that badly. They're gonna say let's do all these tests. But I don't know. So I'm just trying to understand. And I can get some clarification on that but my understanding is this really all comes down to what the provider is expected is diagnosing and what the quick coding they're using on their form. So if the suspicion is COVID-19 and they're attempting to diagnose COVID-19 then everything done in connection with that should be covered at no cost. Okay, thank you. Okay, good question. And it will be important to have clarification as we move forward with us. Representative Cordes you have your hand up. So a comment first about the previous this conversation. It would be important to make sure that all forms of imaging were covered in this bulletin, including ultrasound because as we know they're as part of the impact of COVID-19 includes clotting disorders. And ultrasound is one method of imaging that is used to to diagnose. And unfortunately, someone could have the flu and COVID and pneumonia. Which sounds horrible. So just that's my response to the previous conversation. But I, my question is, are you aware of how widespread the denial of claims has been for this issue. Thank you for the question representative Cordes we have not received any complaints of denials of these types of claims and that's really because there is no flu this summer so when we promulgated the our original emergency rule. It was late spring and we hadn't, we had, there was a lot of confusion about what should be covered but we did not hear of people having to pay for a flu test. While getting their COVID-19 tests for free and then summer came and there, there really just wasn't, there weren't very many instances of flu. So we're doing this as a sort of preemptive, we know flu is going to come back in the fall and the winter. And we want to make sure that this issue does not arise. So we are not aware of this happening at this point but we want to make sure it doesn't. And one more comment the test experts are definitely radiologists are able to gather a lot of information about what kind of respiratory illness it is, including COVID. Thank you. And I, you know, I think this questions like that and the details like that definitely will need to go into our rule. I think this is sort of just giving us a little bit broad rulemaking authority to determine what's necessary based on what's happening in the market and, and speaking with all the stakeholders including the providers to see what kind of tests are done and making sure that we put the right coding guidance and details in the actual rule, if that makes sense. I mean, I, yeah, I appreciate the, I appreciate that I think we will definitely speak to providers to make sure we're putting the right wording in. So the representative courtes is that that's good for you. Thank you. I saw that. I'm reading the language I think it's extremely helpful because it says the diagnosis of and then it says including test for but including means not limited to so it would, I would think that your bulletin and or rules could include x-ray, x radiology, or other types of diagnostic tools. Yes, exactly. And I think the including is to make sure that it's related to the diagnosis of COVID-19 and not, you know, if the provider suspects pneumonia or some other form of respiratory illness that is not necessarily covered if COVID-19 is not the suspected diagnosis. Exactly. Okay. Other questions from House or Senate committee members? Huh. Well, if I may, I want to just jump in and say that I want to commend you, even though we haven't completed this, I want to commend you at the outset for being proactive and trying to anticipate this. I think that is, I, when I, as I first learned of this proposed clarification, I think it is a clarification. I think you're to be commended for anticipating something which we know is coming, which is the flu season. And I think there's this, the anxiety of combination of flu and COVID and possible pneumonia as well is something which makes sense to be thinking ahead about some. Yes. Yeah. Thank you, Bill. I think you speak for all of us on that one. And also in anticipation of the dual diagnostic test. So that's very helpful. Any other comments or questions? Okay. Why don't we take that? I was just going to say, Representative Smith has a question. Let's go there first and then move on. Representative Smith. Brian. Are you there? Yeah, can you hear me? Yes, we can. Thank you. Since we're on the subject of coding. I'm curious. And the reason that I'm going to ask this question is because it just happened recently to a friend of mine. A friend of mine had a serious brain cancer. He suffered with it for a couple of years when in the hospital because it got so severe and he died. Coding said it was COVID-19 related. Now, if something goes into a coding department and they say that it's COVID related, does the hospital get extra COVID funding? First of all, I'm sorry about your friend. And second, I don't know. That's a little bit outside of the scope of my expertise, the CRF provider funding. That'd be, I think that would be more a question for Eva. Yeah, I didn't know. I did not know if this was the right time to ask that question. But since you were on the subject of coding, I thought I would ask if you didn't know. Yeah, I apologize. It's not familiar with. Thank you. Yeah, the coding question gets to be complicated very quickly. So, I don't know that we want to get into that discussion. I see that representative quarters wants to make a comment. So if you can make it short, that'd be great. Coders don't choose the code. Providers do. Providers do based on diagnostic evidence. Coders just make sure that we're in compliance with all the laws. Good. So there you have represented a Smith, another fun opportunity. Now that in the Senate, we have worked on the coding issue in different committees at different times, and it does sometimes get frustrating, especially if you're dealing with a friend or an individual patient. Any other questions for Jill? There is a second part. Yeah. Go ahead. Sorry, I don't mean to interrupt. There is a second. Okay, thank you. Okay, and just one more comment about the diagnosis. I mean, the, the federal cares act. Also covers this and we would, you know, look to their guidance to make sure that we're covering the same types of tests and clarifying that we're sort of covering the same same things that the federal cares act requires us to cover. So that's another part of this. And the third part is with respect to treatment. And this is, I'm not sure if you saw it and I'd be happy to forward it. There is a New York Times article about a month ago that really that went not to the insured population but it talked about the federal program for uninsured individuals to receive COVID-19 treatment without cost share free code or not sorry, not without cost share because there's no insurance involved but for free. So it was happening on a number of occasions when somebody had a comorbidity so they had COPD or diabetes or another serious illness already, and that illness was exacerbated by COVID-19 so they, so they got COVID-19 and they had to be treated for COVID-19. But the provider had listed their comorbidity their other serious illness as the primary diagnosis. Then those were not those cases and the treatment was not being covered for free under the program simply because COVID-19 was not listed as the primary diagnosis but rather a secondary diagnosis. We have not heard of this happening in the insured population. But this is again preemptive we want to make sure that if someone is hospitalized for COPD and really it's only flared up because COVID is happening or they have COVID. If COVID is listed as a diagnosis and not necessarily the primary diagnosis that treatment would still be covered with zero cost share. Really that is purely a clarification. Well, I think I think it's again I think it's it's it's important to clarify this. And in light of the health commissioners recent emphatic statement when there was some question, not about payment but about the reason that people were, in fact, dying. The suggestion that because COVID was a secondary diagnosis in some such in where where many people have underlying conditions. The suggestion was that it really wasn't attributable to COVID. And I think that there's a I mean, it's not it's not the same issue but it's a related issue that if you have a co worm co morbidity as you say, and COVID actually exacerbates the situation or makes it worse or causes in this case. Very serious illness or possibly death. The fact that COVID is not the primary diagnosis does not mean that COVID is not seriously involved in why you're ill or in some cases why you may have in fact died. So I find myself connecting the two as you're as you're talking and again. I agree with the clarification so that people are not caught in a conundrum here. I agree. Absolutely. That's a great point. So Jenny may I can we ask for the for Jill to can you clarify this is about emergency rulemaking authority, but under your emergency rulemaking authority it also gives you or what's the relationship between this and you're issuing a possible bulletin versus emergency rulemaking. Can you help us understand that relationship. Sure, we it's so if we are attorney had suggested that we make clear and explicit our authority to do this by rule, the language. I guess it's arguable whether we already have the authority to do this under our current rules but we wanted to make clear and explicit that we could amend or adopt new rules. With respect to these two items if we determine if our attorneys determine that we already have this, you know, our rule already covers this and we just need to clarify by bulletin we can also do that. So having the explicit authority and statute in case we determine that our current rule does not actually cover these things. Someone or someone were to challenge that. Yeah, that's right. It looks as though the chair may have dropped off of the call. I'll email her to see about getting her back on. Okay. In the meantime, I see that representative Murphy has a has his hand up. David, do you have a question. Yeah, thanks. I'll just keep going keep us going until. Okay, I'll just keep. I'll fill the time until she's back with. No, actually, thank you, Jill. I just want you alluded to the to an article that had been in the news. And I think I've seen several about this at the federal level. There's a confusion over what the the intent was or what's actually happening. What we're looking at here does not deal with our an insured population. Is that correct. This is, this is, this has meant to clarify how the those who are insured and regulated by by Vermont would be covered. And those who have commercial private insurance, not the self-insured population and not the uninsured population self-insured. We don't have any control over and the uninsured population there is a program through the Department of Health, through the for those individuals. And that program, which I which I know is not what we're talking about here does not have any of the. We haven't you mentioned that you're not aware of any cases in Vermont, but if there were issues in Vermont. That would be addressed for the uninsured. Well, there's two things I mean that the program for testing for uninsured individuals is through our Department of Health that there is a federal program for also for. I guess also for testing and treatment of COVID so if there were issues in Vermont with the federal program that would be a little outside of our scope, because we don't. It is a federal program and that is what the New York Times article was addressing. I mean, it's a good question. I would hope those those things don't happen here in there and they're attempting to clarify that program to make sure that doesn't happen again, but that is not within the department scope. Okay, thank you. Are there other questions from committee members for Jill at this point. Okay, I do not see any hands at this point. I think you have maybe clarified as much as what we need to know. So we don't really have we there's nothing. So when you issue this or if you if you issue a bulletin is our bulletins issued for prospective situations. A bulletin were issued. And it turns out there had been a situation that it occurred. You know, some time prior to the bulletin reach back in time or is it only prospective bulletin. Sorry, please. I think that would just clarify our existing law or regulation so a bulletin would say, you know, this is what we meant by our rule. And since our rule goes back to a date certain which is March something I apologize I forget the exact date. It would actually just clarify the law back to that date and then cover all of those things. Okay, well that's that's I think that's good to know that it would, it would. It would reach back to cover a situation and we don't think there have been any instances of these things not being covered again it's it's for prospective problem that we're anticipating and hoping doesn't happen but if it does. We'd like the authority just to make sure that right to say our our goal covers. Okay. Not seeing any other questions on this there is a related issue that has been brought to my attention and I don't know Jill. I maybe will raise it and if it's really not for us to talk about today, but it seems like it might be the occasion to clarify if you do have information. So my understanding that not widespread, but at least in perhaps one instance or maybe instances we're not aware of that a medical provider has added an additional fee to cover coven quote coven expenses. And as a separate fee from the professional office visit or testing or whatever to cover the expenses of having to add PPE to the practice, etc. And I know that I mean I brought this to you know I brought this up with Commissioner P check and he said that was he was aware of the situation but we haven't had a chance to follow up. Is there any clarification that you're able to offer as to whether that type of adding a separate coven fee is an authorized way of proceeding and whether insurance would cover that if it is. Thank you I'm also I've also been made aware of that situation and I know some of our staff and attorneys have had some conversations about that but I have to report back I'm sorry I don't know I don't have any information for you today. But I'd be happy to check it and to and to get back to you. I think again it's the type of thing where we don't necessarily anticipate this, but it'd be useful to understand what what we all think is the way things should be happening. And again, I think I think as you mentioned, clarification around coding or clarification as to what the proper way to address coven related issues in our medical practices would be welcomed to within your scope of authority. I'm bringing us back to our live screen. I've reached out center lions without success both by phone and text etc. I think what I'm going to suggest is that I think we've covered the ground that we had hoped to cover I don't see any additional questions are there any questions that have developed in the interim, or in the meantime. If not, I'd like to thank. If yes, I see you have a question. Okay. Bill I had lost my internet connection for a few minutes so I'm not sure if we had already covered or not but there was more we were discussing when we broke. We had finished discussing part one of the changes and just wasn't clear on whether two and three had already been reviewed. This is, Jen, I'm not sure Jill is still with you but if you are looking at the language. They had provided two and three are are things you passed in act 91. They're really just one that is amended. Yeah. Okay, I just want to confirm that so does that make sense David. Yeah, I had, I had a question about to that. Jill and I were discussing the email and I was just hoping to sort of tie up a loose end but I can. I think we need to do that offline. Okay, thank you. So it's my understanding that the Senate was intending to continue at 1015 that was our schedule at least at 1015. I'm going to suggest that we bring this joint meeting to a close for House members. And Nellie I'm not sure how best you want to handle. We have a meeting with the senators and hoping to reconnect with Senator lines in the meantime. Let me just say two things quickly before the house before we do conclude our joint meeting this morning. Senator lines and I have talked about ways to proceed and move this forward we'll talk further and we'll have some more discussion about that. And this is a reminder that we are looking at tentatively a joint meeting again between our two committees next Thursday from nine to 10. This is tentative because we haven't confirmed all the witnesses but that's to look at an update on the CRF dollars from the health care provider initiative that this with CRF dollars that we put into place in June. Demis and Nellie will confirm that with all committee members but we have the House have added that Senator lines and I again thought it would be more efficient to do it jointly if possible. So I think with that. I think we'll conclude the House members being part of this for the morning. Reminder we're back on the floor to and and we'll be going to the House of preparations on our behalf shortly. I don't see Jill still here but I think it was this was a good idea and appreciate again there being proactive in this regard. So with that Nellie I think we're going to I think we can go off live live feed at this point for certain. And then I'll leave it to you and the senators to determine whether you leave your zoom connection and restart again at 1015. Once you've established a connection with Senator Lyons or how you want to best proceed. So maybe the senator stay on and you Yeah, I think I think I think it's Yeah, I think it might be easiest if the House members if we just signed off and let the senators determine how best they want to proceed. Okay. Thank you everyone. Thank you.