 from I-60. Joe Bellingham, Senator from Caledon. And Charlie Newton on the drawings. Good morning. Ashley Briliner, I'm the Director of Medicaid Policy at the Agency of Human Services. Thank you for having me this time. So I am here with four rules. And I noticed the agenda had two pharmacy rules, a surgery rule, and another pharmacy rule. So if it's OK with the committee, I'd love to do all three pharmacy rules together before we get into the surgery rule. Here are no objections. The floor is yours to give you all three of those. We may very well choose to vote on them one at a time. Absolutely. So the first rule, 19 P-47, is an amendment to the V-Farm prescribed drug rules. This rule, unlike most of the rules like I'm in front of this committee with, is staying under V-Farm rule structure. It's not moving into the H-card framework right now and off-care administrative rules. This rule amends the pharmacy program for the V-Farm only population. It changes prescription refills from five refills per year to 11 refills per year, which we think will help beneficiaries, pharmacies, and prescribers alike. It will reduce the issues happening at the pharmacy. It will require fewer prescription renewals. And the regulations governing prescribing patterns don't change, so we don't perceive any differences in overprescribing as a result of this increase in refill limits. It's updated to align with current state and federal rules. And like all of the rules that I'm going to be in front of you with today, we had public engagement that included sharing the rules with all of the AHS departments and external stakeholders, including pharmacists, Vermont Legal Aid, Vermont Medical Society, the Vermont Associations of Hospitals and Health Systems, and non-medicated and exchange advisory board. For the three pharmacy rules that I'm here in front of you for, we did not receive any public comment. So do you have any questions on the particular rule? Senator Byrd? Yeah, on the clean text, there is a typo, one, two, three, fourth paragraph down that begins with licensed physician. It says, without an A-V available. Thank you. You only thought change. And interestingly, it's not there on the annotated things. Yes, which I'm just track changing. It's hard to clean that up perfectly. Thanks for pointing that out. So on the 11 refills, this will not be in conflict with the opioid rules. No. Prescribing rules. No, it doesn't change any of the underlying prescribing guidelines. I'm going to approval if we want to do it that way. Oh, the chair here will be presented P-47. You've just given a single one. Yes. We'll approve of 19 P-47. Ready for the discussion? If not, I'll give you say aye. Aye. Aye. I'll say nay. And it has been approved. This continues on P-19, P-48. Is that correct? Yes. So this is parallel to the P-Farm rule that I just described for this for the entire Medicaid population. So again, changes the annual refills from 5 to 11. And it also incorporates many of the stipulations that were previously specified in Rule 7501, which I'll talk about in a minute, which we're repealing. So this really takes the place of both a prescribed drugs rule in the old Medicaid rule framework and a lot of pharmaceuticals and medical supplies on equipment rule. So you'll see a lot of incorporation and the track-tune distribution there. And reading many of the descriptions, brief summaries, et cetera, word-for-word the same with the substitution of Medicaid for a B-Farm? The substitution of Medicaid for a B-Farm and then also the incorporation of large sections of the pharmaceuticals, medicals, supplies, and equipment rule. And that specifically talks about qualified providers who are pharmacies, the definition of maintenance drugs, conditions for coverage, eligibility for care around the dual Medicaid Medicare, compound prescriptions, and unused drugs that are all incorporated from the repeal rule. That's all some of the questions. I'm confused as to how this thing was put together with us for us the first page. On the backwards. Mm-hmm. Yeah, it's backwards. Yeah, I guess that's what it was, put together backwards. I'm not. Shh. That's what happens. Yeah. OK. 100% of useable. Yeah, because it starts with 7502, but the clean text is 4.207, that way. So, OK, that's all I needed to know. We weren't missing something or something or other. I'll move approval with the rule. Representative Myers, thank you for that. That way I've heard a wrap-up. Yeah. Sort of betting this will be approved. Is there any discussion? If not, all they just say aye. Aye. All close in name. Is that it? The rule has been approved. Witness. The next rule, 19P46, is the repeal of our pharmaceuticals, medical supplies, and equipment, general information rule. This is something that was largely incorporated in the previous rule that I just spoke about during prescribed drugs. And so rather than move two rules in the new H-car framework, we thought it more appropriate to combine that for clarity and rugby. This is just a repeal in which case the rule of approval of 19P46. Any questions? Representative Myers has moved that the rule be approved, which repeals the conditions under the previous two rules that we just get. There's no further discussion. All in favor, say aye. Aye. All close in May. And we have approved the repeals. So the next rule is 19P49, and this is a brand new rule under the Medicaid program for general affirmation surgery, which is the hand of general dysphoria. This is a big rule. We have been working on this rule for a really long time. We've had lots of public engagement. We've shared the rule with stakeholders prior to formal rulemaking, and then opened it up for public comment again as part of a formal APA process. We've shared it with the Medicaid Exchange Advisory Board, pharmacists, Vermont Legal Aid, Vermont Medical Society, Vermont Associations of Hospitals and Health Systems, outright Vermont, Pride Center of Vermont, the UVM Transgender Youth Center, Community Health Center of Burlington, and UVMMC providers. We have had over 30 drafts of this rule. And are really, I frankly, am really proud of where we've ended up, and largely due to Danny Fiacco and her work. We've received over 200 comments on this rule, which in my five years of doing rulemaking, it is like 10 times the amount of rules, rule comments we've ever had. So we've received lots and lots of public engagement. Not surprisingly, pretty split between comments that were hugely supportive of the rule and comments largely from outside the state that were not supportive of the rule. You may or may not be aware that this rule got picked up in the national media. Breitbart News ran some stories about it, and we ended up getting lots of comment from, I believe, the United Kingdom related to this rule in opposition. So we had over 200 comments, like I said, but the Vermont population was largely in support of it. We did make several changes as a result of the comments received, and you'll see that reflected in the annotated version. So because it's a brand new rule, the annotated changes in front of you are what we changed as a result of the public comments. To summarize what is in this rule, it largely codifies and updates our current clinical criteria. Vermont Medicaid has been covering surgeries for just four years since 2008, but we never have a rule on the books. So this is actually putting it in administrative rule. It outlines conditions for coverage for genital and breast surgeries, and it expands coverage in five key ways. It eliminates the 21-year age minimum for coverage. It eliminates hormone therapy as a prerequisite for a mastectomy. It changes the minimum hormone therapy requirement for genital surgeries from 24 to 12 months. It eliminates the sufficient breast development criteria for breast augmentation, mammoplasty, and it adds coverage of hair removal when required for certain genital surgeries. Do you want to complete your walkthrough? Yes, happy to answer any questions. I said it a bit. Actually, a couple of questions. You said hair removal wasn't necessary. What is the necessary component of that? There are two procedures in particular that vaginoplasty and thalioplasty that require permanent hair removal prior to the surgery as a medical necessity prerequisite. And so we are electing to cover those when determined medically necessary to complete those procedures. We do not cover it for other cosmetic reasons like facial hair removal. It's purely for when you need permanent hair removal to have a surgery performed. So one comment that was criticizing the rule for not covering that in what the state's response was to that? We actually made this change in response to the public comment. Oh, I mean for the facial hair. So this surgery is specific to, this rule is specific to surgeries. So we are limiting it to surgeries this time. One other question, I've noticed a response that said all surgeries in this rule require prior authorization, which allows the state to ensure that treating providers are following clinical standards of care and recommending development in the appropriate treatment. This is in regards to striking with the age 21. Can you tell me how that process works? I'm not on the committee of jurisdiction so I don't know what the procedure is. The individual review procedure. So these surgeries all require prior authorization and we have a clinical team at the Department of Mental Health Access that reviews all the medical documentation submitted with the prior authorization and makes an individual determination of medical necessity for each requested procedure. Who is on that committee? It's not a committee, it's a clinical staff at the Department of Mental Health Access. So we have a chief medical officer, we have a clinical director who's a, you know, we have a team of clinicians made up of registered nurses, social workers, medical doctors. Can I just extend to the committee the jurisdiction chair, at least in the Senate? Is this a similar process for the abortion question? We recently eliminated the age restrictions. I'm just curious if this is a similar process. That's a good question for Medicaid. You're asking a question about Medicaid. So abortion would be in the professional ethic of decision making, medical ethic of decision making and on site. I'm trying to understand the question and the response in the discussion over third trimester abortions. There was a, you said a professional ethical decision making process in body that reviewed those. I'm sorry, I'm not following my abortion. Is you're looking for an analogy between how decisions are made here and how decisions are made for that very simple surgical procedure? So we rely on medical doctors and medical providers in the field who are treating providers with individuals to make an assessment of medical necessity. And then when prior authorization is necessary, they submit that clinical documentation to Divas clinical review team. That's not required in the case of abortion or medically necessary, it is required here. And that's due to several reasons, but I'm not quite sure of the parallel. Well, I was trying to understand the composition of the individuals who might be asked to review these decisions and what that type of group we laypersons could say, oh, that reminds us of. There is our clinicians. This, that or the other thing. And is the group that's gonna review these decisions similar and it's make up to the type of review that takes place in the third trimester? And if not, how is it different? I apologize, I am not aware of what you're talking about when you talk about third trimester. So Medicaid covers abortion in the case of harm to the mother or medical necessity. And then State General Fund covers abortion in other instances. We do not have a medical review in those instances. We do have a medical review here for gender affirmation surgeries in which clinicians that are state employees review the clinical documentation submitted by the medical providers. So it's not the same process. Well, in the third trimester process that it was an ethical review that takes place. I'm not familiar of Medicaid covering abortion. Like I just, I'm sorry. I wasn't tying it to Medicaid. I wasn't trying to open up. So this is Medicaid as an insurance payer only. So we're not involved in other, like maybe, I'm sorry. I'm sorry, the third trimester thing is throwing me, but that's not something that our clinical staff is involved with. Okay, as a male of my age, this is different. And we're sitting here seeing the result of a lot of people who've worked very hard to try and come up with a reasonable and justifiable and, I would assume, ethical solution to a problem that a challenge that many people have. And I was wondering, when push comes to shove, who says yes and who says no? And it's unusual to go from the 21 year old age of decision making to a much younger age. He's one of the third trimester issue and that sort of thing is one of the places where those tough decisions have been resolved and passed in statute. So I can speak to the 21 age restriction being lifted specifically to the school. Medicaid has to follow something called, we refer to the acronym as EPSDT. It's early periodic screening diagnostic and treatment services for individuals under 21. And it statutorily prohibits us from denying coverage to any particular set of services that may be medically necessary. And so having a 21 year of age limit on any particular surgery is in conflict with EPSDT federal regulations. So we did not feel that having an age limit in our role conformed with federal law. And instead we assert an individual review on individuals under the age of 21. So that's all getting prior authorized and we're reviewing it on a case-by-case basis for medical necessity. Individuals under 21 have to meet the same standards in order to receive prior authorization as outlined in the rule as any other age. They have to live in their, the gender identity that they want to transition to for a year prior to any surgery is they have to have four modes depending on the type of surgery that they want. All the same requirements apply for individuals under 21 but it is not compliant with federal law to have a hard age limit. Senator Weiss, this is your committee of jurisdiction. You've signed off as saying this meets statutory intent. Yes, we did. Senator Weiss, thank you. And the statute that's being cited is general authority, I believe. Genus APA, is that right? Yes, and then there's a human services section. That's true. Adoption of rules required to administer medical assistance to your grandmother, Medicaid. Okay. And Medicaid does have federal guidelines to follow and that's what Ashley was talking about. Does federal guidelines incorporate the same elimination of age requirements? So the federal guidelines would not require a state to necessarily cover this for an adult but do require coverage reviewed on an individual basis regarding this service or any other service for individuals under 21 under EPS-DT regulations. So EPS-DT says even if you don't cover it anywhere else in your Medicaid program, if you could cover it, you have to review on a case-by-case basis for individuals under 21. This obviously is a brand new role, something that has a cultural impact, if nothing else. I've never seen it face. I don't sit on the committee of jurisdiction so I'm certainly not gonna stand in the way of anything here but I just wanna make sure that this committee is improving or denying based on what I understand the legislative intent to be and I don't know that we've ever actually touched on this subject. We certainly had a great conversation about abortion in the last go around. I see any kind of medical procedure is having the same required discussion, if you will, in the legislative process. So we did have a discussion a couple of years ago on the counseling, I'm looking at my lifeline. The counseling, yeah, the conversion therapy? Thank you, the conversion therapy. And so we did go through quite a discussion on a lot of the issues here. We did not go through discussion on the specifics of surgery that would be required but this is consistent with the intent of the legislature to ensure that people have an opportunity for self-determination and based on medical support. I just wanna know, I believe that it is in statute that it generates affirmations for the slaughter and I know that Barbara Prine from Format Legally is able to speak to that more eloquently than I can if you have continued questions about this particular area. I'm not trying to cause a stir, I'm actually trying to set up more comedies for a future conversation about why I'm required to wear a hat on my head when I get on board my motorcycle, but that's a discussion for you. Public safety. Wait, have you looked at this? Oh gee whiz, this is big change in the lives of many people and may very well be a big change for the better. And I'm not, that's a policy decision. And I'm not adverse to the big change. I'm always kind of worried when big changes are made without the usual fuss, debate and acrimony that sometimes comes with big changes because usually you gotta get through that to get to the big change. And if this committee is approving a big cultural change and later on the public goes, where did that come from? Then someone's gotta answer that question. I don't believe this is a big cultural change. I believe this is an acceptance of that which has been going on for a number of years. And I think that the data is very clear about the need for this type of surgery for people who identify with a gender different from the one that is expressed genetically. And we have talked about that, these issues in committee. So I don't see this as being contrary to legislative intent. It's very much part of what we have talked about. The fact that there isn't a big controversy about it and a large discussion about it, I think is a tribute to the work that has gone on to bring the rule to us in the first place. Yes, and I would also say we have been covering us since 2008 and we have been making, we have been covering it for under the bills under 21 through a process that is a lot more onerous than it will be under this new rule. So again, I don't think that there's a big substantive change here from what we've been doing since 2008 and it is codified in the state statute that these types of surgeries shall be covered by insurance and the environment can speak to that better than I can, but we certainly are formalizing a lot of our policy in this rule. We've obviously received a lot of comments and we've made changes that we think will make our coverage a lot better for both providers and individuals receiving services. There's a lot more clarity there and we have made changes to make sure that we're covering things like hair removal when necessary to receive the surgery. So I don't want to say that there are any changes, but we have been covering this for over a decade. With policy about administrative rule making, yes. And the decision and what we've been doing for the last decade or so to go or no go on these surgeries was made by the clinical unit at the Department of Rural Access. So the same. Regardless of the age, something of new rule here in the world, my understanding is that at birth, often parents and doctors have to make decisions for infants on issues of gender uncertainty in newborns and that's been going on for years and years and years and now we're, I guess maybe some people would argue directly for corrections in what those at birth decisions were in front periods. So I'm rambling, the chair of committee, wish the chair were here. Any further questions for the witness? Has the vote motion been made yet? No. There's two more witnesses. Two more witnesses, no. Excuse me. We have other witnesses. Two more witnesses to move forward. My apologies. If I had known we had two more witnesses, I would have done. I don't have any remarks until we heard from my questions. We heard from the wall. Next witness. If there are no further questions for this witness. Thank you. Barbara Prine. Hi, yeah. I'm bringing Amiela Schlossberg with me. She's from the Office of the Children's Health Care Advocate at Martin Delayed and I'm Barbara Prine. I'm a staff attorney at the Disability Law Project at Vermont Legal Aids and I really appreciate the committee taking this up and I wanna say we are all learning together. It's information that we're all learning about together. I've been representing people with gender dysphoria for almost as long as I've been at Vermont Legal Aid. It's a very small part of my practice. I've been at Legal Aid 25 years. It's a very small part of my practice. But it is for people who are suffering from gender dysphoria, it is a heart rendering issue when their body does not conform. And so one of the questions that you asked about was who decides and how do you know? And so Medicaid's had a bulletin for a long time that tells doctors what they need to do to get things approved. And they've taken this bulletin which was their policy and actually moved it into regulation. So while this is a new regulation, it's a policy that Medicaid's been using for a long time and they've been updating as they go as we all learn together. But what has to happen is doctors and treating professionals and therapists have to write letters of medical necessity. And these letters are, they are detailed long letters about, and they usually include things like depression, anxiety, suicidality. They are complicated and sad, hard things and nothing you would want any family member of yours to be dealing with. And that's what makes it medically necessary. There's a medical, like this has to happen medically or it is bad for this person not to have it happen. And that's why this is occurring. And I've been representing people, I have never had a client getting this surgery under 15 years old. And I think it would be hard to meet it or probably very difficult and possible, but like I said, we're all learning to meet the surgery requirements much younger than that because bodies go through puberty and people have to be living as the other gender. You have puberty blockers, which can block puberty. You have hormone treatments and the world professional standards. There's this group called WPATH, which is the world professional, I don't remember what the A stands for. Association for Transgender Healthcare has like this big set of how do you know when someone's ready for what? And for trans youth, it's a four step process that you have to go through. So this is not something that happens likely. It's something that happens with a lot of thought and therapy and going to doctors who are specialists and it's super important. It's super important work. We also have, so one of the things that Ashley talked about is we have a requirement in Medicaid that for Medicaid for adults, you can place some limits on what you provide. But for people under 21, you're not allowed to refuse any medically necessary care anything that stops proper growth and development, anything that alleviates a condition. So for people under 21, you have to cover everything in Medicaid. For people over 21, you can set limits. And that is why a rule that doesn't allow it for under 21 actually violates federal Medicaid law. And on top of that, in Vermont, we have a health insurance bulletin that came out from the Department of Federal Regulation that says all healthcare, not just Medicaid, but all private insurance has to cover trans healthcare equivalent to non-trans healthcare and that can't discriminate by age. So this Medicaid policy that's happening now this rule is actually getting things in conformity with federal law. It's getting it in conformity with our Vermont Department of Federal Regulation. And it's also meeting the medical criteria of meeting the needs of youth who are having a hard time. And so I wanna say you said, Representative McDonald, that you're concerned about the fuss and acrimony and the lack of it. Well, we have had some fuss and acrimony but you have gotten to miss that because that mostly happened in the comments which had plenty of acrimony that the department received about the rule change in the 200 comments that Ashley talked about. And I wanna say, I realized people are, this is new and so people want to understand it and be educated and there's concern and it's important to understand why this is happening now. That's completely valid. But I also wanna say our Medicaid department has worked really hard to catch up. And one of the great things they did early on is we had a meeting with the healthcare providers with the trans youth clinic, the surgeons, the doctors. And I think we had like, I don't know, like nine or so medical providers and like doctors never leave their offices. But we got like the doctors leave their offices, the nurses, the social workers. This is a psychiatrist to all come in a room and talk about how to make this rule appropriate, developmentally appropriate, all of that as part. So a lot of work happened to get us here and I really appreciate the work that particularly that Danny Foucault and Ashley Berliner did to get us here and struggling to push through. And it is, you know, super important. And I know Amelia has some things she wants to talk about and then we wanna answer your questions because we wanna help everybody understand this as much as possible. So my name is Amelia Schlossberg. I'm the communications and outreach person for the Mount Legal Aid's Office of the Healthcare Advocate. And first, I really want to thank Medicaid and the agency of Human Services for their hard work on improving access to medically necessary care through this rule. I want to particularly thank them for their attention to medical expertise, medical experts and providers in this field. I also want to thank them and you all for your attention and responsiveness to public comments and for engaging with transgender and LGBTQ organizations during this process. Access to medically necessary care is a deeply important issue for transgender and gender non-conforming folks, especially in light of the hate and misunderstanding leveled at this community and especially important in light of the disproportionate impacts of poverty and negative social determinants of health on the transgender and gender non-conforming Vermoners. This has been a long and careful collaborative process of improvement and it will continue to be an ongoing process of improvement as the medical experts at the World Professional Association for Transgender Healthcare will continue to review and update the best clinical practices for treatment of gender dysphoria. And as a staff member of Vermont Legal Aid's Office of the Healthcare Advocate, I'm deeply grateful for this huge progress and for this ongoing collaboration to improve access to medically necessary care for Vermoners. And finally, as a non-biore Vermoner myself, this ongoing commitment to improving healthcare for my community means the world to me. Questions for the witnesses? Witnesses, stay there. I want to thank you for starting out by saying we're all learning. Yeah, me too, I'm learning too. Let me say that some of us around this table are way further back on the training than most of you who have been at the engine. Some of us are still hanging off the edge of the caboose trying to grasp what is our responsibility here as legislators. As a past chair of Vermont's Human Rights Commission, I'm not ignorant of the problems faced on this community. What I am concerned about as a legislator is we have a process we have to go through to justify to all of our constituents why it is we make decisions in various places. Now, as I understand it, we have been actually practicing what is now hopefully about to be recorded by rule and we've been practicing it essentially since 2008 if I understand that correctly. The process of going through this rulemaking, I've read the comments, I understand the opposition, I understand the proponents, I think I have a handle on the issues back and forth. What I'm a little bit nervous about is that that has not happened in the political arena that we are all engaged in on a regular basis. So I'm a little nervous about making a decision without having the legislature waiting me on the conversation. And I understand Senator Lyons' position that she feels this has been dealt with in a setting that wasn't quite exactly on the same terms as this, but is parallel to what you are making for an argument about how these things progress. So I'm gonna ask this question because I don't know the answer. Do we have to vote on this today? Is that a requirement? I won't make anybody nervous, but I'm trying to think, do I need more time to think about what I'm doing here? The reaction that I have in casting my vote to some people will seem that I am approving a procedure that to some of my constituents, they match the opponent's version of what those are. Two other constituents will match what the proponents are in favor of, and I don't know as I sit here what my own constituency would be telling me about this. But I can see people saying, wait a minute, Benning, you have a legislative responsibility that requires you to examine this issue. And it's unfortunate that I don't sit on the Committee of Jurisdiction, so I'm taking bits and pieces of information, trying to wrestle with it. But if I boil it all down, and I'm probably talking through my own decision-making process here, so forgive me, you have been, the departments have been practicing literally what is now being asked to be codified since 2008. The best way that I sell this argument then to my constituents would be, we are not actually approving or disproving anything other than codifying what the practice has already been. Am I wrong in that assessment? I would be careful about saying it's 100% of what's been happening since 2008 because Medicaid has learned as WTAP has gotten clear, but it has for the very most part been practicing this. And I would say part of what's getting codified is we have a Department of Financial Regulation Rule that you can't discriminate against transgender people and on age. And you have a federal Medicaid law that says you can't discriminate based on age. And there are multiple cases like lawsuits. I mean, so like as Vermont legal aid and Medicaid hadn't done this, we might have thought about lawsuits. Certainly there was a demand letter sent to them two and a half years ago signed by me saying you have to bring things into conformity. So this is the law. They're putting what is the law into place in regulation. Medicaid has to provide medically necessary care. When doctors say this is medically necessary for this 17 year old, they're not allowed to say no. And the Department of Federal Regulation says the same thing, and Blue Cross has to do it too. And so does Sigma. It's, so it's changed. Your logic is perfectly set. Yeah. The headline in Tomorrow's Caledonian will be banning votes to approve 12 year olds having gender surgery. And that's what I have to deal with going back home. So I look at this. I wanna make sure that I'm listening to you and having that thought process is very important. But we are essentially codifying what has been the practice that we have regulations in place that normally would suggest this is something that has to happen, it seemed to be medically necessary. The questions for my constituents will be how does a 12 year old decide that they have to have a medically necessary procedure? I'm just wrestling. Yeah, I mean, I've never heard of anyone under 15 in my practice. And people come to legal aid when they're unhappy with what happens, so people aren't pretty good at finding us. But I understand that it's a, we're all learning together. And I think that, I appreciate what you're saying. I appreciate what you're saying. Appreciate how you're presenting too. I'm really happy to answer your questions because I feel like questions is how we learn about this together and how we do a better job going forward and being as inclusive as we possibly can. Mark. Is that it? Claire. So Barbara, in response to Senator Bannon, you said you've never heard of anyone under 15. Sinking surgery. Sinking surgery. Yeah. What happens when that under 15 seeks surgery? I mean, right now it's always, it's not easy, but it's one of those things that people say, well, I've never heard of anybody doing this. At some point in time, somebody is gonna do that. Well, part of it is because the WPATH standards have these four steps for trans youth that they have to go through and the steps sort of start around the age of puberty. It's a little difficult for me to understand how it gets much younger than 14 if possible. So that's partly why I'm saying that. But it has to be medically necessary. You have to have been living in the other gender. You have to be taking puberty blockers, if appropriate. You have to be going to therapy. You have to be working with a medical doctor. You know, those things have to be in place and you have to have, it's not just that, but it has to be that people are saying it is medically bad for you not to have this happen. And for trans youth, there is a lot of problems. I mean, there's a lot, I think one of the things that was very interesting to me in a very depressing and sad way is the risk to trans youth by our community of getting bullied, beat up. You know, there are rates of, you read these letters and you understand the risk of not passing as your gender presents. And it is not what anyone in this room wants. You know, it is not what we want. And so we have to do things to help get us there. Do you want to say something? I want to just want to add what it looks like in terms of who's writing these letters of support and explaining the medical necessity. So it would be someone's medical provider. So we're not having 17 year olds going out and writing their impassioned speeches. It would be a medical professional who would be explaining, it would be someone probably with an MD explaining why this is, why the person's experiencing gender dysphoria and why this is a particularly important treatment for their gender dysphoria. So explaining the details of the depression or the suicidality or the issues that are going on for a person and for a teen that would be a long relationship with a medical provider. And if you look in the comments or when you read comments you'll see the medical providers that are weighing in on this, including the UVM Transgender Youth Clinic and the Community Health Centers of Burlington Medical Doctors, explaining what their experience has been working with older teenagers and this medical necessity and their support for access to care when it's medically appropriate and developmentally appropriate. The person has to see a PhD level mental health professional, which is a psychiatrist. They have to have their own treating physician. They have to have a mental health provider with a long working relationship. They need all three of those. At all of them saying this is medically necessary and why? These are long letters. But is there, there has to be, is there somewhere that says all three have to be in agreement? Yes. Yes, you don't get through, there are multiple steps to get through the door and you have to have all three of those steps. Thank you. Further questions for the witnesses? We have one more witness. Senator. I really appreciate the thoughtfulness and attention that you're putting in for this. Thank you so much. Thank you. I think we're ready for our next one. For the church hall, I represent the LGBTQIA Alliance of Vermont, which includes out in the open in Bennington, Queer Connect in Brattleboro, in Chittenden County, Vermont Cares, outright Vermont, and Pride Center, in Monterey, the legal umbrella of Central Vermont. I know a lot of you and I want to hope that you will read my testimony and understand that I am so in favor of what's happening. There have been a couple of things that were pointed out to me by folks who are transgender that I work with and I talk to on a daily basis. At the Senator Benning's point, I wanted to point out that while we are all learning, I am teaching. I am talking about particularly many people as I can into a program called Ask a Transgender Person that I've done for mental health professionals, schools, farmers markets, and have had a great deal of opportunity for public outreach and being support in mostly every encounter. I'm going to boil it down to you as simply as I can. What this bill means to me is you're legislating my survival here. And two words that come to mind are murder and suicide. Look at the bottom of my testimony. I mean, we've got two statistics. Additionally, this year, there's been another murder of a transgender woman. So that number needs to change to 19. And probably the most significant thing that you're going to have an effect on today is the suicide attempts for trans folks. Stunningly, 41% of my family tried to commit suicide. Why is these changes or codifying the practices important? Is because of what? People know that these are things that are now looked at by Vermont as part of their right to exist and live in Vermont. I want to take any questions that you might have for perhaps the only trans person that works here in the state house. And I'm absolutely open to any questions I've told folks before. Nothing's off the table. And I can always say, no, I don't want to answer that question. That's a pretty feeling part of between. If you don't know any trans folks, then this might have significant impact that you know one, me, today. If you do know transgender folks, I hope that you do. This is going to have an impact in a very positive way. And with respect to suicides, anybody who doubts that trans person has their own struggles and their own issues doesn't know human nature very well. To not be able to fit into a society to be bullied as a kid, to be set aside from participating in many things, including by the way, healthcare and schools, just as an aside, this is kind of important. Anybody have any questions for me? And don't be shy. Why did you frame it in such a way that you believe we were actually approving a procedure that has actually been approved for quite some time? Not so much approval, because it's kind of fine into a structure that now medical professionals and providers around the state will understand. This is, you have to follow these rules. And I'm assuming that that's the intent of this, is to put it in a position where it's out of different pieces of the WPATH, as an example, current Medicaid practices. I'm going through this process now. I have my letters, I have things that I'm having done. These things are gonna happen, whether this is approved or not, in one way, shape, or form. Trans folks are very resourceful in getting things done, including folks that go out of state. But we have private insurance providers right now that are doing all of this because they have mandates, because they have structure from not just Vermont, but also the federal government. So, it's not even, with all due respect, this is not necessarily no brainer because I understand that you have to talk to your constituents. I'll go out on the trail with you any time you want. I will be at your side and say, this man supported me, of Vermont, and that's what I appreciate will happen today. I appreciate that offer. I think I want to make clear that a vote here today, if some folks are anticipating we are about to vote to approve something that is brand new and never been done before, which is how it will be postured and presented in various quarters. That's not actually what we're talking about here. And so my, I guess, nervousness is when we try to posture it in that way, the political process gets ramped up considerably. And we haven't had this conversation in the legislature, certainly not to this extent that I'm aware of, and I don't sit on the committee of jurisdiction, but I think I'm safe in saying we haven't had that level of conversation in the legislative arena, but some people are going to say, Elkar has leaked ahead and made this policy decision without any kind of legislative discussion other than what is peripherally on the edges of other conversations. I will say we have had conversations. What we haven't had is this going into statute. So this is in rules. And so it allows for protection of the patient. It allows for a process that ensures that it is medically necessary. I'm, Judy, I'm 100% comfortable with what you're saying. If this was a statute, in other words, we would have a committee of jurisdiction looking at the conversation. We'd have a great big battle between the pros and the cons in this legislature. To some extent, there will be angry people out there that we didn't have that process in the legislature. And this will be how it gets presented to us politicians when we're out there talking. I think I can defend at any point in time why folks have medically necessary surgeries and make that explanation. But that's not really what I'm wrestling with right now. What I'm really wrestling with is we're gonna make a decision and if we prove the rule, we will be hit by people who say you bypassed the legislative process that normally would have taken place. But the reality is, and I'm thinking through again, we've been doing this for some time. So all that we are technically doing is codifying what has been happening with the understanding that we are aligning this with federal law that requires us not to discriminate. I think I've got that part of it down. Politically, we'll wrestle with it where we have. Available to anybody that has to answer those questions. Appreciate that at all. That said, and with all due respect, if it saves a life, as it has to pass, it has worked through different processes, whether it be a suicide attempt for an attempted murder or a murder, it's done its job. It's done what we really need our legislation to do is to protect us, and I appreciate that very much. Thank you. Actually, did you want to say something? Ashley, for the record. We were going to call on you when the questions for the status have been, or any of the other things. Frederick, can I ask one more question? In your testimony, you were concerned that this didn't go far enough. Are you not suggesting that we disapprove of the rule because it doesn't go as far as you would help? That's correct. The work that the partners have done, what Legal Aid has done, is, in my words, long overdue, and it's very welcome to hear. The discrimination that I point into within the context of these rules has to do with some nuances that aren't always apparent to people. And within the occurrence of transgender folks who transition from either male to female or female to male, there's certain processes that inherently favor trans men versus trans women. One of them is their ability to pass, if that is what they're looking for. By inducing hormones, they will have beard growth, and they will have an appearance that matches the current binary that we're all tied to. Trans women will continue to have to shave or remove hair in a way that is both costly and a barrier for a lot of low income or folks that don't make enough money for electrolysis. And facial feminization surgery again contributes to their overall well-being and their appearance. So that they may, again, if that's their goal to pass in society, fit the binary and look to themselves as they look in the mirror as the whole person that they believe themselves to be. Both of these procedures are excluded as cosmetic surgery and therefore not included. But I would argue that they are not cosmetic surgery but medically necessary, life-affirming procedures that really wouldn't add a huge burden to taxpayers but would, again, go a long way to benefit individuals who are seeking these procedures. Perhaps I would suggest that this may be a continual evolution of process that we look at the good that's been done and the words that are codified in the process today. And I won't be around a while so I'm sure we'll talk about this again. No further questions for this witness? Senator Williams, if you have a question for her. I think Ashley wanted to respond to some of the discussion that was going on to clarify. Yes, Senator Benning, in particular, and Ashley Brunner for the record. I just wanted to say that I really appreciate where you're coming from about if this is something that needs to be hashed out in the legislature versus in the administrative role process and I would say that the path that you're going down, we've been covering this since 2008. We have, I spoke with Representative Lippert about some of the conversation that happened well before my time in the legislature when Medicaid first started thinking about covering this in 2008 and so I do think that the conversation happened a very long time ago and I would also say that we have, we've been working on this rule for over a year very much in, not in the state house but very much in the public. We've had multiple Vermont Digger and we're going to pre-press articles written about this rule. We've received lots and lots and lots of public input as I've already discussed and I would say that we feel as an apartment that we have clear authority to proceed with this rulemaking and what our, well my understanding of this committee is, is approving that rulemaking authority and not necessarily the policy in and of itself that the policy discretion is happening with an overarching statute that exists on the books that the legislature already weighed in on and then with Diva's authority to proceed with this rule. I appreciate that Ashley but I know what the new paper reports are going to be from my own and I guess I've got enough legislative experience to understand what happens when I walk up and talk to you. Sam Myers. Ashley, or maybe this might be for Barbara, either one of you. What you're saying is that federal law allows this. Just federal law, does it? Yes, and I would go further to say that regardless of this rule we are mandated by federal law to cover gender affirmation surgery when medically necessary for individuals under 21 and the federal law is explicit that even if it isn't in your rule even if it isn't explicitly in your state plan even if it's not in your statute you have to cover it. It is a violation of federal law not to. Okay, so federal law says that. Yes. If we should say no on this as it's presented to us what happens to the state of Vermont through federal law what happens to the state of Vermont in terms of Medicaid, et cetera, et cetera in regarding this specific rule? Vermont would continue to cover gender affirmation in terms of gender affirmation. And we would not have a rule on the books and it would lead to lots of confusion on the behalf of beneficiaries and providers for not, you know, I would anticipate what has existed for the last 10 years where there's a lot back and forth to get the right materials, to get the right supporting documentation. The intent of this rule is really to clarify what is required to receive prior authorization without this clarity. While we would likely try to put some of it into clinical guidance we would anticipate a lot more confusion on the part of providers and what they need to submit a prolonged process, decreased access to care and potentially more appeals. But I understand that. Would there be reason for the federal government not to, we know how much money comes in through Medicaid to the state of Vermont? Would there be a reason for the federal government to say, well, you're not doing what we're requiring to be done under federal law, we will then cut off our funding in some way or other Medicaid funding that would be coming into the state of Vermont? If the state were to reverse its current coverage policy and no longer cover this, it would be in violation of federal law and we would likely be sued by Vermont legal aid and we would not be able to defend ourselves in that lawsuit. So I don't think that the centers for Medicare and Medicaid services would be proactive in doing anything but they would know that they're relying on lawsuits being brought forth which they certainly would be in this case and that's what we're trying to force their rules. I don't know if you want to add anything. I think you described my role very clearly. Thank you. Any further questions for the witnesses? It's the committee's pleasure. I move that we approve the rule. Is there any discussion? All in favor say aye. Aye. I will vote say nay. Pardon me? Can I make an aye with a declaration? Sure. That's what I wanted to ask. Why not? Thank you, pardon me. Say that again. I did, but I would like to make an explanation. Did you? Okay. I'll start by saying I have enough history on this subject to know that we have a segment of our population that has suffered for a very long time. This is not something, this procedure is not something that people go through simply because they wake up one day and decide they want to do it. I do understand that there is a complicated procedure that folks have to go through that it all is based upon a medical necessity, not a simple will and will. For that reason, I understand the need. Secondly, I don't think we are actually creating new legislation here. I think that we've been doing this since 2008 and what we are simply doing here is codifying what is in existence in order to protect the state from potential legislation. So because A, I believe it's the right thing to do and B, because it aligns us with what I understand the federal process to be, I'm in favor of having a little think this. Did you get all that? Yes. Senator, I haven't voted yet either, so I'd like to explain. You haven't voted yet? I haven't voted yet. I will vote yes on this. However, I vote, I'm voting for it because I have long health. I have, but my issues with my voting yes is the fact that for as long as I've been in the legislature, it has been very important to me that we have had that full discussion on both the floor of the House and the floor of the Senate to come to some kind of an agreement. I understand again, we've been doing this since 2008. And so I don't wanna say reluctantly because I feel it's very important that we offer what we've been offering and continue offering to those people in our community that need this. So I will vote yes, still feeling reluctance that we have not had the opportunity to do this on the floor of the House of the Senate. Thank you. Anyone else wish to make a statement? Oh, I will. I'm gonna do this because it's the right thing to do. Not because the fence have required us to do that. And even though they have, but I'm doing it because it's the right thing to do. And I know we've had discussions on this often and in various committees. And this is the buckets coming through here today. And we're happy on it, it's my statement. So, the vote is, all in favor say, raise your hands, say aye. All in favor say nay. That's the vote for today. Thank you all for being here. Thank you so very much, we really appreciate it. So next item on the agenda, refugees, medical assistance. And I have one more item to bring up is new business that will be finished with the medical, refugees medical assistance. And the witness for refugees medical assistance, we have one. Daniel Fiacco. I'm a policy analyst. Sorry, it's on my agenda, I'm sorry. So, my apologies. For the record, your name is? It's Daniel Fiacco, I'm a policy analyst with the Department of Health and Health Access. So, refugee medical assistance, the rules for you. This is kind of a small program, very individualized. The rules had not been updated since well before the Affordable Care Act was passed in an effort to update agency rules and get rid of some outdated information, we updated this rule. It is updated to a line with federal law and guidance. It reflects the current medical assistance programs that we have in Vermont now with the ACA and methodology for calculating eligibility. The updates is it expands the length of time for the agency Human Services has to process an application from 30 days to 45 days and this aligns with a recent change in the health benefits, eligibility and enrollment rules for Medicaid. It expands the financial eligibility limit for the refugee medical assistance program to 200% of the federal poverty level, which is an option provided to states under federal law. And there were no comments received on this during the proposed, during the comment period, a hearing was held attended for this rule and some of the changes were subsequently made from the proposed rule. And just a quick explanation because it often gets confused. Refugee medical assistance is not Medicaid. So when refugees arrive, they are screened for Medicaid first and if vice versa reason, they are not eligible there then screened for the refugee medical assistance program. So it's in addition to Medicaid? Yes, it's specifically for refugees and assailees. It's provided under a different part of federal law that Medicaid law. But it is very closely tied to the Medicaid program in the sense that it relies on the people who, people have to be first screened after they've been found ineligible. And then they are screened by the same folks over at Diva for this refugee medical assistance program that has additional criteria specific to immigration status and I'm codified in federal law. Thank you. You are saying that the refugees are not recipients of Medicaid and that what the rule deals with a program that is separate and distinct from Medicaid? Yes, it's hard to see that it's separate and distinct. Once they are found eligible for refugee medical assistance they essentially receive the same benefits as Medicaid. But it is funded entirely by the status program. Yes. It's a closely managed Medicaid program. So the eligibility period is determined yearly based on federal rules. Can you just briefly talk about what those rules can conclude and how one might be allowed to stay on is it all economic? Eligibility or are there additional considerations? So the eligibility period is currently eight months for refugee medical assistance. And then annually the director of the federal director of the office of refugee resettlement can change that. They have to provide notice, I believe through the federal register if that does change, it has not changed in a while. So if someone, and I think maybe you're getting it, how are they eligible beyond Medicaid? So they would be screened for Medicaid and if they were over income, for example, as an adult because the Medicaid income limit for adults is 133% of the federal poverty level and this is 200. They would then, you would follow the criteria outlined in this rule and also use the 200% federal poverty level limit. Will this be integrated into our integrated eligibility program once it's online? So it's, I'm not sure if I can correctly answer that specific question because they don't have to say that the eligibility has worked into our rules even. Thanks, thank you. Any further questions? Any further witnesses? How many refugees do we currently have following the RMA? So for federal fiscal year 2019, there were two people on the RMA program. We have a thought that there were three. With the ACA expansion, most refugees became eligible for Medicaid and so this is just really in places kind of a catch-all. Well, this is a question maybe we can talk about another time but moving that eligibility to a state subsidized program might remove the federal subsidy. Anyway, we can talk about that sometime. Do we have a motion? All right, I'll move that we approve the rules, the number 1950, what was it? Oh, P-50, 19, P-50. The move that 1950, see that union service switch, refugee medical assistance, it will be approved. There's no further discussion, all the papers AI. Right. I'll go say nay. 19 P-51, agency of natural resources and regulations. Visitor conduct and fees for state and park services. I thought Ashley Berliner was going to do this one too. Ooh. I'm a good one, thank you. Prepare just to have my nervous. Craig Whipple, director of state parks, the Department of Forest Park Association, was cruel. Welcome. Thank you. Good morning. Who put us last on your agenda? I'm always grateful for that, because it's a fascinating subject. Don't end me here. So yes, I'm Craig Whipple and director of state parks and we're here to talk about our standard suite of rules that attempt to provide standards for visitor conduct in state parks. It also includes our fees that we charge for services that we sell, and also for commercial use of forest parks and recreation memorials. This round, these rules have been in effect for decades. This round is largely a group of editorial or administrative changes just to tidy things up. In our world, the only things in substance relative to your previous conversations, it is about substance, but in our world, we're talking about raising the price for camping, tent size, a dollar per night, lean twos, three dollars per night. There's a proposed change in the rule about dogs and pets to be restrained on a leash. At all times, the previous rule said that they had to be on a leash during the operating season. We have situations across the park system now where in the non-operating season, we're really quite busy, it's a density issue when there are dogs running around and biting other dogs and people. We have to sort of wrestle that one. So we're proposing to require a pet on a leash at all times. Beyond that, I think there isn't a whole lot of substance. I'd be happy to address it in the administrative range or the changes or anything else that's on your mind right now. Can I ask a question? Certainly. So just looking at the various charges and fees that are in here, how many of these are currently in place into the fee bill? None of them. Okay, so they're all, this is all consistent with what has happened previously? Correct. The statute allows the Secretary of the Agency of Natural Resources and the Commissioner of Forest Parks and Migration to establish fees for sales and services on the Department of Lands by group, as opposed to legislated through the fee bill. It's been like that for 100 years. Almost. 2024 is our hundredth anniversary. Yes. Oh, wow. Okay. That's a valid question. Senator Morris. Mr. Wibble, I just want to say that I was especially pleased to see in this role the comments regarding the rule regarding restraining dogs. We have Indian Park in Essex, which is not a state park, but it is community park. And we are constantly having problems with that decision and making that and what's happening there. So not that this is necessarily going to get back to those people, cause we're trying to work it through, you know, through the town. But I appreciate that because I understand every dog owner. I used to raise breed and raise dogs. And I understand every dog owner feels that their dog's the best and nothing's ever going to happen. But unfortunately, things do happen. So I'm really glad that we're going through that. Somebody else's dog always. Yeah. And the famous last words is, oh, don't worry, it's friendly. Yeah, yeah. But thank you for that mention. We are the largest and busiest park system in the state. So other park systems look to us for guidance. When we do things often, others just follow up. And we felt that this is a necessary response. Thank you for that. And with that, if we have any other questions, I will move approval of this rule. 19, P-5-1. Vice President Meyers. P-5-0. Sorry about that. No, P-5-1. I'm sorry. All those in favor, paying for the discussion? If not, all those in favor, say aye. Aye. All those in favor, say aye. Thank you. Thank you. Thank you. Welcome for the record. Can you please identify yourselves? Yes. I'm Keith Levinson, Department of Public Service. I'm Megan Madrigan, Secretary of the Department of Public Service. And I'm Chris Granda. I'm a senior researcher advocate with the Applying Standards Awareness Project. For us. Thank you. We're here to present the Department's proposed rule 19, P-039, the Applying Sufficiency Rule. This rule was developed by the Department of Public Service to fulfill our obligation under Act 139. It sets forth minimum efficiency standards for the 17 products in nine VSA section 2792, which the state's efficiency standards had not yet been applied. And this applies to 17 products, which includes air compressors, commercial disc washers, commercial friars, commercial hot food, golden cabinets, commercial steam cookers, computers and computer monitors, faucets, high color rendering, and index fluorescent lamps, portable air conditioners, portable electric spas, residential ventilating fans, shower heads, spray, sprinkler bodies, uninterruptible power supplies, urinals, and water pools. And in the rule, we have incorporated by reference the standards of the legislature to direct us to adopt. And I was very, very happy to entertain any questions. Chair of Natural Resources for the Senate is not here. Probably have the best questions. Should there be any? Do we have an official paper on it? Do you need some? No. No, we didn't. It's in the statement. Yeah. Pass one here, say it. It's fine, but it's a pool. That's their say. So you should read it to us, and I thought that's all right. We did hold a public hearing. No one attended the hearing, and we did not receive any comments. Remember the first time we passed the Appliance Efficiency Standards, we allowed for rules to be promulgated based on federal standards through the DOE. This is consistent with that process. It's different. It's slightly different. Yeah, the first Appliance Standards rule that we promulgated was designed to go into effect if the DOE withdrew their standards. So it was very unusual in that respect. And I remember the discussion about that. This covers products that are not covered by federal standards, but we are incorporating by reference to other standards in other states, the Energy Star program through DOE, et cetera. California standards. Several of them are California standards. Or reference. Right. Which we have. We've incorporated by reference. From the mid-'90s has been incorporated California standards. Questions for the witnesses? This is going to make my little computer cost more. I'll pass that to Chris. What? So the economic impacts, I guess, is what I'm asking about. Sure. So the Vermont standards for computers and monitors are directly taken from the California standards for the same. And that is, I'm not trying to duck the question, Senator, but it's a very difficult one to answer because of the rapid evolution of technology. All of the efficiency requirements that are being put in place in California and in Vermont and now three other states which have adopted it are ones of readily available technology. And what I would say is that maybe for the first year it will cause price increases, but as volume rules and electronics, and I wouldn't expect to see durable price increases for computers over time. But that's just my opinion. As long as China keeps, I guess. In Taiwan, and in Vietnam, and that's a global industry. Thank you. The rational thinking behind it is eventually over time the efficiency offset, to some extent, to every additional cost you have. That's an excellent point. I want to stress that all of the standards have been subject to life cycle cost analysis as part of the development process. So the idea is that customers do recover even very conservative estimates of projected increases in costs. And there's actually been some analysis that shows that DOE's estimates of those costs and frankly our estimates of those costs over time have been overstated. So industry has a way of driving down prices for energy efficient equipment as it enters the mainstream. Any questions? I believe the economic analysis that we were given said that there will be fewer sales than it was targeted towards retailers. Didn't say that people with inefficient stuff would be more likely to hang on to it a little longer if the prices were higher. But the difference between those two truisms and to pick one versus the other is just where perhaps your emphasis would be or what you thought was more harmful than the seller or the buyer waiting a little longer. Can I ask another? This is probably maybe tangential to the rule. But there's public health data that indicates that the blue light from the screen stimulates the development of macular degeneration. And will this, how will this, if at all, how if at all will this relate to that? Do we know? I'm not familiar. It's a little bit beyond why expertise. I mean, it's clearly it is. It's energy efficiency. But it's interesting whether or not there's any conversation outside of this rulemaking process that would lead to a light that is less inside on that crystal. What I would say is that at the federal level, statute actually restricts the non-energy criteria that we can consider when sending standards. States aren't limited in that way. And actually, even at the federal level, there is some particular latitude that's allowed around light sources. The area that you're describing is one of active research right now. It's not just with macular degeneration, but also disrupting circadian rhythms and things like that. So yeah, there's a lot of attention being paid because this is around LEDs, particularly in there in the computers and smart phone screens and light bulbs and everything now. So really understanding that is something that a lot of people are working on. There aren't any conclusions yet, at least on that I'm comfortable pointing to. There's no reason why that can't be addressed in future standards in a way that things like color of light or what they call color rendering index has been. And there also are no technical barriers. There's nothing endemic to LEDs that requires them to have more blue light. So I think in the short story there, if states want to regulate that in the future, they can. And I would expect there to be a lot better information to design this right now as it's gone in the near future. Does that directly relate to energy efficiency of a source? Is that more tangential? It's more tangential. Yeah, it has to do with the technology behind light of any diodes. So good. OK, thank you. That's very helpful. Any other questions for the witnesses? Committee, what's your pleasure? I'll move the floor. People behind. Move approval. So any further discussion? If not, favor say aye. Aye. All opposed, say nay. Here to have it, take due, and the rule has been approved. Thank you very much. The last item on the written agenda, many review of response, protection, and draft, demo, communities of jurisdiction, residential building energy standards, and commercial building energy skin. I said I got one more item for the end. To just summarize, the last agenda item relates to the RVs and CBs rules that Elkhart reviewed at your last meeting. At that meeting, you had approved the substance of the rule, but did object to the portion of both of those rules that would place a copyright on the rules on behalf of the private entity, IECC, the International Energy Code Council. Because the copyright existed there, because much of the rule was based on the IECC that had the Code Council, and then went from all specific tweaks. So Elkhart did issue an objection solely on the basis of that copyright. The commissioner of public service responded. And in the response you have before you, a commissioner indicated that the Department of Public Service would welcome an opportunity to cure that copyright defect. And in order to give the department some time to work on our vision to the rule, that would keep the substance of the rules as is, but would address that copyright issue. The department, as I understand it, is going to take a little bit of time to figure out how to revise the rules to not have the copyright on the rule. So the department did provide to Elkhart an extension of its review period. That review period extension is now to December 20th of this year that Elkhart would have to review the rule. DPS, I believe, has until January to finally adopt the rule. And what I understand that DPS will do in between now and then is to come back to Elkhart with a revision. So that Elkhart could actually see the revision and then determine whether to certify the objection or if it addresses your concerns about the copyright and you could move forward and approve what the rule features to do so. So that's the status of the objection that you'll be seeing that rule again and you'll have time to review it. The second thing that's related to those two rules is the draft memo to committees of jurisdiction. Elkhart did request that a memo go out to committees of jurisdiction at your meeting to highlight for the committees of jurisdiction some of the substantive issues that were raised about RVs and CDs. And so what I have attempted to do here is to lay out the main issues that were discussed in testimony. Those are in this draft memo here. The memo would address the design implications that were discussed, the lack of enforcement particularly for RVs. There were recommendations for a builder registry and that DPS should have someone or an entity available for informational assistance to the builders attempting to comply with RVs and CDs. And then of course that the changes would have funding implications. The memo takes no position on the recommendations made in witness testimony but was drafted to give the committees information on the concerns that were expressed in regard to the policy enacted by the General Assembly. This draft memo is still in draft form. You see it right now refers to the objection but Elkhart may reconsider whether to certify the objection. So I was thinking that you could review this memo now to just while this issues freshen up in your minds but perhaps Elkhart will hold off on sending it to committees until after you take final action on the rule we have to certify the objection. I mean as far as I'm concerned I think it does express very well the concerns that we had, the comments that we had. But I agree we should wait until the final rule goes through the process. We'll have to acquire an action on our part. We'll decide to wait for the final rule or? Well now you have Elkhart has that been granted the extension of the review period so I think it'll just be a matter of when DPS is able to resubmit the rule of its revisions addressing the copyright issue. And during the extension of the review period the provisions and the rules that Elkhart did not object to remain in advance or will they start forward on their own? So DPS as I understand it will not move forward with adopting the rule until Elkhart gets to see the final version. Double checking so we're all operating on the same same way that we did. I'm sorry, Senator Lines what did you say about the letter to the committees? I think we should hold off until the final rule has been approved or not approved. I think that's the answer to the question. I'm happy to accept any recommended revisions to any of the substance if you don't think the address is enough or too much. And I mean you indicated that maybe that footnote should go but that depends on what happens. Correct. So. I don't think Elkhart needs to take any action on this now. We thank you. We thank you for putting on paper the previous meeting asked you to put on paper. So was that it for this particular, that's it for this, based upon that I would chair was in error in the approval of the minutes because I did not attend on that meeting which left four vote approval which is one short I think of what's required. So at the next meeting we would perhaps be in order to ratify or to confirm the approval done today about a few minutes if you can think about that. Records. Secondly, I said alliance with myself and put in a drafting request for a bill that deals with how health officers pursue rabies, animal bite bites and their health officers responsibility to the rabies protections. And Senator Lanz and I are put the bill in because it appears that the guidelines published by the health department dealing with health officers tasks that they are supposed to perform and the judgments and procedures that those health officers do in fact perform such as quarantining of animals that don't have rabies shots or this and the next door and how those quarantines take place have been, have been, have been likely rules of enforcement of law and they're just guidelines and they have of course confusion which committee of jurisdiction might seek to take testimony on. A remedy would be for the committee of jurisdiction to direct the department of health to promulgate such rules. The LCAR also has according to our attorney the authority to direct the health department to initiate such rules but not necessarily to pull the trigger to make them take place. So at the next meeting I would ask that we consider asking the health department to initiate the rules at the same time that we might send a letter to the committee of jurisdiction performing them that the rules to deal with these issues have been directed to the health department to put forth the rules so they would be getting started by the time the legislature convenes and it might help the committees of jurisdiction to be noted the rules process was already up and going. So Senator, yeah. Any decision on this would be I would ask that the committee take up at its next meeting with a more thorough explanation than what I've just given it. Right, we're gonna need information just to do that and I think some of that information would be fully vetted in a committee process. I have a list of things that the committee might be able to deal with and that we might be asking the health department to deal with such as if you're quarantined a dog do you have to give paperwork to the kennel and can they release a dog without some sort of official whatever and right now it's kind of loosey-loosey. The other piece of it I think is that it does it involves local decision-making or select boards and then if we start talking about that then it does get into having money to support some of this and whether that comes from the select board or from the department of health. So I think we just need to be sure that we're not stepping in the middle of the Hornets Nest the way my sister did last week. So there have been cases where the health officer has discharged the health officer's duty in the according to the booklet with the guidelines and procedures and then the health department has said you shouldn't have done that and we just need a guideline so everybody knows what they're supposed to do and there's a bigger. So at the next meeting we might get a more organized proposal for the Elkhart to consider or reject but this was a heads-up. Can I ask? So I'm looking at the rules that we have outstanding are we continuing to get other rules? So I think there's just two on that list. There's only two right now but I'm expecting seven for the agency of human services. Great. That have very little changes but yeah so that's they're gonna be on the 31st. Oh. Also. And that meeting is not going to be here because the State House that's gonna be a comment. We are. Maybe we should do it in Chittenden County. Joe. But we're just going to nationalize, right? It's going to do it. It's going to do it. Yeah, yeah. Be good. No meeting on the 17th. Oh shucks. With that I'll move to adjourn. Thank you. So I guess we'll move to committee adjourn. But for the discussion we'll take a say hi. Hi. We'll say hi. We'll adjourn.