 So we're going to start, so this morning we're starting by this recap where we've been. Yesterday we were asked by the speaker's office to try to come up with short term emergency proposals that would address the health care needs of our monitors in the midst of the situation we've been in with COVID-19, since particularly looking at issues of health care around home health, mental health, and related issues. We had the good fortune to be working with the group of stakeholders in the room yesterday who very actively on our behalf and with some conversations with me came back with a list of specific proposals. I haven't seen it, I mean it says all my notes all over it, but I don't know how to record for documents other than it's been posted yesterday, but this issues talking about emergency, possible emergency steps during measures. Looking how to sustain the care network workforce and issues around, the recommendations for issues also around compliance and insurance or consumer Medicaid recommendations. Our legislative council who's worked very, very late through the night to try to put this in a form that we could possibly consider. And that's what we're going to look at now. So Jen's going to walk us through. I should say that I took the liberty because we don't know what form this may be used in today. One thought with some of this might be amended to something. I took the liberty to ask Jen to include in that amendment our telehealth bill, which we've already said to the senate, our workforce bill, which we have not yet reviewed fully, and we talked about it, but we haven't actually approved in the committee, which we have to do, which we will do later today regardless at some point. So we understand that that's in that amendment as a preliminary thing that's not been approved by the committee. And the interstate nurse compact, which is coming from the senate, we were just trying to think, what are some of the essential pieces of staff story work that we're doing that is pertinent to the situation we're in? We're not going to be reviewing those parts this morning. And I didn't want anybody to separate when you saw that. I asked to have that done. But this is, we're looking at all kinds of possibilities. So what we're going to do now is to walk through the pieces that respond to this memo and to some of the few of the suggestions that Jen Oxford made around the pharmacy. Blue Cross Blue Shield also alerted. I don't know how broadly that was shared, Sarah, but there was a- I sent it to our committee. So about the pharmacy resales being authorized, and we can come back to that just to know that, would you send that to Jen? I'll send it. Well, and just that there are two other pieces that Jen included, so that we had it there for discussion that came as a request from inpatient psychiatry. So when you see those, that's the source. I'm going to mention the resolution. Yes. One of the other suggestions that came out in our discussion yesterday with Brian, Jen on the phone, was concerned for undocumented Vermonters, folks working in Vermont who are undocumented, and what can we do to protect them from fear of seeking healthcare services in the midst of this situation. And there are limits to what we can do, but we felt like we felt it was imperative to make some type of strong public statement. And we have a recommendation, and Anne is working and taking the lead on a resolution around that, which would be possibly introduced today. And Anne can maybe just- I can give you a snippet because we've looked into it. The President has, on a couple of prior occasions in an emergency, declared health facilities as safe zones when it's critical to have folks come in and be tested for the sake of public health. We did it in some hurricane situations and the water crisis for Flint, Michigan. So this would be a request to please consider this such an instance and apply that. And also for the group of people who are legal immigrants but afraid because of the new rule that's about to come out on public health burden. If you burden the system and your notices, that that be delayed implementation so that it doesn't affect getting people to come in and be tested for public health protection. So that would be what it is and that's being worked on. So then the Joint Rules Committee is meeting as we speak. That's the leadership of the House in a second. I'm told there's probably going to be a chairs meeting called for somewhere between 9 and 9.30. I'm going to be ready to go to that. Lori is going to take the lead on walking us through the review of the amendments. And depending on what might emerge from the Joint Rules Committee, there are announcements from the podium. I'll come back and then I want to make sure everyone, we were going to work through the first hour of the floor this morning. That was our understanding of the plan. If it's appropriate or necessary for us to be on the floor to hear any announcement from the podium to do that. We also have third reading on price transparency that Representative Rodgers is presenting yesterday. And as importantly or more importantly, actually we have second reading on our emergency services bill, which is also something that would become a component, possibly something we didn't expect. And Mari is presenting that. I looked at the order and it's kind of late in the orders of the day. So that we may come back and do some more working committee. If we leave with the speaker to be on the floor. We have our tiny snippet part of the commerce bill. That's a meeting. So, yeah. Thanks to Congress for this. That really required a lot of our attention. So with that, well, first of all, questions. And things are changing as we're doing our work. We're trying to prepare ourselves for different possibilities and what form or action they take will be unknown until we take next steps. But I think we should be prepared. We should prepare our amendments as best we can so that they're prepared to be used. So, I mean, just, I know no one knows yet. One of the possibilities would be that we would not be in the state house next week, right? That's a possibility. I have no idea what the decision would be. Yeah, I guess I just, it feels like from everything I've been reading, it seems like there's a lot of evidence that people in leadership roles being proactive about disbursing gatherings could be a really important thing. So I just think for whatever it's worth for me to say this here and someone to say it somewhere else, I'm going to say that. It's being said in lots of places in room 10, they're making that decision right now. Okay. And I don't think there's anything more we can do to influence what decisions get made. Understood. So with that, I'm going to turn it over to you, but Jen, would you begin to walk us through, and if there are a couple hard copies, if people need a hard copy? Yeah, that would be great. Could we go and just, just for our purposes to, Mike, let's start with you, and just go around very quickly who's in the room and their affiliation, so we know who we're working with. We invite different people to come, not all of them work. Mike Fisher, health care advocate. Wayne Fisher, org of media. Lauren Hibbert, director of the Office of Professional Regulation. Mr. James, department of Vermont Health Access. Sarah, teach out Blue Cross and Blue Shield of Vermont. Emily Brown, department of financial regulation. Greg Sepsundiva. Susan Krakowski, MVP. Stephanie Winters, Vermont Medical Society. Also representing the Nature Center. David Hurley, executive director of environmental practice. Director of hospitalization. Keith Gilman, professional regulation. Thank you, Lauren. Thank you. I don't know if somehow it's just me, but there seems to be extra background white noise this morning. So I will ask people in that into the room to speak up because it's very likely to hear someone. We have guests on the phone, right? Yes. Yes, thank you. Thanks for the reminder. I think Brian Cina, would you say you represent Brian Cina, our committee is on the phone, and Commissioner Swirl from the Department of Health. Thank you. Great. Jennifer Kirby, legislative counsel. So this is my attempt to put the ideas that you looked at on a list yesterday into draft language. And I don't think any of them are here, but a lot of the stakeholders who were talking to you yesterday were probably helpful to me in coming up with more detail for the language. And I didn't say if those very stakeholders are also meeting separately at another meeting, we could not join today, but we invited others for whom we were drafting, saying, does this work? So we're going to be looking for them, but this is what we'll look forward here. We'll be looking for them. Yes, and I do not have particular pride in ownership. I think there's a lot in here that could probably be improved upon by people who know more about the subject matter. I think we have around a lot in this, so I don't know if it would be better, Jen, than your perspective to walk through the emergency pieces once or stop at each one and talk to the respective groups who might be able to provide feedback. What would you like to do? I'm not sure. From a time management standpoint, I'm not sure what makes more sense. I mean, I think maybe to the extent that we can fix up each section as we go through it, that's great, although you are missing a lot of the... Right, so we'll come back to the one. We'll go PR and medical practice, and we'll watch the time. I think you might at least want you to get through it once. All right. So we start off with some legislative intent around the state of emergency, and you've heard from the stakeholder yesterday that we're here about some external things that kick in or some things that are not tied necessarily to the governor's emergency powers that kick in if the state of emergency is declared. And so this is an attempt to get at that, although I'm researching one of them I actually don't think it's applicable, so it's not in there. This would say it is the intent of the General Assembly that if the coronavirus disease 2019, which I then refer to as COVID-19, pandemic continues its expected spread in the state of Vermont. The government should exercise the authority granted by 20VSA Section 9 to declare a state of emergency based on the all hazards event of the COVID-19 disease-related emergency. That's just using some of the language from the emergency powers statute. In addition to the emergency powers granted to the governor by 20VSA Sections 9 and 11 during the state of emergency, such a declaration may initiate opportunities to expand access to necessary healthcare services. For example, 3VSA Section 129A10, which is in the Secretary of State Office of Professional Regulation statute, allows certain professional licensing boards to issue temporary licenses during a declared state of emergency to healthcare providers who are licensed in good standing in another state to allow them to practice in Vermont for up to 90 days. These temporary licenses will likely be necessary to help provide critical healthcare services to Vermonters who become afflicted with COVID-19. So the other piece of that that you had heard about was federal telehealth and that Medicare coverage kicks in if there's a state of emergency so that it waives the site and the rural locations requirements, geographical requirements. I looked into that last night and based on some recently enacted federal legislation, that seems that it should already be in effect. It's based on a federal declaration of emergency including declaration of public health emergency, which happened on January 31st. And it doesn't seem to have any connection to whether a state declares a state of emergency. So I did not put that in here both because it didn't seem applicable based on the state emergency declaration and also because it seems that it should already be in place. It seems like it was enacted specifically in part to address COVID-19. So it describes the emergency period as kind of being while we're having this emergency and for future emergencies. So do you want to stop there and seek necessary clarifications if there are any? I mean, mostly I'm thinking if there are any. I got that language wrong. You got it right. Okay. Great. Great. One, I got it at least one. All right. Next we have measures. So I kind of grouped these together somewhat the way the stakeholder document had I called this measures to support healthcare and human service provider sustainability. One thing I should say up at the very top of the document it says House Healthcare Committee, parentheses and House Human Services proposals regarding COVID-19. House Human Services, some of the members of the committee provided some input while I was next door working with the stakeholders that has been included in here. I think they're also working on other language. I'm not sure how this is all going to roll out. I just sent it while we were sitting here on the chair and committee assistant there in case they want to take a look since their name is on it. But so you'll see there is some human service provider also given the sort of blurred lines between what is healthcare, what is services. So all of that said, measures to support healthcare and human service provider sustainability. The first one is some temporary provider tax waiver authority for the secretary of human services. This would authorize the secretary to waive payment of the assessment imposed by 33 BSA chapter 19, sub chapter 2, what we call the provider tax. For one or more classes of healthcare providers for all or a prorated portion of fiscal year 2021, I'm not sure if that's the direction you want. There's a couple of different pieces in there, but as far as timing goes, it seems like they get imposed at potentially different times by depending on provider class. And while I wasn't sure you would want to go back and the stakeholders were not interested in you going back and recouping anything from during the emergency period, I put the prorated language in there so it didn't necessarily cut off that source of funding for all of FY 2021 if that was not necessary. So that's why language reads the way it does. So the provider tax can be waived if the following two conditions are met. First, the governor has declared a state of emergency as a result of COVID-19 and you'll see that language repeated a lot in here. That was my effort to get at this temporary authority and have it linked to something. So it would automatically go away at the end of the state of emergency. So if the governor has declared a state of emergency as a result of COVID-19 and the waiver is necessary to preserve the ability of the providers to continue offering necessary healthcare services. How much annually is the provider tax? Let me show you. I'm looking at either no one or no one. It's like a hundred, something million. Hospitals are lower. It's significant. It's between one and two hundred million. What is it? Do you know, Nolan, that it's a percent of... It's an e-group. Six or seven provider classes and they all are assessed at different rates and some are like nursing homes by being per bed. Pharmacy is prescription claim. It's prescription where hospitals are 6% in patient revenue. Yeah, 6% in patient revenue. So they're all different. Hospitals are just... I have any misinformation I can give to you. No, that's fine. Just the ballpark is helpful. Thank you. Great. Anything more on this? So I do have a clarified comment and a suggestive number on health access. So under section two, we're listening to the Secretary of Human Services. When we break out the separate assessments, it always lists the Commissioner, the Department of Homeland Health access. And so I just want to make sure that we're not going to run into any issues that may exist. Okay, that's fine. I'm going to change that. We'll check it. Okay. I will plan to change it unless I hear anyone else. I'm sorry. Mike Fisher. I believe the provider tax represents that quarter of Medicaid funding given that I wonder if we want to give the right person the authority to waive or postpone. Waiver postpone. Make the terminology waive or postpone. The collection of those money. Get them the authority to do it either. Okay. I mean, that makes sense. Flexibility, yeah. Can I clarify something? I'm interpreting this and just to clarify, would it be correct to interpret this that they could say it's waived for nursing homes, but nobody else, like the one or more. Yes, that's what I was doing with classes. There are requirements in the federal law about provider taxes being applied uniformly across a class. And so I was concerned about allowing them to pick among providers. It's an interpretation of necessary to preserve the ability that without the cash flow they would have to shut down and cease operations. I think that gives some discretion to the commissioner to decide. I mean, it may be that their ability to continue long term would be threatened. It may be that their ability that they would shut down short term. And I think it's looking at if that is affecting their cash flow needed to respond to this crisis or to keep the hospital or nursing home or whatever open in the future, that would be sufficient for the authority. Does it also make sense to get the commissioner authority to maybe change the rate because if we don't let provider tax at all, then we might have a cash flow issue for ourselves. Okay, so what about wait, modify or postpone? There you are. Sounds very easy. I don't know how easy that is. I'm just thinking the more I'm not saying anything about his comment whether it would provide flexibility or not. But a lot of the this is one of the ones that the legislature would need to give us authority on. There's a few others I think that we saw were not. So we do need to build intent and flexibility, just not knowing exactly the expectation of how easy it can be. I'm going to say out loud what I said to Ian a few minutes ago the ways I mean it's not easy. We'll have one, two way end on this because they the revenue, there's serious concerns about revenues for the state as well. So there's going to, I don't know exactly how that works but they will have a word on this. Okay. I'm sure you did. I'm okay. I'm thinking about how for the current fiscal year or the current provider tax year, I would say it this way that part of the issue is your taxes generally relate to your revenues but we set them and then they have to pay them and if the revenues are off but the provider tax level has been set. So how long until the next for it's kind of that current situation and if we do the calculations going forward that's a different story than meeting the obligations that are set for them today if their revenue changes. So that gets all your fun work if we've given the authority for you to waive, adjust or defer. Should it be for FY20 and FY20? That's what I'm getting at. I mean I'm getting at and you mentioned that there's different timelines for the different some I'm not clear on. Yeah I did the statutes last night and it seemed like that there's a schedule for years and no months as opposed to like one day for hospital ones. Some are quarterly some are lesbians. You put that in and it's going to go to WACP. I'm going to do at the chairs meeting trying to alert from the ban song that this is a piece of one thing we're looking at and that's the people with expertise around this in ways that means are going to need to help crap if we move forward. Right. So I'm making some changes to this one just to recap to make it diva to make it wave modify or postpone and to apply it for FY20 and FY20. Next is agency of human services provider payment flexibility and I did make a lot of these agency of human services thinking of them as kind of the umbrella agency but if that is not if we need to make it a department within there we can make that change. So this would say not withstanding any provision of law to the contrary during the declared state of emergency in Vermont as a result of COVID-19 the agency of human services may provide payments to providers of health care services long term care services and supports home and community based services and child care services and the absence of claims or utilization if a provider's patients or clients are not seeking services due to the COVID-19 pandemic even if federal matching funds that would otherwise are not available in order to sustain these providers and enable them to continue providing services both during and after the outbreak of COVID-19 in Vermont. So this is this idea of paying them in ways that they wouldn't otherwise get paid in order to keep the doors open and have them exist to serve people when this is over. It is a May. And it's a May so it doesn't sound right but it gives authority. Right. Okay. This is Commissioner Squirrel. Can I make a comment? Yes, please. Please let me know if you can't hear me. We can hear you. I just wanted to note just for the committee's understanding that the Department of Mental Health currently through payment reform has a case rate for all the designated community mental health agencies. So what that means is that they are paid a prospective payment on a monthly basis and that reconciliation for that at the end of the year. So I guess my point is that this model makes CMA truly well poised to adjust for substantial decreases in services and utilization across the state already. We can also adjust our valuation model at the end as well to adjust for that which would mitigate the impacts of decreased utilization due to COVID-19. So I just wanted to make sure that committee members were aware of that. Thank you. That fits for me. Yes. Okay. All right. The next and I is my understanding there's more language coming. Some had been provided early this morning but stakeholders are still working on it. This is the idea of Diva providing allowing Diva to provide cash advances to Medicaid participating providers. There's some reference to rules about expected claims payments. Well, I had so this is really just a placeholder that's why there's a question mark. Okay. We'll come out with the heart. And if it makes sense to Diva and you want to help find a way to deal with that. I mean, the only comment is that would definitely not be Medicaid match dollars would be state-only dollars. Again, I don't know that we need legislative authority to do it but we could not it's more of a CMS conversation and it speaks to a point that should be made is a lot of this will be colored by what the federal government does in terms of assisting. I would just say there are times in here where I'm going to suggest that we might put language in even if it doesn't not appear that it's necessary because it begins to reflect our intent of hopefully that's being reviewed as a possibility. All right. Section 5 again may need more again a little bit of information last night but maybe not enough. This is on FQHCs and rural health centers and the Medicaid encounter rate. So again during the declared state of emergency in Vermont as a result of COVID-19 Diva shall reimburse FQHCs and rural health centers using the alternative payment flexibility Medicaid encounter rate instead of the standard perspective payment system Medicaid encounter rate. That's possible. Can I? What? What is a rural health center? Rural health centers I am not familiar with. It's a different federal designation and beyond that I'm going to it's I guess I'll specifically like in my county most of like many of the It's not just describing a health center that's in a rural area it is a specific federal Right. So I'm wondering about like many of our rural counties depend on independent positions for their rural services. Does this do anything for them? I don't believe they have an encounter rate. That's a sort of an FQHC and rural health center term of art in the So if they were to need different Medicaid reimbursement in parallel to FQHCs what would we need to do to I don't know if you do it in parallel to FQHCs this is kind of specific in the sense that the obligation to the rural health not rural FQHCs there is with that designation comes a guarantee of a certain coverage of their expenditures our current methodology falls in line with that if their encounters rob then we would in all likelihood they would have a fiscal situation on their hands and we could find a way to adjust those rates to match what our obligation to meet their expenses are so that's what I mean by it's possible in that case I guess I would I don't know how many we're talking about and I don't know our rates right now are at the Medicare levels and I think we'd be open to looking at rates is how I would say basically our entire provider community this FQHC one is kind of specific I was just going to say I received I received after this work I've done last night a request from David Mickenburg on behalf of independent practices suggesting that because of the possible cash flow pressures on them that we might consider including that Blue Cross as an example Blue Cross was shielded to temporarily hold any recovery that are occurring in the process right now but not to not to end them but to temporarily well I'm just saying what I've received and so I'm going to just suggest that there's there's someone who has been advocating on behalf of independent physicians and made a suggestion it's not incorporated into this yet but we can review that and have the right people understand what it is because I'm not sure I'm representing it actually but I will forward this to Lisa in court um yeah and Jen and Sarah and I'm sorry it sounds of course yeah that's why I was doing you were Lisa Blue Cross and you were me and I oh full heck oh yeah right I will forward this to everybody heard I will see so if you need anything to change on that one yeah no I think again that might be one that we don't need actually alright so then we get into group sections called compliance flexibility so the first of these deals with healthcare and human service provider regulation and allowing waivers and variances so notwithstanding any provision of the agency of human services administrative rules or standards to the contrary during declared state of emergency in Vermont as a result of COVID-19 the secretary of human services may waive or permit variances from the following state rules and standards governing providers of healthcare services and human services as necessary to prioritize and maximize direct patient care and to allow for continuation of operations with a reduced workforce and with flexible staffing arrangements that are responsive to evolving needs and regulations waived or vary from would be the hospital licensing rule hospital reporting rule nursing home licensing and operating rule home health agency designation and operation regulations residential care home licensing regulations assisted living residents licensing regulations home for the terminally ill licensing regulations standards for adult other rules and standards for which the agency is the adopting authority under the administrative procedures act to the extent such waivers or variances are permitted under federal law that's David any initial comments I think that would be fine I don't see from the board of medical practice I don't see real impacts but on the hospital licensing potentially it could be because federal standards into our hospital licensing rule and so there may be situations there's as you know huge volumes of rules out there that may come out in place that would be okay Lauren this is fine I don't have much to think I think this is largely on facilities so it may be something that somebody wants to let Dale know about just one quick comment this is Sarah I think it was captured in the end I'm sorry I'm having a little trouble hearing that Vermont can't override federal law so as long as there's understanding and language that still would have to be in compliance with federal law CMS and joint commission I have one question and this might be just because it's under the agency services provider payment flexibility to child care services do would agency of human services also be the responsible party for licensing child care services yes I think DCF would be under them I think that would be important to add so let me find out what those are and I think in response to the commissioner's statement I think it wouldn't hurt the waivers are permitted under federal law and then I can just take it out of the hand so maybe I'll just move it actually and I think when we get to it I was sending things didn't know what was already underway it's possible that the peace on hospital licensing in conjunction with recognizing we can't override CMS will actually cover for the mental health issues later what made the comment yesterday about and I just want to make sure that this covers it which I think it does if you had brought up someone who's not quite out of school like third or fourth year it's called it sounds like this would cover that by so this is really looking at I mean I guess it gives additional flexibility at the end although it would only be for rules and standards for which the adopting authority so OPR would be outside of that scope to me this is looking more at facility rules around staffing and you know administrative responsibilities that take away from direct patient care and things like that so I think if you want to do something but when I was working with the state for the group they weren't quite sure how to put that into place especially given that it sounds like things not put them in but we can look at that in the context of some of the section on retirees I have a point though we did discuss yesterday of relaxation of license rules for those that are retired that's coming up stay tuned stay tuned two more sections alright so this next one is Medicaid and health insurer provider credentialing during a declared state of emergency Diva oops I should have a capital A there Diva shall relax provider credentialing requirements for the Medicaid program and DFR shall direct health insurers to relax provider credentialing requirements for health insurance plans in order to allow for individual health care providers to deliver services across health care settings as needed to respond to remunters evolving our needs so this was supposed to the idea from the providers to allow somebody to move to lots of different settings to provide the services that are qualified to provide without getting stuck in a waiting period for credentialing from the payers so I don't know if there's any comments sorry yes so this is James department of her mental health access so I think there are a couple of components here that we need to consider so this language may look a little different than what we talked about earlier management system currently we are set up to if necessary enroll providers within 24 hours I think when we use the word shall relax provider credentialing as a phrase we get into concerns around patient safety and whether or not our enrolling providers would then make CMS requirements and so I think to commissioner squirrel's point earlier several of these sections to add in that language around CMS the extent permitted under federal law exactly we'll be saying the same thing okay well then we'll just put that in the lead-in yes that would be great Emily Brown to get far we don't have any issue with this language alright so alright so I'll add that to the lead-in so say during the declared safe emergency to the extent permitted under federal law perfect next we have the retired healthcare providers for medical practice and OPR again during a state of emergency in Vermont as a result of COVID-19 the Board of Medical Practice and the Office of Professional Regulation may permit former healthcare professionals who retired within the past 10 years 10 years does a place to start if you can make changes to that who retired within the past 10 years with their the Board of Medical Practice and the Office of Professional Regulation may issue temporary licenses to the former licensees and may impose limitations on the scope of practice of returning healthcare professionals as the Board or Office deems appropriate silence is in for well it's important not to see some shaking yes just we have some providers that might be involved if it gets and not licenses so license or certificate I would mind adding registration as well yep license certificate or registration just a question I mean it doesn't say anything about money yes the intent that this is free within that would just be that we have the authority to wave and we could set by emergency rule and just make it for volunteers or maybe some other certain classes I don't know maybe you and I should talk I don't I don't know how many people are going to take us up on this so I'm not worried about the cost of operations I think we should just be free personally thank you okay and you're going to potentially put in just take out the reference to former licensees because it's complicated to say the rest of it again I will say may issue temporary licensees to these individuals at no charge and then you can let me know if that changes after you okay section nine this is one of the ones that representative Dunning had asked to put in and that may need either revisions or may be unnecessary depending on input of others so this is involuntary procedures documentation and reporting requirements waver permitted notwithstanding any provision of law to the contrary during the declared state of emergency in Vermont as a result of COVID-19 the court or the Department of Mental Health may waive the documentation and reporting requirements related to involuntary treatment pursuant to 18 BSA chapter 181 so Sarah be great to hear I wasn't sure because we were being responsive but you know Jen was also already working on other pieces whether this is already covered under the you know hospital as long as it still meets CMS and all that and other than designation I don't know that you actually have penalties this was a concern obviously of inpatient providers because of the many specific things they need to do and should do for documentation around for instance involuntary medication orders there's a lengthy requirement about weekly reviews and if they have no staff and they're authority to waive some of that but it may be covered under what we've already been discussing where you might not be the right one to waive it so if you could just weigh in on that yeah this is commissioner squirrel I think that it will certainly help with the EIP rule and and we certainly agree with the language as presented as I noted before we can't override federal law with CMS and joint commission we have gotten some guidance related to licensing and protection related to how hospitals can manage this from a documentation standpoint so we do have some initial guidance from CMS but I do think this would help with the EIP rule and the other thing that I would just know I did have a question about what the difference between isolation that's a that's a later piece we're just looking on the document section nine yeah section nine that's in section 14 sorry it's okay okay so can I ask commissioner do you think it's necessary to add to the extent permitting under federal law or you just wouldn't try to waive something you weren't allowed to waive under federal law well we wouldn't try to waive it so next group of sections is what I called access to healthcare services and human services section 10 health insurance plans Medicaid COVID-19 treatment cost sharing prohibited and some holding up as used in this section I used actually the same health insurance plan definition you have in your telehealth bill so that's any health insurance policy or health Sorry, so I don't want that one because we're going to talk specifically about Medicaid in one piece. I don't think it applies. I don't think the first two apply to Medicaid, although we'll take a look maybe next. And does not include limited benefit coverage. So during a declared state of emergency in Vermont as a result of COVID-19, first health insurance plans shall not impose any co-payment, co-insurance deductible, or other cost-sharing requirement for health care services directly related to COVID-19 treatment or prevention. So this is broader than just the testing. I was just going to put treatment, but to the extent there becomes available any sort of preventive measures that seemed appropriate as well. The second would require, and this is one of Jeff Hochberg's recommendations, require health insurance plans to suspend deductible requirements for all prescription drugs and shall impose only the applicable co-payment or co-insurance requirement under the plan. And then I did a carve out here, except to the extent that a deductible suspension would disqualify a high deductible plan for eligibility for a health savings account. So recognizing that you couldn't necessarily that it wouldn't make sense for some people to have that. And then third, health insurance plans. And this is where I added in Medicaid because I don't think the first two apply to Medicaid shall allow their members to refill prescriptions for chronic maintenance medications early to enable the members to maintain a 30-day supply of each prescribed maintenance medication at home. And it sounds like now there's 180 days. So maybe you want to expand that. But based on these two. This is my turn to pass that. We're not at 180 days. That's just across. So 30. And we've already just tell the early refill. We have that in place. So can I just ask that makes for, I didn't see one and two, the copay or deductible or anything applying to Medicaid. And I didn't see deductible requirements for prescriptions applying to Medicaid. So I only put Medicaid in number three. I could keep Medicaid. Dr. O'Neill, you're right. The copay, yes. We have one, two, and three other copays. Right. But this is for health care services directly related. And then the deductible is waived for the prescriptions. Yeah, so we just got word we're going to gavel in and gavel out and then go back at 10. So we can keep moving forward. You won't get to be there. Yeah. So for outpatient hospital services, we have that $3. Well, there is, okay. So what we have already put in place is confirming with CMS that we have broad approval to remove that. But I do think it would be applicable to us. And then I'm just going to leave the definition in the beginning that includes a health insurance plan that includes Medicaid in it. And then have it all. And then the deductible part just doesn't look applicable. I think we should have the word diagnosis in there as well. Oh, treatment. Diagnosis treatment and prevention. Good catch. Does that cover the testing? So testing is already happening. But yes, it's already happening. But I think, I mean, I think, yes, to the extent anybody who's covered under this wasn't already doing that, yes, diagnosis would be rather as well if there was more involved. So I think that's all there is. Hopefully it would also cover flu testing as an aspect of ruling out COVID. Sarah. So Sarah, teach out with Blue Cross. We do support emergency measures in the state of Vermont. We would prefer to give the Department of Financial Regulation broad authority to do whatever emergency measures they feel are necessary and not try to put it all in statute now, recognizing that it's a quickly evolving situation and that we would like them to be able to respond with a lot of free sort of ability and not do everything in statute. I can talk about what Blue Cross has done already and what everything that we have done so far applies across every one of our covered lives and we would prefer to be able to do things that way because we feel that it's better for the population as a whole. Is he a lot of shaking heads in that corner? So is he shaking? Not, yes, I'm sorry. Brian, we'll get to you in a moment. Emily Brown, DFR, we agree with Blue Cross's position in giving DFR broad regulatory authority and as well that will enable us to react to what's happening at the federal level as well as the state level. And like Sarah said, have the flexibility to react quickly rather than be constrained by something that was put in statute. So what I was going to say was that, Brian, we'll just let them, I just want to make sure I'm keeping it in. Yeah, and then we'll come back to this side. MPP agrees. I agree. I think I agree with the strong legislative intent to diminish or eliminate any financial barriers to care. Yeah. All right, sorry. So is there an objection to adding the word diagnosis in there? And so if I could speak for them, I think only in the sense that they would prefer you took a different approach to doing this and gave authority to DFR in these areas as far as what insurance plans should be doing. Like we did a day with the telehealth. Exactly, right. So would that mean also taking out treatment or prevention? I think it would be taking out the specifics. Yes, I think you could add those general guidelines, but then not be so prescriptive as to say, you know, what kind of cost share or what kind of solutions. So I would feel more comfortable to have language in there that included those, but completely agree that it be worded in a way that it'll give you the flexibility. Can you guys think about what that language might look like? I'm sorry, what do you go ahead and do? Well, I'm just thinking about this teacher's comment. Couldn't we eliminate this piece of legislation and just have one final item that there's just one paragraph that gives broad authority to all the agencies that... So I would say yes and no to the extent that you are delegating your legislative authority. You need to do so in a reasonably narrow way. It gives direction to... But it would be just for a set of time during this crisis. So I think there's a way to get... I think this proposal is potentially a way to have more of a middle ground on that with some direction and some parameters, but more flexibility to be responsive. Brian, I think you were trying to speak. I have a question. And I think you're addressing it, but I still want to make this question statement whatever it is. When I read that language, it's found it's really focused like if a person has medical issues, they go in and it's determined that it's COVID-19, things would be covered. But I think my concern would be if you have a respiratory illness right now, you might be afraid to go to the doctor because if it's not COVID-19, you're gonna be slammed with lots of bills, especially if you're not working, the person's not working, it might be like they don't have food at all, et cetera. So my concern was around like, let me turn the language, be broad enough that people go, get checked out. And if it's determined they don't have COVID-19, it should be considered a good thing, but I don't think they should make it slammed with a medical bill because they don't have the disease for going to the doctor either. Does that make sense? So I don't know if there's a question. So I think the diagnosis language helps. And I think I'm now turning to DFR to see if that's the kind of thing that they would consider if we directed more broadly to have you do limitations on cost sharing around diagnosis if you would consider a diagnosis of exclusion to be still a diagnosis. Yeah, so Emily Brown, DFR. So we, DFR just issued a bulletin around testing and which provides the testing at no cost share. So that would include if you went in and you had the test and you weren't positive, it would still be covered at no cost share. What if you went in to see if you needed to have the test and they determined you didn't need to have the test? So I believe how, and I don't want to speak to the provider community and how they're handling it, but I believe a lot of providers are encouraging people to call and then talk to their provider about whether they need a test or not. And I believe in the tele, the telemedicine language which will pass include its audio and I want to make sure I'm speaking correctly with that. Yes, I'm scrolling to this bill as well so we can just look at it here. Which would then allow, I believe, the providers to count that as a telehealth visit. So there's the, during a declared state of, oh no, that's the different, that's not okay, right. So the language that we gave, one piece was may require a plan to reimburse for services delivered by store and forward. Right, so then the whole bill is in piece. The audio piece I think actually is in here. Commissioner may require health insurance plan to provide coverage and reimbursement for things delivered by audio only, telephone, email or fax to the same extent as coverage for telemedicine not to exclude 180 days. Right. Are there people who want to get tested even if they feel good? Or- I think that's up to the providers. So my, as I see it, there's such a shortage of testing, tests available that my understanding the providers are being pretty conservative in which, yeah, screening people before using a test. I actually had a question about the phone call piece which is, and I'm sorry if it was said already, would this create the potential that someone would then have a co-pay for their phone call to their provider? Yes, because you allow a co-pay for telemedicine. And is that something, I would feel concerned about. But not if it was in the context of COVID-19. COVID-19. Because we're already doing the work. Because that's already, right. Okay. So someone would not potentially not call their provider. And so I want to get Emily and on this to, if you want to repeat your question. Okay, sorry. Yeah, no, I guess I just, I want to, I'm struggling with the language and I just want to make sure that we aren't potentially creating a situation where because providers could now get reimbursed for phone calls, then the patient would have a co-pay for a phone call and would be disincentivized from calling their provider. That's a good question. And I think I deferred to the providers and the healthcare, the health insurers on this. I mean, currently I think a lot of times you can just call your provider and it doesn't count as a visit. So that's a good point that I like. Right, so if it now counts as a visit. That may trigger that response. Sarah, teach out with Blue Cross, so under current. Policy, yes it would. We are changing our policies rapidly. And you should all be aware that there is a weekly meeting that's happening at least weekly or more quickly with DFR and all of the insurers to discuss potential changes to our policies going forward. Let's, let's on this issue, because we got to get through this. Let's, you have our intent. So if you can come together and craft some language and get with Jen, that would be great. I mean, Lucy's concerns in mind, which are concerns, does that work? Well, if I could just interrupt, just to say I think it's already been shared that the Florida Post comes until 10 when the request is for everyone to be on the floor at 10. There will be further, the Joint Rules Committee, but what is public at this point the Joint Rules Committee will be, we will be adjourning at the end of the day today until March 24th. So, but we are asked to continue our work because some of what we're doing may need to in fact be incorporated into actions we take on the floor today. It's a fluid situation. And so some of, many of us are recommending the calendar be clear to things that do not require a response. Because we have a full calendar and that the program and the speaker meeting with the governor as we speak, and that the issue of crossover, crossover is being shifted. We don't have the specifics on that, but we're not going to be under the pressure of crossover for today. So, which is a great concern. I'm sorry, Jen's music's down. So I think they said leave me until midnight tonight. Yeah, no, but I think there may be other announcements, but I think how we proceed through the day, all members are requested to be present through the day. We will need a quorum, we will need to be taking actions in committees and on the floor. So this is not a please go home now to members. It's in fact asking members to stay. Potentially, please, so please leave me. We don't know, we don't know. We don't know, it's an evolving situation, but know that we will, the decision has been made to adjourn until March 24th without committees meeting in the intro, with the possibility that that could be extended, but that's what the decision is at this point. So with that, I think we should continue our work, but we should stop at five o'clock so that we can be on the floor, so that we're not missing any further announcements. Mike. A little bit of higher level statement. This bill, this draft does a great job of protecting people from Medicaid and commercial, but I don't see anything for uninsured. Should we delegate that to someone to work on that? Well, I think so DFR does not have authority to do that, but I'm sure we do not. You have an authority over uninsured, we do. Yeah, I mean you would have to, right, yes, you'd have to either have the providers do it at no charge or have the state pay the providers for doing that. So let me say one other thing that there are, there's also actions being taken at the federal level around possible sick leave and et cetera. I mean, this is not directly addressing this, but I understand that there is a series of actions that haven't taken by administratively within departments, we're all working hard. At the same time, there may be some proposals coming out of, from the administration that address some of our concerns. We should continue to move our proposals forward so that in the event that I was brought to my attention that emergency management had put out a long email which I frankly did not see. It came from our police department which I do not read everything our police department sends because it's often about weather. I would need to read that. But I think at this point when they send something we should at least see what's there and apparently it's that he is the point of contact for emergency management, which is important for us now, no, and there's a long list of actions that have already been taken, some of which may have some influence here. I have not changed my view on it. Okay, so let's keep the uninsured up here, but let's make sure we get through this in the next 10 minutes, because we'll be coming back. Yeah. Section 11 is on pharmacists and clinical pharmacy and allows for the extension of a prescription for maintenance medication. I took just a little tiny slice of the OPR bill around pharmacists prescribing. It didn't take most of it because almost most of it wasn't relevant here, but this would allow during this declared state of emergency in Vermont as a result of COVID-19, a pharmacist to extend a previous prescription for a maintenance medication for which the patient has no refills remaining or for which the authorization for refills has recently expired if it is not feasible to obtain a new prescription or refill authorization from the prescriber. A pharmacist to extend the prescription for maintenance medication pursuant to this section must take all reasonable measures to notify the prescriber of the prescription extension in a timely manner. As used in this section, maintenance medication meets prescription drug taken on a regular basis over an extended period of time to treat a chronic or long-term condition. The term does not include a regulated drug, which is controlled substances. So I look to you. Oh, you are. This looks good. Thank you. Great. Section 12, this is something from the Human Services Committee, older Vermonters nutrition services expanded capacity. Again, during a declared state of emergency as it was in Vermont as a result of COVID-19, the Agency of Human Services and Consultations for Area Agencies on Aging shall expand the state's capacity to provide nutrition services to those individuals who are eligible for nutrition services under the Older Americans Act and who have critical health issues. And the concern here is about people who may come for congregate meals and are no longer able to either, they're not happening or the person is concerned because of their health issues about traveling outside of their house and making sure that they would then get home delivered meals. That's my understanding of the intent. And we'll talk to services about this and we just had a request. So if you're not right at the table and are speaking, if you could just speak up because people on the phone are having a hard time to hear if that would be a great thing. Section 13, I don't know if it need more language in just this long-term care facilities and programs, bed hold days and during a declared state of emergency in Vermont as a result of COVID-19, the Agency of Human Services shall reimburse long-term care facilities and programs for bed hold days. This is based on the requirement that the facility hold a bed, not put somebody else in it while a patient or resident is in the hospital. And this would allow them to get paid for that. I'm starting to get my people in there. I just want to throw out a comment on the last one not to address it right now. I think it probably is being addressed elsewhere but we should also be thinking of the children as well as older Vermonters if the school's closed. So, Jen, I don't know if you want to put something in but then we can also check with education if they're doing anything. Yeah, check with education and human services. And I know that the state is looking at that. All right, then we have a new standalone section on quarantine and actually we should probably put this way as a quarantine isolation for COVID-19 as exception to seclusion. So this would say notwithstanding any provision of statute or rule to the contrary, it shall not be considered the involuntary procedure of seclusion for an involuntary patient in a custody of the commissioner of mental health to be placed in quarantine if the patient has been exposed to COVID-19 or an isolation if the patient has tested positive for COVID-19. So in looking a little bit into quarantine stuff last night, quarantine appears to be what you do when somebody has been exposed to an infectious disease but has not shown symptoms of it or has not tested positive for it. Isolation is what you do to contain it when somebody has tested positive. Quick FYI, there's been an email circulating with Sarah, Disabilities Rights, Vermont Legal Aid. They get it, this is good. There's a phrase to add to the earlier part which we can do offline that it's all needs work to do. Certainly if there are others who know more about infectious disease terminology and that is not right, let me know. I was looking on the CDC's website late at night. All right, then we get into mostly stuff you have done except a few things you haven't. I don't think we're gonna continue. So telehealth is in here. Yes, there are additional, there's an additional piece in telehealth. Let's go over that one and that's what we have the other bills for what just jumped to. So this has your age to 723 that you recently passed versus goes on for several sections but then section 20 would be new. It's telephone, I put it in under telehealth that people don't want that we don't have to put it there. To the bottom of page 12, top of page 13, this is Diva Medicaid healthcare services delivered by telephone. During a declared state of emergency in Vermont as a result of COVID-19, the Department of Vermont Health Access shall reimburse Medicaid participating providers for health care services delivered to Medicaid beneficiaries by telephone including mental health services and including other services delivered by providers who may not previously have been included in the department's telephone reimbursement policies as long as the services provided are clinically appropriate for delivery by telephone. I know this was in part to deal specifically with the concern about video being required for mental health visits but it sounded like there were also concerns about other providers who are not currently included in Diva's coverage of telephone services but who may need it during this time. Good to say AHS instead of IVA because some of the people who are in the DMA share that much with me. Yeah, thank you. This is Sarah Squirrel, the Commissioner on Mental Health. I think the caveat around mental health covers us but for emergency evaluations and warrants we will be allowing emergency screeners to utilize telehealth but those assessments cannot be done just via telephone. So just to clarify that but I think that's fully covered in the language. Can I ask, is that a legal requirement or a clinical appropriateness requirement? I'm just wondering if we need to say legally, clinically and legally or something or if you think that's covered in clinically. I think it's covered, I think we should say clinically and legally. I just think they're moving so quickly. I just wanna make sure that for those individuals who are at the point of maybe having going involuntarily into the care and custody of the commissioner that we still have appropriate measures in place to ensure that they're assessed appropriately. We can legally, okay, we'll look at whether that makes any impact or not and I'm thinking maybe it isn't, anyway. From the field, I'll make sure you speak up on that. Julie Chaston from Care Partners. The feedback I'm getting from the field is there may be an extended waiting circumstances where you can have eyes on observation or you've earned the availability of the video. So we did want the opportunity to be able to use a direct phone line and extended waiting circumstances never as a first preference. We always would rather be able to have some eyes on, but we're concerned and we have very few staff on our crisis teams. They're not deep, so if we lose a few due to the virus for whatever reason, then we're gonna be doing mutual aid for each other too. So are you just speaking in support of the language generally or in response to the commissioner's statement about the screening? The language, for us, gives us the flexibility of receiving the commissioner's concern. I get her concern, but my providers are saying we may not be able to always meet that, and so we would like that flexibility because we're very concerned about our staff's ability at this point in just having staff to do this and do the level that we prefer. Right. And again, if this is on specific authorization of the commissioner of DMH, in other words, we're not saying right now you can just start doing it that way, but that the commissioner has the authority to waive that, then the commissioner feels it shouldn't be. Yeah, that would give us the opportunity to keep this dialogue going, and that's what it would be about. It does require, so it says, H.S. shall reimburse the providers for services delivered by telephone as long as the services are provided are clinically appropriate for delivery by telephone. Do you think that is sufficient flexibility to say these rights, okay. I'm not sure they'll legally part, frankly, hopes so, because I don't think, I think the issue is the clinical appropriateness for involuntary. Right, which fits. Right. So DMH still controls that. So DMH still has that. Yep. Okay. And David, China. Yeah, I don't want to, I'm sorry to interrupt, but one really important request on licensing that hasn't been come up yet, we don't, the provision about emergency licenses that's in section one that OPR has, we don't have that, and I'd like to ask the committee to consider allowing me and Jen to talk about adapting that to the board. About putting a similar career, you actually looked at the board's stuff last night. Yes. Okay. Please do. Please. Can I just add something as well? A lot of times it says the board shall issue the emergency license, and I just want to make sure that David or I have the authority to issue that license that we don't have to convene a quorum because we're already dealing with quorum or it is only money. So that may be a separate provision, but any, yeah, that's the board's health issue, I want to make it really clear. Yes, let's connect because I think it would be good to do sort of a blanket whenever it says forward, it may be, it's for this purpose, it may be the director. Okay. Right, so I would just, thank you everyone.