SmartTranscript of House Appropriations - 2025-01-16 - 9:50AM

[Chair ]: Good morning. This is the House Appropriations Committee on, Thursday, January sixteenth twenty twenty five with a continuation of budget adjustment testimony. And we have joining us now the Department of Vermont Health Access, also known as DIVA. And we have D'Shawn Groves, who's the commissioner. Welcome. And Stephanie Barrett, chief financial officer. So welcome, both of you. We have a bunch of new members and we have a guest from the health care committee here. So we'll introduce ourselves and then you can introduce yourselves and tell us all about your budget. [Dave Acaboni ]: Dave, let's start with you again. Dave Acaboni, the representative for Memorial, Washington. I live in North Shore. [John Kosasco ]: Good morning. Welcome. John Kosasco from Essex County Home Industry, and I'm from the town of Burke. McNagro representing Bennington and Powell. Tom Stevens from Law Waterbury representing Washington Chippenden. Jim Harrison Chippenden, Benden, Hill, McNeese, and Hipsfield. Welcome. [Chair ]: Robin Shai from Middlebury. This woman from Burlington. [John Kosasco ]: Barbara Swirl, Underhill of Jericho. Daniel Ranche from Isaiah Franklin, Berkshire, and Richard. Good morning. Mike Rohitke, and I represent the Wyndham Ford District. [Lynn Dickinson ]: Lynn Dickinson. I represent Saint Holt's Town. [Chair ]: And we have a member of the health care committee here. Woody, you'd like to introduce yourself? Yes. [Dave Acaboni ]: We've reached five and four. [Chair ]: Yeah. So that's us. And introduce yourselves for the record, and Yes. We look forward to hearing from you. [Deshaun Rose ]: Good morning. I am Deshaun Rose, the head commissioner for Department of Vermont Health Access. [Stephanie Barrett ]: And I'm Stephanie Barrett, the the financial director for DEVA. [Chair ]: So what [Stephanie Barrett ]: is the committee's pleasure? Would you like to go through the narrative document and just and, you know, switch to the to the ups and downs, or would you like to go line by line through the ups down sheet? Do you have a preference? [Chair ]: Well, we we have an hour. David, this one's yours, isn't it? [Dave Acaboni ]: Yes. [Chair ]: Okay. So I I think we, we have new people who aren't familiar. We don't need to go too we can keep it fairly high level, but, then I know the big questions. So we'll start [Stephanie Barrett ]: with the narrative. Okay. Great. And go from there. Yes. Thanks. So, the the first section in our in our in our budget world is our administrative budget. And out of our total one point two five billion dollar budget, the administrative budget is just under a hundred and eighty million dollars. And so out of the administrative budget, we pay for all the staffing costs, contract costs, operating costs, and there are small amount of grants mostly related to blueprint that that flow out of our administrative budget. And just to give you a little context, our administrative budget was very tight, a little bit underwater closing last year. So you'll see adjustments that are due to, you know, catching up in terms of actual to budget mostly, and then basically ministerial catching up in the administrative budget. So in the staffing part, which is in your you you know, in the budget bill, the personal service line of the appropriation section, That is the staffing and the DIVA held contracts are what are included in that section of the line item in your budget. And our total up there is one point seven six million dollars, all funds. Of that, nine hundred and sixty four thousand dollars and some change is GF. There is a need in our staffing budget to hire temps to help us finish, the backlog we have for some of the redeterminations for our mostly our, what's called our MA, MABD, our our age of blind and disabled population. These are the more manual, redeterminations. And so that's the first piece that's contributing to that ask for an up in our staffing budget. We have what is a up in our in our admin budget, but it is a gross neutral move because it's coming out of another part of our budget. We have a a line of funding of five hundred and forty seven thousand dollars that goes to Vermont Legal Aid that had been carried for years in our program budget. Under new guidance, we need to move that into our admin budget. So it is it is an up in our admin budget, but you'll see it also as a down when we get into our program budget. Mhmm. And then we have several adjustments to DIVA held contracts that total eight hundred and eighty four thousand dollars with five hundred and twenty four of that from our general fund. And I'm gonna stop there and see if there are specific questions that you want to go through. [John Kosasco ]: Simmons? Just to be clear, Vermont Legal Aid funding is for the ombudsman's office and more, or is it just the general appropriation to them? [Stephanie Barrett ]: I believe this is for the health care advocate. [John Kosasco ]: Yeah. Yeah. But yeah. And, [Chair ]: what are the so that's a lot of money for contract funding adjustments. I wonder if you have a [Stephanie Barrett ]: Yeah. It's we can this is where we we twitch to the ups and downs. Alright. [Chair ]: And so contracts for, I guess, on [Stephanie Barrett ]: kind of this. So the there is one line item. The the line item that's DEVA contracts net funding change for Medicaid advantage planning documents. And that is when you go across that line item, if you're in the ups and downs, it's the second line down in our admin budget. You can see that that nets to zero, but it has an increase in our general fund. And that is internally us, maximizing federal match dollars and putting, functions that should be in a purely Medicaid APD into that position. And so while it's an up in our general fund, it's a down. You can see from the internal the interdepartmental transfers, that means it's saving another mostly the central office money. And then it's an up in federal funds, and that nets to zero. That's one that's one piece of the contract changes. Yeah. The second piece is an amendment to our MMIS system main contract, our MNO contract, and that totals three hundred and thirty one thousand dollars. So I don't know what the wait. That's for the oh, no. I'm sorry. I read the wrong line. That I'm read the wrong line. It's yes. It's six hundred and eighty four thousand dollars. Most of [Chair ]: which is federal funds. Most of which is federal funds. Oh, Medicaid management information system. Okay. [Stephanie Barrett ]: And then the very last line, justice reentry, MMIS modifications, that's the third. And that line is in at a fifty fifty match, and that is an initiative that is underway. And so this that initiative requires modifications to our system, But it's not an implementation piece that has the higher matches the other one. [Dave Acaboni ]: Great. Thank you. Okay. [Stephanie Barrett ]: And then the other piece in our administration budget is, in our operating section or operating expenses. And, as you can see, it looks like a very large down in our budget, that is almost entirely on the it is entirely on the federal fund line. We, several years ago, had a one time appropriation where the the general fund is identified as one time, but the federal funds sort of got baked into our base. And so we took we took it down last year. We didn't take it down enough. We're taking it down again. So it's it's basically due to timing and and the sort of artifact of that that we had over appropriated in our federal fund line. And just to, you know, remind the committee, just because we have a federal fund appropriation, it doesn't mean that we can actually spend those federal funds. We have to actually earn those spending authority in our federal fund line, but, there will always be a difference between what is appropriated and what we actually you know, almost every done in the budget will be like that. But so I so we're bringing that line down by eight million dollars just to correct the the level of federal fund spending authority. So that's basically a technical adjustment. Then we have the same situation that I just described where these Medicaid only, advanced planning document for There are contracts that we pay for, but that are held by ADS. They're they're technical, you know, contracts with or technical service providers. And so there's a chunk of those expenses that we wanna make sure that we are maximizing the match on for the Medicaid only pieces of that work. And so you see that that also nets to zero, but it's an up in our general fund, a down in the transferred money. And the savings that this is this generates for all state funds, even though it's not doesn't generate a g f savings for DEVA, is is the value of the federal funds that you see there estimated. [Chair ]: So you're taking it out of interdepartmental. Who would have otherwise been paying for it? [Stephanie Barrett ]: The central office, primarily, who can get it. Paying for it. And then we have what are called yeah. I think you've talked about this a little bit as I talked from an email yesterday. The ADS service level agreement charges, that is catching up from what was budgeted to what is actually billed. And there's usually a timing gap. So it's trying to close that timing gap across our part of the agency. That's almost a million dollars between general fund and federal fund. Yep. And then the last item on our operating expense is a ninety ten matchable assistance. We have a large procurement coming up, not in the immediate future, but this is giving us the technical assistance to start the process for our PBM reprocurement process. And so that's that that money lets us get started this year. We will probably carry some of that money forward, just timing wise, but that's what you see on that last line in our operating budget. [Chair ]: And that's intended I know we've talked a lot about pharmacy benefit managers over the last few years, and I know we're trying to reduce our costs for for Vermonters because it's really expensive. So is this helping down that road, helping us down that road? [Stephanie Barrett ]: So this is this is the pharmacy benefit management function for GIVA for the pharmacy benefits that are members Medicaid members, not the whole state. [Chair ]: Right. Okay. [Stephanie Barrett ]: Medicaid members. So the the they manage that service as well as the rebates that are associated with Medicaid pharmacy expenditures. And that is a complicated and needs a lot of we have a pharmacy unit in DIVA that do great work and interact with the with the, vendor that provides these services. And on the fiscal side, we are very keenly always watching the cost of the the pharmacy claims expenditure and then the nature and the trajectory and trends on the on the rebates, which we'll probably talk about a little bit more in the in the twenty six budget. Okay. Great. Thank you. So that's that's the picture of our administration budget. [Chair ]: K. Continue on then. [Stephanie Barrett ]: Okay. Thank you. So now we're gonna move into three new, line items in the budget that are the program budget in Veeva. So all the money in these lines go out as grants to providers or to, in some cases, to pay the federal government for, like, our buy in program, clawback payment. But, the vast majority of the dollars of the one one billion seventy million dollars of program budget go up they go out to providers, mostly in state providers, but some out state out of state provider. So that's the the nature of the these three program three three line items. And they're in three line items for a reason, for, the basically, the funding source of the service that we are paying for. And so our biggest line item is three zero seven, which is, if you are looking at the ups and downs to the bottom right hand, nine hundred and sixty four million dollars, but it's all one funding source. And that is paying for basically all the claims, for and said global commitment eligible expenditures that flow through DIVA. And so do folks want to stop and, talk about the global commitment, the nature of the global commitment? This is a blended state and federal dollar. This is a blended state and federal dollar. [Chair ]: Right. We had no one talked about this. And so yes. So this is the global commitment section. Yep. So some of this is general fund and some of it is credit funds. Right. Correct? And it's is this To us, [Stephanie Barrett ]: it's all one dollar. Right. And so if you're back on our narrative, the biggest driver of our increased ask for caseload and utilization is our biggest driver for the increased ask for funding here. And we did end last year, June twenty twenty four, underwater in our program budget. A portion of that was due to timing to the of the of the rebates, and you will see that timing offset a couple lines down in our narrative. But a a good sized chunk of it was due to claims coming in higher than we had forecast previously. And so, I know you've probably talked about the consensus process, but the consent of the process is Viva, central office of the agency, joint fiscal finance and management staff meeting to forecast what the fiscal need is for the Medicaid DEVA budget for and we look at recent claims experience. We look at caseload. We're very good at forecasting caseload. Forecasting expenditures on the per member per month has been a more difficult process for the past two years because of the impact of the the redeterminations. When we had the public health emergency, we people weren't redetermined, so they stayed on. So they looked like they were on as a case as a caseload, but they might not have been using Medicaid services. And so that has a distorting effect across our expenditures as we as we go through. And last year, when we were making our estimates, we weren't seeing, until we got six months further on, the the bigger divergence between, the expenditures for those that were made remaining in Medicaid and those that were coming off through the unwind year. And that's the biggest driver that we're seeing here on the caseloading utilization. And representative Yacoboni has a question. [Dave Acaboni ]: Do you still use the fifty two points of life? [Stephanie Barrett ]: So we've converted it to a a monthly. [Dave Acaboni ]: Is it a useful tool? [Stephanie Barrett ]: Oh, it's very useful to [Dave Acaboni ]: me. It used to be weekly. Fifty two weeks of writing. [Stephanie Barrett ]: Yeah. Track that number. And and and we switch to weekly as we head toward the end of the year for reasons to close the year, clearly. But we send out and you will be getting well, the the folks that are on the list are getting it shortly, either Friday or next week, early next week for we we provide the most recent spending against the budget. In this case, it'll be against the budget adjustment and what we're what we're seeing. And so so and we do it by categories now that are very useful to me, understanding claims versus agreement based payments versus pharmacy spend versus pharmacy rebates versus the other pieces of our budget. Everything in our budget are big chunks, but JFO is on definitely on that list. It [Chair ]: has a question. [Stephanie Barrett ]: We we usually let JFO just distribute it to the members that are interested in it. So is the acuity [Dave Acaboni ]: of the claims, is it running hot in some programs more so than others? Do you for instance, do you do you look at hospital claims? [Stephanie Barrett ]: So we in in in doing this work of the of the forecast through the fall for our base budget, this seventy eight million dollar piece. We do we we go by the Medicaid eligibility group, and we did internally look at four of the major categories, the inpatient, the outpatient, the professional, and the pharmacy services. And for the stayers, the people that remained in Medicaid versus the ones that were leaving, you could see [Chair ]: Mhmm. [Stephanie Barrett ]: Almost in every category, a very big difference. You Some were you could see it up through twenty three and then flattening, but we we have to go back and actually sort of finish because we were doing it within complete twenty four data. And so we do look at that to try and understand. But for for example, for inpatient, the majority of that expenditure flows through, except for the out of state piece for attributed lives through the ACO. So that's it's in our agreement based payment as a prospective payment. So it becomes very complex to understand, what the drivers might be. There are some areas which I think are fruitful to look at when we have some time in terms of understanding because the kids aren't as our general child population isn't as subject to the the variation of the unwinding because they're at a higher income level. So so that might be a fruitful area to understand. And we are seeing a higher cost per case there, not necessarily, you know, driven by clearly identifiable that it's inpatient versus professional versus outpatient, but it might be very fruitful to understand what those look like. If I may, madam chair, [Dave Acaboni ]: I just want a quick follow-up. You may or may not have the ability to look at this, but I was approached by some of our folks from our dental community who were saying folks were presumably for affordability issues, not doing preventative work, cleanings, etcetera. So when they did go into the dentist, it was more intense because things had deteriorated. Is that something you're able to look at and say over time we are noticing that the preventive claims nature of the claims that are preventative are are less than what they used to be? Do you have that ability? [Stephanie Barrett ]: We can ask and see if it's not I'm [Dave Acaboni ]: not sure what it would drive from a policy standpoint other than to tell us that, you know, it's there's reasons people don't go to the dentist, and I'm assuming some of it is caused. Dental benefit is not extremely robust [Stephanie Barrett ]: So it did [Dave Acaboni ]: young children. [Stephanie Barrett ]: No. It it well, we we did an increase in payments two years ago starting July one twenty three, a significant increase in payments to dentists. And we increased the adult dental cap. Okay. And you yesterday probably got a report on dental program, and that might be helpful to look at. [Dave Acaboni ]: What is the cap now? [Stephanie Barrett ]: The cap is now fifteen hundred a year. Thank you. And so that's that there is no cap up, though, on children. But it's I'm sure from our population, cost is an issue, but it's also an access issue clearly across the state and with dental services. Thank you. [Chair ]: Yeah. For Harrison and then rep Judson. [Jim Harrison ]: So, Stephanie, when I look at the initial spreadsheet and the ups and downs overall, you know, obviously, the thirty five million regardless of what department it is is a big number. Yep. And what I'm hearing you say is perhaps we projected, you know, maybe a little short because we through the redetermination, which at least one member referred to it as a very big deal in a in a for speech that had become famous that your average because you had a lot of members or clients in name only, essentially, because after the pandemic, they got other jobs that had health and care. So they were there, but your average claim overall were lower. Our average cost. Weren't drawing on it because they may not even know they still had Medicaid. [Stephanie Barrett ]: That is that is fair. And just to for the folks that were on the committee last year, when I was in this chair last year, I was saying you we actually said take fifty million dollars away from us. That was a mistake in you know, after, you know, nine months of experience. [John Kosasco ]: I'm surprised the member had [Jim Harrison ]: to carry the plug. Catch that. [Stephanie Barrett ]: But we did not catch that, so we're not going to hold him to that. [Lynn Dickinson ]: Rick Dickinson. Yeah. I just wanna speak up for the representative who didn't work that [Stephanie Barrett ]: you are very hard to say. [Lynn Dickinson ]: I'm not So you're [Chair ]: welcome anytime, Wendy. [Lynn Dickinson ]: I do wanna point out that my suspicion on the issue of the preventive dental claims is a workforce issue. We have a crisis in hiring and training a dental hygienist. And if every dentist in the state is looking for more hygienists and you don't have them there, you're gonna treat future that's an access problem. You see fewer we then work. That may be part of [John Kosasco ]: it. Okay. [Chair ]: May I Bonnie, yep. [Dave Acaboni ]: Where in the narrative would it be appropriate for me to bring up the issue of some providers who are struggling and need financial assistance? Would that be under the global payment program or would it be here under utilization for both? I'd I'd like to bring that up. So if it's not Germaine, tell me. We've had some were you waving, or did you have a question at all? [John Kosasco ]: I I was gonna comment on that. I just thought that might be a budget issue, not a big issue. There might be a budget issue, not a VA. Well, if it's happening now [Dave Acaboni ]: in the middle of this fiscal year, I'm not talking about twenty six. Talking about now in twenty five. Thank you. So some providers yesterday, we had testimony about extraordinary financial relief in the long term care sector. But there are other providers, maybe in primary care, who are experiencing a similar situation. Would you welcome language in the BAA that created a pathway, if you will, for extraordinary financial relief for, for home health or FQHCs, for other different providers. So they too could have a place to go because like the long term care policy, it was determined years ago. It's such a crucial service that you can't go without it in a community and you need time to develop a bridge solution. I don't think you have that language. Would you welcome him? Yeah. [Deshaun Rose ]: Yeah. So I am I am aware of the provider of financial hardships, conversations that you have you mentioned, and we continue to monitor what is going on and what is really driving those issues out in the community and what kind of solutions there are. I think that's open to a a longer discussion of what we can what are the potential policies or what are the potential options that we would are needed? And I don't have any answer with that. [Dave Acaboni ]: Well, we're trying to find out the solutions, though. Some may go under, and that creates a hardship for our communities. So it's almost like a lifeline, a temporary lifeline to keep things afloat, maybe the wrong word, but to keep things somewhat stable until maybe those more challenging, analyses as to the reason why could be determined. Would that be helpful? [Stephanie Barrett ]: I'll I'll just be the sort of hard dollar person here. We don't have funding right now within our budget for that, and [Dave Acaboni ]: we would work with whatever you would, you know Well, listen to VA, the place where someone would ask. If if you saw that there were providers more than once, but what looked to be possibly a systematic issue, isn't BAA a place or a department, if not you or someone, to come in and say, we'd like an additional ask in this area for these reasons? [Deshaun Rose ]: Yeah. So that the BAA would be the appropriate place to to make that connection. Yes. [Dave Acaboni ]: Nobody seems to be making that request at this time. And yet, some providers have come in to the department saying, gee, would you look at our scope of services? We'd like a review. I'm I'm concerned I'm not being critical because I'm not but I'm concerned that our solutions may not help Vermonters who depend on these services if we lose some provider. And how can we be more, you know, forthcoming, more, preventative, more upstream instead of letting them actually break, but to to repair them, so to speak, until we found out, as you appropriately say, what's the root cause? I don't see that here. And if not here, where would it come from? [Stephanie Barrett ]: The it is not geared. There's not a there's not a line item or a consideration of that in the in the proposal that's in front of you from DIVA. I know that conversations have been going on, and so I assume that that will come as a collaborative effort with the legislature and administration if that's [Dave Acaboni ]: the decision. I'm thinking about some language to do that. My concern is, you know, BAA doesn't just because we may vote on it later in January, it could be May before the city gets signed, and we'll lose people before that. So thank you, Madam Chair. Thanks. Let's continue. [Stephanie Barrett ]: So just on on item one in the, in the narrative, the the caseload and utilization pressures, they do total eighty three million dollars, eighty three point four seven million dollars. That is thirty five point four seven million dollars of general fund. Of that thirty five, the thirty three million dollars of global commitment. That is that general fund is not in our budget. That is in the central office budget just to to recap. And so that's that's where we see the baseline for what we provide right now for the caseload that we have right now. As we move to item number two, we have two areas pretty much annually where we have to keep up. We have to increase by what's called the the medical economic index, the the encounter payments that we make to our FQHCs. And so that has gone up by three point five percent that starting in January. So the February payments will go up to the FQHCs. That's what, a portion the the largest share of this is. And then we also have to maintain a floor of what we pay for hospice services, and that's a very modest amount that increases every year. And so on top of the caseloading utilization, we have these mandatory rate adjustments midstream included in our budget. [Dave Acaboni ]: Mandatory? I'm sorry. [Stephanie Barrett ]: Well, sort of required to keep up. [Deshaun Rose ]: Probably mandated. [John Kosasco ]: Thank you. Yeah. [Stephanie Barrett ]: We have one piece of good news. It was not good news in June, but it's good news now. Item three is an offset. Because we had the change health care cybersecurity attack last spring, February through April, that delayed when rebates were invoiced to manufacturers and when they were collected. And those have come in now in July and August. And so we can apply them here. So that reduces the the amount that we saw in number one for a need. It's just one time in nature. It it contributed to our deficit when we closed the year, but it comes in. And that's what you see being offset here as a negative. So that's that's good news in terms of just the budget adjustment in a sense. [Chair ]: And hopefully, it'll be interesting to the narrative. And this wasn't stare. It wasn't your fault, but it was it did create a bit of a habit to damage. [Stephanie Barrett ]: Yeah. And it was you know, it was nail biting. Didn't understand how much was gonna be collected, how big the bread box was going to be. The next item that we have is what is our ACO reconciliation. And this is for the twenty twenty three program year, and it's a calendar year. And it usually takes a good eleven, twelve months to reconcile the ACO. The ACO, as we know, is is not going to be in business in twenty twenty six, but there will be reconciliation activity that follows the the end of the ACO. The majority of this need is similar to the the total need, as we're presenting it here for reconciliation, is about half of what it was last year. The portion that's due to the total cost of care is actually very, very, very close. It's within, you know, you know, like, ninety nine point nine percent of what was projected. In fact, it would have been a small amount of money due back from the ACO to the state. But, the impact of the public health emergency and not redetermining folks, the way we we make prospective payments based on attributed lives for regular adults, ABD adults, and children. And so when you sort of stop the clock in terms of the public health emergency and the redeterminations, we weren't picking up the change in the age as kids aged from being kid at a kid perspective rate versus being an adult perspective rate. And so that's the true up that you're seeing here for the majority of it. So for the twenty three year, even though we started the redeterminations midway through twenty three, for the first half of twenty three, and through the rest of it as the as the unwind unfolded, we have still and we you saw this last year in our ask as well, this impact in reconciliation where we weren't making the payments based on the actual age of the individual, being in the right category. And so that a little bit of that normally happens, but it gets not it doesn't build up like it built up from twenty to twenty one to twenty two where you had a large number of attributed lives that didn't move to the right category. And so we should not be seeing this again for the twenty twenty four reconciliation or the twenty twenty five reconciliation. It should just be the normal amount of of transition. But that's the that's what's driving this five point one million dollars. Is that true up in that agreement setting? [Chair ]: A question on this time. This is from fiscal year twenty three. No. [Stephanie Barrett ]: It's it's it's program calendar year twenty three. [Chair ]: Calendar year twenty twenty three. So are we gonna have two more of these? Because there's two [Stephanie Barrett ]: You're gonna you're gonna have two more reconciliations. You should not have the degree of what's happening to the true up of the the age of of folks, moving from the child category to the adult category. [Chair ]: So what happens in two years from now? The ACO will have been gone for a year. Where does the money go? [Stephanie Barrett ]: So the activity I did that's not I don't I can't ask answer that question. I don't I I believe there's planning for the what the Coming up. What what needs to happen for the [Chair ]: K. [Stephanie Barrett ]: The continuation after that Right. Ahead or whatever. I'm sure that the the ACO could answer what their intention is in terms of the the the shutdown of [Chair ]: because if it's gone, who do you give, you know, who do you give that? [Stephanie Barrett ]: You know, all the I'm sure those considerations are I just didn't [Chair ]: know if you knew that already. So rep Stevens? [John Kosasco ]: So consider me just a newbie with with this language in the way that you do budgeting or the way that we're we should be considering this. [Lynn Dickinson ]: And it's [John Kosasco ]: a BAA request. So I I just wanna ask a question about the global commitment. Global commitment funds are for services that are being provided. There's more services needed. Therefore, there's more funding needed to this level of thirty whatever, thirty five million that's our state request. [Stephanie Barrett ]: What you saw on the chart for item number one under the program budget? [John Kosasco ]: So that's reaction to what was budgeted. I I noticed that you make your first estimate or request in calendar year twenty three for fiscal year twenty five. So we know that there's a lot that's happened that that happens in the rest of the world. I can I get that with all the cost sharing reductions [Stephanie Barrett ]: Yeah? [John Kosasco ]: Manipulations, I mean, in a positive way. It does this then when go into your thinking when you're budgeting in this big bill of lifting the base amount? Because this particular year you had more, more use of that global commitment and or do you go back to a base number and say, well, should traditionally or however you wanna put it, we get this number of cases. It just so happened that this year was of high high use. [Stephanie Barrett ]: So we do the the consensus process looks at the two years, the year we're in and then the next year for the for the twenty six budget. And so our consensus process does look at the the baseline, which is the twenty five as passed, and then looks to see what what is now halfway through twenty five as it need to be, and then what in twenty six as it need to be. So you will see, at the same time, we are looking at the caseload trends. And so you will see a similar analysis presented to you in twenty six based on that process. [John Kosasco ]: And do you include, potential population changes where, for instance, inflation may push some people over, x percentage of federal poverty level? Do those get added in as part of the algorithm? Or [Stephanie Barrett ]: So we do not we base it on what we're seeing in the trend in caseload. And so that that's usually a pretty steady month to month by each Medicaid eligibility category. We are not projecting a recession and saying the caseload's gonna go up because of that or something like that. We are saying, you know, the general adult population is looking like this, and it's you know, its trend is this way. The the new adult population, which is where the most of the people came off, is trending slightly down. But we are not making sort of bets on the the economic picture in twenty six beyond what the current baseline is telling us. That, you know, could change. We would be in a catch up situation, but we don't we are assuming pretty much status quo in terms of the the current caseload trend line that we see. You know, years ago, in the great recession, Medicaid was one of the leading indicators where, you know, same people were assuming a a baseline. As the economy deteriorated, Medicaid is one of the pace places where you saw, you know, enrollment increase quickly, but that's not part of our forecast. Obviously, if we were heading into something like that, that we don't you know, we would start to pay attention to what what do we think it means, and it would fold into this regular budgetary cycle. [John Kosasco ]: This is this this increase is simply not simply. There's nothing simple about it, but just the idea here is what's actually happening as opposed to what might have been expected or projected. [Stephanie Barrett ]: Yes. We're not we're not we're we're we're making projections based on the trends we see right now. The you know, taking the baseline that we have, which is what we passed a year ago, for the twenty five budget and saying this is the way we see the caseload going. This is the way we see the cost per case going. This is what we're asking for based on that. If the greater economic scenario starts to change that, we would be paying attention to that and saying, oh, we think that's and that's where representative Iacovone asked about the what's what was formerly called the fifty two points of light. We now call it the monthly program dashboard. We will be monitoring it through that process. [Dave Acaboni ]: Yeah. Please continue. [Stephanie Barrett ]: So no more questions on the ACO reconciliation? [Chair ]: We're there. [Stephanie Barrett ]: Okay. We have a couple of neutral program adjustments. One of them we've already talked about. That is the legal aid moving up from the program budget into the admin budget. So it's a down here, but it's an up there, so it's it's neutral in terms of gross dollars. There is a small difference in the match rate between the two. Sure. So it'd have a a little bit of a general fund impact. But in terms of the amount going to legal aid, it is a net neutral amount in total. And then we have two programs that were in our program budget but need to be in on our in our global commitment investment budget. That is our blueprint spoke program and what is called the the Pregnancy Intention Initiative, which used to be the women's health initiative, which pays for, you know, care for prenatal. It has enhanced payments for that activity. But it need it's not a it it's no change in the estimate of the cost of the program. We just have to move those two programs out of what is base Medicaid, and into our investment. So it doesn't change the dollar amount or the match amount at all. It just has to be accounted for in the waiver in the right bucket. And we had it in our program budget, and our review shows that it needs to be in our investment bucket. [Chair ]: Great. Thank you. [Stephanie Barrett ]: And then our last adjustment is in the Vermont cost sharing, reduction program. And that is a fully general funded program that we've had since, Obamacare turned on. But there was a significant change in the way the silver plans were priced, at the Green Mountain Care Board, and so we have less people in the silver plans enrolled now for twenty twenty five than deliberately in in a sense. And so we don't have as large a cost on this program. It means people are going into other metal, categories for their for the for the folks that are not they're buying their insurance on the exchange. They're getting premium assistance help still, but the the cost sharing reduction piece that was tied to this the the silver plans is has changed. And the the you'll see this annualized in our twenty six budget as well, but this is a is a pure state g f reduction. And it's a half year cost because we're a fiscal year, and the the plan here is a calendar year. [Chair ]: The repairs and then we're back enough. [John Kosasco ]: Stephanie, I think maybe in the fall, [Jim Harrison ]: I saw one of the notices from our health care advocate, and it sounded like, if I recall, that, like, the gold plan for people who are getting help was actually less expensive than the silver. [Stephanie Barrett ]: I I I'm Yes. Yeah. I'm not I'll defer to to no one on. Yeah. And so [Jim Harrison ]: we we can ask later. I just knew what curious to me as to k. Why that was, and maybe it's relation to this cost sharing reduction. But [Stephanie Barrett ]: And I think it's decisions about how to, you know, with the advanced premium tax credits, how to maximize. And you will also have a report on the marketplace that should be have dropped into your realm. That might be helpful if you have more questions in that regard. [Chair ]: I can [John Kosasco ]: talk to you offline. [Jim Harrison ]: Okay. Thank you. [Chair ]: Thanks, no. Rebecca Bonni? [Dave Acaboni ]: That is covered. Okay. Thank you. Great. [Chair ]: I'm working. [Stephanie Barrett ]: And the last item in our budget is, we had a onetime request that you funded last year, for pilot a global payment program pilot, that was to so the the ACO, covered attributed lives for services. This was to actually have, hospitals that wanted to opt in to have a global payment for the unattributed for the nonattributed lives, so the same set of services that would be under the the ACO. And so we had five hospitals, UVM network, so Central Vermont, UVM, Porter, Rutland, and, Northeast opt in. And we are asking for an increase in that appropriation. It is not this appropriation is for what's called the tail of claims. So when you're switching from a fee for service to a prospective payment, you have a gap where you're making the prospective payment sooner and you still have claims coming in. And that's what this this is covering. And so, allowing, additional hospitals to join and also to true up that tail cost, because we had the largest hospitals join. And so we can we know what the tail is for the five that we have that started in August. And, you know, it takes about eight to twelve weeks to fully understand what the tail is. And so that's what you see here is an increase of four million dollars. You gave us nine point three, and this would allow additional hospitals to opt into this pilot program. [Chair ]: So the this should be the only time that we have this particular Yeah. [Stephanie Barrett ]: It's it's not a it's not a it's not an ongoing base cost pressure. [Chair ]: Sales. Can't put keep it's a [Stephanie Barrett ]: it's a fiscal gap that if we do this program, it's a fiscal gap to us. Right. And this closes the gap. This closes the gap. Yeah. Mean chance. Okay. [Chair ]: This not close. Great. Rebecca Bote. [Dave Acaboni ]: May I ask, what is the what has the pilot shown thus far? What were you hoping to accomplish in as of [Stephanie Barrett ]: So the the pilot was to to, allow us to make a sort of a more full global payment between the hospitals that opted in under their regular ACO payment. And so those Moving them away from fee for service? Moving the unattributable [Dave Acaboni ]: People who were not [Stephanie Barrett ]: covered by away from the fee for service And so that it it is we're only, six months into it or even five months into it. But the this program is fully reconciled to claims. There there won't be an sort of an over under. [Chair ]: Okay. Do you have anything else, or is that your presentation? We're good. [Stephanie Barrett ]: That's the money in Neeva. [Chair ]: Maybe, is anybody or or rep Paige, anybody have any last questions for this? And you've probably all figured out that Rep. Yakoboni has this budget. So we thank you very much for coming in and explaining it all. And I'm sure we'll see you again when we get the FY twenty six call check. [John Kosasco ]: Well, I did. I [Chair ]: I looked over and I didn't see. So so thank you, committee. Before we break, which is in just a couple of minutes, I'm sending out, I hope during the break, a letter to the chairs and vice chairs about the budget adjustment and that they need to get back to us by a week from today on their issues. But what I'd really like is to have you all connect with, your committee's jurisdiction. And you kind of know now what what they've got in a budget adjustment and let them know as well. So they're gonna be looking on their end, but you can also help them by saying there's something here in the department of labor. There's whatever. So and be sure in the in the language that you're looking at the reversions and all the other pieces, not just the you have b two hundred. It's there could be language and reversion, so help them see all those things as well. So it would be great if between today and tomorrow, you can connect with everybody. So that's what I've got for now. And, why don't we go offline? We'll meet back here at we, start [Stephanie Barrett ]: with Department of Mental Health at eleven AM.

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