SmartTranscript of House Healthcare - 2025-01-22 - 1:00 PM

[Chair ]: January twenty second, and this is afternoon of health care committee. We're gonna continue with h thirty five. That's the act regarding unmerging individual and small group markets. And first up, we have Mike Fisher. [Mike Fisher ]: Like, I'm never here. [Chair ]: It's gonna be like deja vu for us this morning, I think. [Mike Fisher ]: Good afternoon, Mike Fisher, health care advocate. I was thinking after this morning that I would try and fly on a much higher level and just really clearly state that the HCA supports this bill as drafted. Our position on maybe I should say my position on whether it makes sense to keep the markets together where a part has changed over the years as other things have changed. But the, the current dynamic, the current dynamic with, you know, with with the the available things that we can do to support the individual market and the really tremendous stress that the small group market is under, it leads us to have the position that it makes sense to maintain a separate individual and small group. And I should also say there's a number of other details that Diva asked to be a part of this bill that all make sense to us too. I am happy to go into more detail than that, but I don't wanna give anyone a post traumatic stress response. No. I'm I'm happy to to to go into more details if or respond to questions. [Chair ]: Is there anyone that would not be for this? [Mike Fisher ]: I was actually gonna say it's I I'm not aware of anyone who's opposing this. [Chair ]: That's what I was thinking. Not that [Mike Fisher ]: And nor can I think of anyone who might? [Chair ]: I I know. Okay. Let me ask. So because I did neglect to ask, Diva this morning, all the other changes, just the technical changes, you're you're fine with all of those. We keep forgetting that there's other pieces of this bill which are just technical changes. You know, to your point of you can't think of anyone who wouldn't be. In light of some things that you said this morning regarding being unsure about what will happen on the federal level, we will be faced with possibly some catastrophic thinking, some things happening in the individual market. I was wondering if you could speak to those at all. [Mike Fisher ]: And Yes. [Chair ]: I mean, I I do think it's something that we have to weigh. [Mike Fisher ]: Yeah. Let let me be perfectly clear that my concerns about what is coming next, you know, for twenty six in the individual market, doesn't change my position on this bill. But yes, absolutely. The, twenty six looks to me like it will be a even harder year for us to figure out how to make sure people have access to health coverage. And, you know, I wanna remind you that you have this really interesting detailed report that came to you last week, and, it lays out a number of options and applications for each of those options and funding needs for each of those for any of those options. And, and so I do think that is the place where it's really gonna make sense to to think about sort of how do we protect Vermonters as best we can. And I'm also I should say, you know, I read that report with some curiosity of you know, I'm looking forward to the the governor's budget recommend. Is that Tuesday? Mhmm. I sure hope that the recommend has addresses this, because we really are going to need, we're going to need the governor's thinking, the administration's thinking, and your thinking about how to best move forward. I think, you know, in particular, we we continue to have this from our premium assistance. And, it sort of fills an interesting role of sort of backing up the federal premium assistance. We buy it up by, you know, a percent and a half. But that tool may be a useful tool to be able to think about how to sort of protect parts of the population that are gonna be that may well be losing the federal premium tax credit subsidies. [Chair ]: Could you talk just a little bit because I know that you know all of this stuff. But can you talk about what was in existence before, twenty twenty with the enhanced, tax credits? What what was the playing field like at that time? [Mike Fisher ]: I should not bring tax credits. I should not bring my computer with me with the chart that I showed you this morning or reference this morning. So, before the enhancement tax credits were the tax credits as defined in the Affordable Care Act, which which were good and really did support, you know, a a broad swath of Vermonters. But a major shortcoming of that of the Affordable Care Act was the is the the cliff at four hundred percent of poverty. And so under the Affordable Care Act rules, people who earn over four hundred percent of poverty lose all of their premium tax credits. And pre enhanced tax credits that represented a a really disastrous cliff. And we've been playing with some numbers. I'm not gonna say it it we think that that if the cliff comes back, if the four hundred percent of property cliff comes back, that we'll see cliffs of of twenty five or thirty thousand dollars And so people who earn just a little too much for the subsidy will lose substantial tax credits. [Chair ]: And I'm looking at a chart provided in that report. We're talking currently, I believe, in twenty twenty five, they have approximately fifty eight hundred people who are estimated over four hundred percent. So of that market, the individual market of about thirty two or thirty four thousand, We're talking about around fifty eight hundred people that would lose any tax credit, all all their tax credit. Brian, did you [Brian (unknown role) ]: Yeah. You said there would be a clip. You said twenty five thousand to thirty thousand. Can you explain what what you mean a little more? [Mike Fisher ]: I I mean that the what I really mean is that the value of today's tax credits to somebody just over four hundred percent of poverty, and let me I I should always be prepared to do this. The poverty level is just a little over fifteen thousand dollars for a family of one. So four times that for for a family of one. If you for somebody who earns just over that, they the subsidies are significant. The subsidies are are worth thousands of dollars. And [Brian (unknown role) ]: Yeah. I'm just trying to understand that the so, like, you said that the difference could be twenty five to thirty thousand dollars. So what I'm trying to understand is if someone makes, like, forty five thousand, are you saying that going one dollar over or whatever is gonna make their insurance is gonna cost twenty five thousand dollars? [Mike Fisher ]: So let me say, the worst case scenarios for a family of four earning just over four hundred percent of poverty could represent, yes, those kinds of numbers of of loss of subsidy. [Brian (unknown role) ]: And it's because they they're they're the family plan costs you more than the individual plan. That's how that's how you get those numbers. [Mike Fisher ]: Well, certainly, the family plan cost more. Yeah. Yeah. [Brian (unknown role) ]: I'm trying to understand, like because I know insurance is expensive, and I know I I get the tax credits. And if I didn't But [Mike Fisher ]: in in this case, I'm I'm comparing the, the cost of the of the family plan with the subsidy, you know, at four hundred percent of the federal poverty level versus the cost of the plan, the same plan, without the subsidy at four zero one percent in the federal poverty level. So somebody who earns just over loses in the Affordable Care Act rules, loses all of their premium tax credit subsidies. And it's you know, let me be clear. This is not this is something that is completely out of our control. The federal government is needs to take action if we're gonna continue to have the subsidies. And it I mean, being responsive to care's collection represent a substantial risk to Vermonters access to care. [Speaker 3 ]: Easy. So we're talking about the premium tax credits. Can I give an example and you tell me if I'm on the right track with understanding how this relates? So a family of four at four hundred percent is who those premium tax credits are potentially Mhmm. At the end of this year. Calendar year, the tax credits may go away? [Mike Fisher ]: In short yes. This is on this is for twenty twenty six calendar year. Yes. [Speaker 3 ]: Okay. So that family of four at four hundred percent would be making around a hundred and twenty four thousand a year. And they would then have to pay twenty thousand dollars more for that same insurance plan. [Mike Fisher ]: Yeah. Let me let me let me do a little bit of work of getting the the chart in front of you. So you can see our modeling. I I we did a very quick look at it. [Chair ]: Rough estimate. Okay. [Speaker 3 ]: And the second part of the question is that's separate from what the bill does. Right? The bill has nothing to do with that. [Mike Fisher ]: That's correct. [Speaker 3 ]: Okay. Just to be clear. And then Yep. Nothing to do with that. So it's kind of a separate discussion. This bill doesn't impact anything to do with the credits. But can you kind of weave that together for me? Like, why are we talking about the premium tax credits while we're talking about this bill, which really just keeps things the way they are? Like, how is [Chair ]: is anything that That is [Speaker 3 ]: the reason bill gonna make insurance more expensive for people? [Mike Fisher ]: No. The bill won't make insurance more expensive to peep for people. The bill will maintain the status quo. Not saying insurance is gonna cost the same amount next year. It's gonna go up. It goes up every year. But the reason it is linked in my mind is the enhanced tax credits and the the way we have separated the market is because it was the it was the enhanced tax credits in twenty one, I guess, the ARPA tax credits that really convinced us who convinced me and my office to come forward and say that we thought it made sense to consider separating the market. And, you know, I I'll just mention there's other tools available to us. One of them I've mentioned earlier today, silver loading, and they're I'm keeping an eye on you. One of them and there are other tools available to us that are explored in the marketplace report, that, all of those tools are tools to help us in the individual market. Not a one of them, as my understanding, helps us in the small group. And so, you know, I know traditionally over the years, the HCA has probably been more concerned about the individual market. It was a place of tremendous you know, we were worried about it back in the day. Still worried about it. But, today, when I look across the landscape of access to health insurance, I find myself more worried or particularly worried about the small group. I think I think more and more employers are gonna have harder and harder time offering insurance as the costs go up. [Chair ]: Right. I want? [Alan ]: The cost goes up. So what's your recommendation? We know cost goes up since I've been here. Yes. So we're looking for a fix. Now we know that cost is So what? [Mike Fisher ]: Let me let me keep steering us back. This bill is not about any of that. Okay. And we should pass this bill independent of any of that. But if I could just say on a very high level without going into the this is this is days of testimony to do to talk about why it's expensive and what to do about it. I just have to say price. We have a very expensive health care system, and we have to address that. Unless you've got a printing press in the basement where you should print some money, we have to address the press. [Chair ]: Leslie? I guess I'm feeling more hopeful. This may not be the time or the plate Mhmm. Per liter or whatever. But we keep talking about the enhanced subsidies going away. But what if they go away on December thirty first? You know, when are we gonna know, and what how are we gonna respond? And that's what I'm worried about. [Mike Fisher ]: I think our opportunity to respond to the potential of them going away is this year, this legislative year. But I have to be honest. I yeah. The timing is short. [Chair ]: Yeah. So have a if if we're gonna be responding this year, how does that look? Yeah. And I'm I'm not saying you just I'm not suggesting you mentioned that now. Say, I wanna think about I don't know how we think about it. [Mike Fisher ]: And and and wow complex puzzle for this table, to consider what steps should be taken this year without the knowledge that they will for sure. Yes. Yes. Yeah. And and let me just say, her in law is they go away. Or in law as as as they end after twenty twenty five. And so, I guess my opinion given the way, you know, given who congress is and who, and the presidency, is that it is that we plan for the reality that we won't have enhanced tax credits next year. I might be wrong, in which case [Chair ]: It'd be great if you're wrong. [Mike Fisher ]: I would be really happy if that was wrong. [Leslie ]: I didn't hear what you [Chair ]: said. He's he implied that if he's wrong [Leslie ]: Oh, oh, oh, yeah. Okay. Oh, I hope you are. Me too. Just I know we've said this many times. The bill that we have in front of us has nothing to do with that. [Mike Fisher ]: It has no impact on on that. No. [Leslie ]: All it is is we're both putting in place Maintaining the status quo. What we're doing now. And maybe we should be thinking about what you just talked about. Yep. Agree. And and doing something about that. And that's why I'm waiting to see what comes through tomorrow so that we can [Mike Fisher ]: what's happening? [Alan ]: Tomorrow. Tomorrow. [Speaker 3 ]: Yeah. What's happening? [Sarah Teachout ]: Was it tomorrow? What's [Leslie ]: the government doing this? Oh, Tuesday. [Mike Fisher ]: Tuesday. Tuesday. Oh, Tuesday. I'm sorry. [Leslie ]: So I'll wait till Tuesday and see what that is. [Chair ]: I think Woody has a question real quick. [Mike Fisher ]: I'm just curious. What do insurance companies think about maintaining this status quo? I think you'll get to hear from an insurance company as soon as you dispense with me. [Chair ]: Alan, did you [Alan ]: Well, I just yeah. I've heard all this stuff. Health care has been around here a long time. And you folks, you've been here a long time. You guys have adjusted. You do what has to happen to make things go. And instead of talking doom and gloom about what might happen Mhmm. We gotta look what we can do in this building. And we we can't find excuses. Mhmm. So just keep that in mind. [Mike Fisher ]: That's fair. [Chair ]: Just So by doing this, it's it wouldn't recap anything that we would have to do in the future. Okay. No. [Mike Fisher ]: I don't believe so. Okay. May maybe to say it a different way. The strategy of keeping the individual in small group, I believe, served a purpose at one point, and I don't believe it it it serves the right purpose now. [Chair ]: Right. [Brian (unknown role) ]: So if we unmerge the markets [Leslie ]: It's already unmerged. [Brian (unknown role) ]: We maintain the unmerging of the markets if we allow it to continue, if we delay the sunset, sunset, whatever the right language is. Mhmm. It applies to the to the calendar year, January twenty twenty six to December twenty twenty six. And that's and then during that year is when Congress has to make the decision if they're gonna extend the tax credits or not. [Mike Fisher ]: It it I don't know the exact date by which congress would have to act, but it's well before January twenty twenty six. So [Brian (unknown role) ]: I'm just trying to, like, understand the timeline of of things. [Chair ]: This bill eliminates you know, you're talking about a sunset. It essentially eliminates the sunset. It puts it permanent that the markets will remain Right. [Sarah Teachout ]: Unmerged. It eliminates the it sunsets [Chair ]: the sunset. Somebody around this table decides that they wanna merge them. [Brian (unknown role) ]: But what I'm trying to understand is just the of what's of of so so in in the calendar year in in this calendar year, Congress is gonna make a decision that will then go into a Congress either makes a decision or not. But the point is, so I don't I I'm sorry if the technicality is wrong. I just the main point here is that we can we're gonna make a decision to keep if we make a decision to tell let the let them remain separate. And then after we go out of session in June, let's say Congress decides to repeal or eliminate or not allow to continue whatever the language is to tax credits. We won't have an opportunity to do anything to help the individual market if if suddenly those people are [Mike Fisher ]: Let me try and state it this way. The HCA supports maintaining an unmerged marketplace with the belief that we won't have the enhanced tax credits in twenty five. The belief we won't have? We won't. I I, we support maintaining an unmerged marketplace independent Okay. What comes This is [Brian (unknown role) ]: what I'm trying to get at. So it's like it's not it doesn't matter what happens. It's gonna be better either way is your opinion. Okay. This is what I was trying to get at. [Chair ]: Anyone have any other questions for Mike? [Leslie ]: And I I would just make one statement, man, too. If we came back here in two thousand twenty six and we found out that, something that we did today was detrimental. We can people around disabled can change it. They can do what we're doing right now. [Chair ]: But, like, I said, we I think that That's why you come back. Yeah. And that not I don't believe that anything that we're doing in this bill is detrimental to the the small group market. That is unchanged. So this bill doesn't address that, and this bill doesn't address the individual marketplace or the the tax subs the federal tax subsidies. This bill really has nothing to do with that. It's just that that was the reason for merging them in the first place. And so that's something that we need to be cognizant of in perhaps other legislation or budget or anything else that we wanna discuss. So this bill doesn't make this bill does not address any of the issues that we have in the individual market. Right. Mari, did you want to say so? Oh, I'm sorry, Leslie. I just looked over in this direction. So I there, Mari. We're cold. Just to make go on with this timeline problem, I understand about this bill totally that I know, you know, going forward. But let's say in topic scenario, we we go through this session. We don't have any response yet because we don't know information. Then we get information. By the time we connect next year, there's gonna be a gap for a population of people. Probably, there will be downside effects. I'm not I have no solution clearly, but I worry about it. I'm worried. And that's that's all I'm saying is that, yes, we can wait and be patient. I I once again, I was just wondering, can we get something in place to protect the case? And maybe we can't, and I don't know. It's certainly not my brief. But once again, if we don't, then there's this gap for our population, if that's something to that. Laurie, and then I'll say something. [Leslie ]: I was [Chair ]: gonna say [Woody ]: maybe comment to that. I think what Topper said is what we have to focus on right now. We need to see the governor's address on Tuesday and then hear over the report and take up testimony. I mean, the the answer is money. Yeah. Mhmm. I mean, let's be clear with that Yeah. The answer is. [Chair ]: What I was gonna say is I was I just wanna remind everybody of the chart that Veeva showed us today that had the how much it costs to ensure the individual market. I don't know if this is going on YouTube the right way with directional. And how much the premiums are for the small group market. And if we merge them back together, which would happen minus our inaction of doing anything here because the unmerge goes away, then what would happen is that the small group and the individual group would meet somewhere around the middle, and I'm sure there's actuarial stuff that but let's just say for all intents and purposes, they would meet in the middle. The small group market would go up significantly. The individual market would come down slightly. And whatever Congress does regarding the tax credits doesn't change anything significantly that the individual market would be losing other than their premiums might go down a small amount. But in the meantime, the small group market would go up. [Mike Fisher ]: And and that just leads me to wanna say one more time, we have precious few strategies to reduce the costs in the small group, and we're worried about the small group. We have quite a few strategies. Gonna take money, but we have some strategies to think about what to do in the individual group, how to respond to things that congress does or doesn't do. But but maintaining a separate individual and small group is the action you have to to avoid what the chair just said, increase costs in the small group. [Chair ]: I'm sorry. Go ahead. And there's no way that you that the BPA could be targeted just towards, like, the small business. Like, if you you're talking about a small group of people, we have to do it all. [Mike Fisher ]: We're supposed to have a big, long conversation about what to do with BPA another [Chair ]: day. Okay. Right. Any yeah. What is comment [Mike Fisher ]: in next year's budget, I would I would never assume anything. But we would think that DIVA is planning for perhaps the inevitable loss of of federal funding funds, and we'll have that in the budget for next year. I I hope you're right. [Chair ]: We get to save the budget Tuesday, I believe. [Mike Fisher ]: So the recommendation. [Chair ]: The recommendation. The recommendation. Thank you, everyone. Thank you. Thank you. Sarah, do you wanna join us? [Sarah Teachout ]: Afternoon. Thank you. Sarah Teachout representing Blue Cross and Blue Shield of Vermont. I'll state it very clearly. Blue Cross strongly supports passage of this legislation to keep the two markets separate permanently. There are several reasons that we support that. I was gonna start with a little history. So when, when the cost sharing reduction payments to insurers were eliminated, Vermont was the only state in the country that could not respond immediately to those changes, in part because we had this merged marketplace, and it requires legislative action to separate them and do the silver loading strategy that we now have in place. It was pretty cumbersome, so and I heard it incorrectly, so I'll say it correctly. Insurers are required to pry provide these benefits, the silver loaded benefits, to members who qualify for them, and the federal government in turn pays the insurer to cover the cost of those benefits. When the federal government stopped paying, we still had to provide the benefits, so it came out of our reserves. So that's what happened for one year. Mhmm. We became like every other state after, whole group of us got together and recognized that it was a better approach for Vermonters, and that's the place we've been in. I think there's a lot of reasons to make it permanent. Standing out and being the only state with this unusual structure when we're probably going to have to respond to a lot of federal changes that could be not beneficial for the, you know, the residents of the state, it puts us in a position that's more similar to other states and it makes it easier to respond. So that's one of the reasons we support it. We also support it for, stability in the healthcare marketplace. I completely understand why the legislature did this temporarily at first and then extended it for a few years for a while while we were all working out what could be done. But we need to make a permanent decision. It's better for the marketplaces to know where we're gonna be. And then the last reason you know, the most important reason is this benefits for Monitors. For Monitors receive more money in federal subsidies through this program than they would if we remerged the markets. Again, we know that we don't really know what's gonna happen. So that's the problem, and and, you know, some of the things you're wrestling with. I would say I have no idea what's gonna happen in Congress, but there is a coalition, in Washington, DC being funded by healthcare the healthcare community broadly, providers, payers. It's called I had to look it up. It's called, Keep Americans Covered. It was started over a year ago. And what they've done and they have an interesting website if you want to look it up, but they've quantified the benefits in every state of the advanced premium tax credits to the residents of every single state in the country. They've also calculated those benefits and showed how many people are benefiting from it, and the idea is to educate members of Congress on how important this is for their constituents. So, you know, I am hopeful that, they will look at that and recognize the good it's doing for this country and the people who need those subsidies. So I won't, labor it, but I we really support the bill. We really also would like it to pass quickly. And the reason for that is we're already planning with the Green Mountain Care Board to make two filings for next year showing the rates if the subsidies go away and the rates if they continue at the federal level. And this adds another layer of complexity because then we'd have to have rates going away, merge marketplace, rates going away, unmerged marketplace, rates continue, you know, subsidies continuing merged and unmerged. It just makes it really complicated and very difficult to plan. [Chair ]: And so you have to have your rates in to the macro. It's early in May when you start planning that. [Sarah Teachout ]: We've already started our actuaries are working on it. We file early May. [Chair ]: Okay. So it would be very beneficial if we did this as expediently as possible. Yes. So we decision on that. [Sarah Teachout ]: You and thank you for considering the [Chair ]: book. Brian? [Brian (unknown role) ]: Yeah. I think it I mean, it's it's really clear that the decision is the and I'm I'm I'm rereading the report while you're both talking to me just to, like, reduce the need to ask questions. It's really clear, like, that it's beneficial regardless of what happens federally. It's not in this bill, but it's been referred to in the And so we don't have to get into this in detail today, but I wanted to just ask this, and then we could always talk about it later. That if the federal policy changes and people can't get that those subsidies anymore, and they and then the people in the individual market can't afford the plans and they start dropping into n twenty six, what would be the impact moving forward on the cost of premiums when if the if the pool starts to shrink? [Sarah Teachout ]: Right. So some of that is in that report. [Brian (unknown role) ]: There's an This is what I'm looking at. [Sarah Teachout ]: Yeah. There's an assumption of how many people would forego health insurance coverage because the costs go up. And then I don't think we know yet, but our our actuaries would make an assumption about who drops and who keeps coverage. We all know that the people who are likely to maintain coverage are people who really need it. They're older and they're sicker. And someone who is perhaps younger and healthier might be the person to forego coverage. So then that makes the risk pool Exactly. Less healthy and the premiums go up. [Brian (unknown role) ]: So what I'm hearing though is that it's it's it's unpredictable. It's very unpredictable what the the impact of that federal change would be. [Sarah Teachout ]: And there's also the other you know, there's it's not just APTC stays or APTC disappears, is some negotiated compromise that Congress comes to, which could be good or it could be bad. We don't know. It's very hard to plan for that kind of middle ground as well. [Chair ]: Thank you. Thank you. Anything else for Sarah? Thank you. Thank you. Sarah? We were scheduled for a break, and then we were going to have CFR in at two fifteen, but I noticed that they're here. So if they would like to just continue [Mike Fisher ]: Sure. [Chair ]: Emily, if you want to come up? Sure. [Emily Brown ]: Everyone. Hello. I see some of you again. My name is Emily Brown. I'm the deputy commissioner of insurance at the Department of Financial Regulation. And I did wanna ask, I know there's a few new members if you want me to do a high level overview of what our department does, or I can save that for another time and just talk about the bill. [Chair ]: Yeah. Okay. We have time. So, yeah, let's just do that. [Emily Brown ]: Do a very high level, and if you want me to come back and provide more details or talk about it in more depth, I can do that. So there are several different aspects of healthcare and health insurance regulation in our state. The Department of Financial Regulation largely oversees the commercial health insurance market in Vermont. So when I say commercial health insurance market, that doesn't include Medicaid and it doesn't include Medicare. So Medicare Advantage, original Medicare that is held by the federal government, and then Medicaid is held with the feds as well as the Department of Vermont Health Access, who I think you heard from this morning. So within the commercial health insurance market, there's a lot of different types of health insurance. The one we're talking about today is major medical health insurance, qualified health plans. Those are the plans that you think of when that provide comprehensive coverage and that you would buy on the exchange or you receive from your employer. There are a lot of other types of health insurance products we regulate, such as Medicare Supplement, indemnity products, as well as accident and sickness policies. For major medical, we have kind of a nuanced role. We are the enforcers of the Affordable Care Act at the state level. So while DIVA administers the exchange, the Department of Financial Regulation enforces the federal laws and the state laws that apply to the Affordable Care Act. So, we work really closely with them on these types of issues whenever they arise. And then for major medical health insurance, our department oversees the solvency of domestic insurance companies who offer major medical products. So, in the case of Vermont, there's only one company, Blue Cross Blue Shield Vermont. And then we also approve the health insurance policies that are sold in the state for qualified health plans or major medical policies. There are some nuances there, which I won't get into, but then you have the rate review for most of major medical done by the Green Mountain Care Board, who we also work with whenever we're doing our form review. There's kind of a stacked process and timeline that we all work together on to make sure that approval process happens. So we're here today because while DIVA is definitely the subject matter expert on the exchange and the subsidies, we are the department that has the enforcement authority over the insurers in this market and making sure that they're complying with our state law. Is that enough of a background? Any questions before I talk to the bill? [Chair ]: Just how many insurance companies are licensed to sell insurance in our state? [Emily Brown ]: Yep. So there's two different types of insurance markets. There's the fully insured market, which you could consider the state regulated market, I think. I saw Jordan Etsi from MVP, I think it was yesterday, come in and talk give you that pie graph, right, where he kind of talked about the self insured or federally regulated plans. And then kind of there was a a grayed out section, which was the small group, individual, and large group. Mhmm. So that's the area that we regulate. So within that that area that we regulate, there's three insurers. [Chair ]: K. [Emily Brown ]: There's Cigna, there's MVP, and there's Blue Cross Blue Shield Vermont. The rest of the commercial health insurance market is regulated at the federal level. They're called ERISA plans, or it falls under a federal law called ERISA, which again, I can come here and talk more about later. And that is not under state authority. So, whenever we pass laws in Vermont, our laws do not apply to that self funded or ERISA employer plan or health insurance plan. It just applies to our fully insured or state regulated market. And there's about eighty thousand covered lives in that market right now. Alright. Did you have a question? [Speaker 3 ]: Yeah. I was just wondering if you want to it's not related. Do you want to touch really lightly on how PBMs are involved with HP? [Emily Brown ]: Yeah. So, we do regulate other types of, entities who have a part a a role in the health care system. One of those is pharmacy benefit managers. So last year, the department, received licensing authority over these entities, and what they do is they essentially manage the prescription drug benefit for your health insurance plan. So when you go to a pharmacy and you get your drug from the pharmacist, it's actually the PBM that is reimbursing the pharmacy for that drug, not your health insurer directly. So the health insurer contracts with the PBM, who then is charged with developing the formulary. So the formulary determines what drugs are covered, what cost share. They also do utilization management, which means that they decide how drugs should be used and can be used in some instances. So, we license actually January one, twenty twenty five. Any PDM who's newly operating in the state has to license with the department. In that timeframe they have is a year for PDMs who are operating right now in the state. They have till January one, twenty twenty six. So we're we've set up a licensing page on our website, and we're I think we've received one license application so far, so we're starting to get into that process, which should be fun. But yeah. So PBMs are a very large part of our health care system. There's been a lot in the news about it, and I I know, a colleague, Sebastian Arduango, he would be happy again to do a refresher on PBMs for for your committee. I know he's been in here before. [Speaker 3 ]: I was I was gonna ask if you would be prepared if we did have, the department in Sure. To give a report on how the licensure works. Yes. Definitely. I think you just answered. Yeah. [Emily Brown ]: Yeah. It's it's starting. Yeah, we'll see. [Chair ]: It could bring there one as an example. Yeah. Oh, thank you. Yeah. Do you administer or enforce anything with third party administrators? Yes. [Emily Brown ]: You know, I'd have to look back. We have a regulation that governs how third party administrators, TPAs, you'll hear that acronym. It's a lot of acronyms in health insurance and health care, so I'll try not to use them. But you'll hear the phrase TPA, and so that's a third party administrator. And they a lot of times, for employers who decide to self insure, though I talked about the federally regulated plans, What they do is they'll hire a TPA, third party administrator, to administer their health benefits, the benefits they're offering to their employees. In that way, they're able to have the formulary, have the benefit design. But it's essentially a company that's administering or operating the health insurance plan for the employer. [Chair ]: Any other questions before Emily moves on to page thirty five? [Emily Brown ]: Great. So our department does support age thirty five. We worked with Diva on this, and I don't want to you know, for all the reasons that they pointed out this morning, you know, saving small groups money, more affordability mechanisms for the individual market than there are for the small group, and then really no clear advantage to uniform reading and plan design. So, we support the bill and maintaining the unmerged market, the status quo as it is now, for the foreseeable future. And I will emphasize again, as several individuals have before me is the timing. So we do have a March deadline. DFR is the entity that would be filing for any changes with the federal government for adjusting our market structure. So we do urge the committee to move quickly on this and support this bill. [Chair ]: And you have no I'll ask the same question. You have no problems with any of the other sections of the bill? No. Just the technical. Yeah. Technical [Emily Brown ]: corrections also we support. Yeah. I think it's a good opportunity to clean up some of the language. Great. [Chair ]: Well, thank you. Thank you. If there weren't any questions, no? [Brian (unknown role) ]: I a question for you, but I have to ask. [Chair ]: Okay. [Brian (unknown role) ]: Or for the committee, not you, but it's through you to the committee. Okay. We haven't heard from anyone yet who has expressed any opposition to this. Right? [Chair ]: Not as of yet. We do still have one more scheduled witness. This might be a good opportunity for, me. We reached out to several entities to see if they wanted to comment. It is my hope, you know, with the expediency that everyone, I think, has expressed to us that tomorrow we can have committee discussion and the final markup of this and that we vote this out tomorrow. So for anyone who's listening, wants to comment or wants to speak on this bill, then I would suggest that they contact us and can submit written testimony, but we probably will be voting this out tomorrow. [Brian (unknown role) ]: It's a I was getting at kinda like seeing if we you were ready, you know, like, you make a last call for witnesses kind of thing. Yeah. So twenty four hour notice, like, last call. You know, if you have any opposition in the house, it's your chance. [Speaker 3 ]: Last call. Yeah. [Chair ]: I I think we're gonna go is Megan in the room by any chance? I she wasn't scheduled until later. So why don't we [Mike Fisher ]: take [Chair ]: a break?

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