Lawmakers approve emergency measures for COVID-19 response  

On Wednesday, the House advanced H.742, the omnibus health care and human services bill that addresses the state’s response to COVID-19. The bill provides administrative and provider flexibility in responding to the pandemic. It also includes a variety of changes to labor law to accommodate a surge in applications for unemployment insurance due to this crisis. The bill is now awaiting action by the governor.

The bill:

  • Increases flexibility for the Agency of Human Services to address theCOVID-19 pandemic by:
    • Waiving or modifying existing rules, or adopting emergency rules and considering the importance of the financial viability of providers that rely on public funding;
    • Modifying hospital provider taxes and waives or modifies other provider taxes;
    • Waiving or permitting variances from the AHS health care and human service provider rules as necessary to prioritize and maximize direct patient care;
  • Requires all health care facilities and human service providers in Vermont to follow guidance from the Department of Health regarding measures to address employee safety, to the extent feasible;
  • Allows the Green Mountain Care Board to waive or permit variances from laws, guidance, and standards related to hospital budgets, certificates of need, health insurance rate review, and accountable care organization budget review for up to six months after the emergency;
  • Requires the Department of Vermont Health Access to relax provider enrollment requirements for Medicaid, and the Department of Financial Regulation to direct health insurers to relax provider credentialing requirements for health insurance plans;
  • Allows the court or the Department of Mental Health to waive any financial penalties for a treating health care provider’s failure to comply with statutory documentation and reporting requirements for involuntary treatment;
  • Specifies that it is not the emergency involuntary procedure of seclusion for a voluntary or involuntary patient to be placed in quarantine if the patient has been exposed or tested positive for COVID-19;
  • Directs DFR to consider adopting emergency rules to expand health insurance coverage related to COVID-19 and to waive or limit cost-sharing requirements, to modify or suspend health insurance plan deductible requirements for all prescription drugs, and to expand patients’ access to and providers’ reimbursement for health care services delivered remotely through telehealth, audio-only telephone, and brief telecommunication services.
  • Reimburses Medicaid-funded long-term care facilities and other programs providing 24-hour per day services for their bed-hold days.
  • Offers changes to prescription drug coverage requirements, and prescribing laws to:
    • Require all health insurance plans and Medicaid to allow members to refill prescriptions for chronic maintenance medications early so individuals can maintain a 30-day supply of each medication at home;
    • Allow a pharmacist to extend a previous prescription for a maintenance medication if the patient does not have any refills left or the refill authorization recently expired and if it is not feasible to get a new prescription or more refills from the prescriber;
    • Allow a pharmacist to substitute an available prescription drug for an unavailable one in the same therapeutic class if the available one would have substantially equivalent therapeutic effect even though it is not a therapeutic equivalent drug; and
    • Allow a health care professional to authorize renewal of an existing buprenorphine prescription without an office visit.
  • Increases health care professional licensing flexibility by:
    • Allowing professional regulatory boards attached to the Office of Professional Regulation to issue a temporary license during a declared state of emergency to a graduate of an approved education program if licensing examinations are not reasonably available;
    • Allowing the Board of Medical Practice to issue a temporary license during a declared state of emergency to a physician, physician assistant, or podiatrist licensed in another jurisdiction, free of charge, for 90 days or until the state of emergency ends, whichever occurs first, and allows the BMP to reissue the temporary license if the state of emergency continues for longer than 90 days;
    • Allowing the BMP to waive supervision and scope of practice requirements for physician assistants during a declared state of emergency;
    • Deeming a health care professional licensed, certified, or registered to provide health care services in any other U.S. jurisdiction as licensed to provide services to patients in Vermont using telehealth;
    • Allowing the Board of Nursing to waive or modify a collaborative provider agreement requirement as needed to allow Advanced Practice Registered Nurses to practice independently during a declared state of emergency; and
    • Allowing OPR and BMP to issue temporary licenses, free of charge, to former health care professionals who retired from practice in Vermont.
  • Expandstelehealth insurance coverage by:
    • Requiring health insurance plans to reimburse providers the same amount for the same services whether provided in person or through telemedicine;
    • Requiring health insurance plans to reimburse for services delivered by store-and-forward means;
    • Expanding existing telemedicine coverage to include dental services;
    • Allowing for waiver of telehealth requirements relating to HIPAA-compliant connections if it is not practicable to use such a connection under the circumstances and for waiver of informed consent requirements if it is not practicable to obtain or document informed consent under the circumstances; and
  • Allows the DCF Commissioner to direct more than statutory limit of 0.5 percent of the fiscal year 2020 Child Care Financial Assistance Program appropriation to assist childcare programs that are at risk of closing due to financial hardship.

H.742 was amended to include a variety of changes to labor law to accommodate a surge in applications for unemployment insurance due to this crisis. Under the bill:

  • Employers’ UI rates will not increase because of benefits paid to an individual who quits employment for good cause related due to:
    • Self-isolation or quarantine at the direction of qualified authorities;
    • Need care for or to assist a family member who left employment because of an unreasonable risk that they could be exposed to or become infected with COVID- 19 at work; or
    • Need care for a child under 18 years of age because the child’s school or childcare has been closed or the childcare provider is unavailable due to COVID-19.
  • Employers UI rates will not increase because of COVID-19 temporary closures, an order issued by the Governor or President, or employees temporarily laid off in order to comply with a quarantine;
  • UI rate relief is offered if the employer rehires laid off employees within a reasonable period of time after operations resume or once the employee’s period of quarantine is completed. This relief is limited to eight weeks of benefits or a longer period at the discretion of the Department of Labor.
  • Individual can receive benefits if they quit employment for good cause due to:
    • Self-isolation or quarantine at the direction of qualified authorities;
    • An unreasonable risk that the individual could be exposed to or become infected with COVID-19 at work;
    • To care for or to assist a family member who is self-isolating or quarantining at the direction of a healthcare provider, public health authority, the Governor, or the President;
    • To care for or to assist a family member who left employment because of an unreasonable risk that they could be exposed to or become infected with COVID- 19 at work; or
    • To care for a child under 18 years of age because the child’s school or childcare has been closed or the childcare provider is unavailable due to COVID-19.
  • An individual’s ability to receive UI benefits is limited if they are receiving sick pay, or other benefits provided pursuant to federal programs.
  • Provides that individuals will transition from State UI benefits to federal wage replacement benefits if and when the federal government makes them available.

AHS senior leadership provides efforts to address COVID-19 to Senate Appropriations

The Senate Committee on Appropriations Committee received a COVID-19 update from the Department of Vermont Health Access, the Department of Disabilities, Aging and Independent Living, and the Department of Mental Health on Thursday on its current efforts to address the crisis. DVHA Commissioner Cory Gustafson reported that DVHA is developing a “methodological approach to financial relief options to address immediate and ongoing needs.” The Vermont Association of Hospitals and Health Systems and individual hospitals are putting together a scope of need to determine where resources need to be directed. Efforts are being made to create a more predictable cash flow model for non-hospital providers and DVHA will also be giving lump sum payments to certain types of providers who are in most need of financial assistance.

Department of Mental Health Commissioner Sarah Squirrell said that DMH is well poised to provide financial stability to the designated mental health agencies and specialized services agencies who receive lump sum payments at the beginning of the month. Staffing shortages are a concern for the agencies, the Vermont Psychiatric Care Hospital and Middlesex Therapeutic Community Residence. Squirrell reported many staff call-outs and a loss of travel-nurse staff due to recruitment to other higher paid positions.

In response to questioning by Sen. President Pro Tem Tim Ashe, DAIL Commissioner Monica Hutt said that there was no plan to re-open adult day centers and have them function in the same way as child care centers. She said that the population that attends adult day programs is the one that is most at risk and it would be a recipe for continued contagion and disaster. Hutt consulted early on with Vermont Department of Health about the issue and said that she “would like to believe that the reason that we haven’t seen an even bigger spread, is because we closed them early on.”

Appropriations committees receive situation report on Vermont financial situation

The Senate Appropriations Committee received a situation report on Vermont’s financial situation from Department of Finance and Management Commissioner Adam Greshin on Thursday. Vermont currently has a robust $228 million in reserves, which can be used to “tide us over” until delayed payments are received, but Greshin said that it’s not a long term solution. He said that a reduction or postponement of discretionary spending was likely necessary, and rescissions would be difficult to avoid. Federal funds that have been and will be incoming are critical for standing up and sustaining Vermont’s relief efforts.

The most recent Federal bill, the Coronavirus Aid, Relief, and Economic Security Act, was signed into law on Friday. The $2 trillion stimulus package will offer enormous relief to states and individuals, with Vermont’s share expected to be up to $2 billion dollars. But Vermont policy makers and their fiscal advisors are trying to understand how the money can be used. Joint Fiscal Office Chief Fiscal Officer Stephen Klein told the House Appropriations Committee that the money is supposed to arrive within 30 days and will cover activities after March 1, 2020 and through the end of the year. The main issue will be determining what qualifies as “necessary expenditures incurred due to COVID-19,” with Klein admitting there is a lot of “grey” with that delineation, such as whether lost revenue can be covered. A summary of the CARES Act can be found here.

Klein also provided a quick overview of the formula funding for Vermont in the first the two stimulus bills. Klein highlighted that for the money that comes in through an existing program, like Low Income Home Energy Assistance Program, there is no need for legislative action. That will just be distributed to the appropriate agency. For new activities, legislative action will likely be required. Rep. Bob Helm, R-Fair Haven, asked if programs like LIHEAP could be expanded to fund other things, and Klein said likely yes or it could maybe be carried over for the next year.

The next steps for the committee include reaching out to more contacts to better understand the legislation, determining if there is a claw-back provision and what that entails, and coordinating with the Administration to see what the best course of action is.

Woodside facility to temporarily transition to COVID-19 psychiatric facility

The Woodside Juvenile Detention Facility was closed temporarily on Tuesday due to the need to utilize it as a psychiatric facility to house patients with symptoms of COVID-19.  Department for Children and Families Commissioner Ken Schatz announced the closure to legislative committees on Wednesday and reported that the four youths that were at Woodside were moved to a facility in St. Albans. The Department of Mental Health said that an isolation facility was needed for patients who required appropriate psychiatric care and had mild COVID-19 symptoms. The facility will likely be up and running in ten days, and until then, there is capacity in the health system to handle patients.

On Friday, Vermont State Employees Association Executive Director Steve Howard updated the Senate Judiciary Committee on efforts to address staff issues relating to the transfer of youth housed at Woodside. Howard said that the staff are 100 percent committed to making the transition work and are dedicated to taking care of the youth, but the sudden move created problems. The DCF commissioner has responded to staff housing issues by lodging staff in a hotel in St. Albans and in response to security concerns, an alarm system will be placed on the front door and locks will be installed on the windows. Issues that remain unaddressed include a lack of guidance on programming and inadequate personal protective equipment supplies. The current census at the facility in St. Albans could increase if there is a need for additional delinquent youth housing.

Department of Mental Health recommends temporary move of Middlesex residents

Department of Mental Health Commissioner Sarah Squirrell told the House Health Care Committee on Friday that they are recommending the temporary transfer of Middlesex Therapeutic Community residents to the Vermont Psychiatric Care Hospital. DMH currently shares staff between the two facilities, and staff have been cross-trained at each. Middlesex patients will not be registered at VPCH and will occupy their own separate unit. There are currently seven residents of Middlesex and 16 at VPCH. VPCH has 25 beds.

House health committee receives updates on COVID-19 response

The House Health Care Committee heard from the Department of Financial Regulation on Friday on its draft telehealth emergency rule, and the Department of Vermont Health Access and health insurers on their actions taken in response to the COVID-19 crisis.

DFR Assistant General Counsel Sebastian Arduengo said the proposed emergency rule is the result of collaboration with stakeholders and requires health insurance plans to provide coverage for services provided through telehealth or audio as if they were provided in person. The rule would also require health insurance plans to provide the same reimbursement rate to providers for the services using equivalent service codes as if service were delivered in person. The requirements that the provider must have an existing relationship with the member is waived during the crisis, as are co-pays for testing and visits related to the COVID-19. The implementation date of the store-and-forward provisions included in H.742 will be moved up to May 1, 2020. DFR said that the emergency rule will be in effect after filing and the governor signs the bill.

Blue Cross Blue Shield of Vermont Director of Government Affairs Sara Teachout said that BCBS has already implemented the telehealth directives included in DFR’s draft emergency rule and both MVP and BCBS reported that they have already changed many policies and procedures in response to the current crisis. Enrollment periods are open, prescriptions can be filled early, prior authorizations are suspended for a number of different services, and cost-sharing is waived for COVID-19 tests and visits.

DVHA reported that Vermont Health Connect opened a special enrollment period last Friday and it will be open until April 17. Anyone who does not currently have health insurance can enroll in a qualified health plan if they otherwise qualify. DVHA Deputy Commissioner Addie Strombolo said that 50 households have signed up already. If enrollees had previously had coverage terminated for non-payment, they are required to pay arrears before coverage is activated. For Medicaid, DVHA has taken steps under their existing authority to facilitate enrollment, including temporarily waiving financial verifications for those seeking to enroll. They recently processed about 300 enrollments and are processing only voluntary terminations. Strombolo stressed that if someone loses private coverage for non-payment, they may qualify for Medicaid due to change in financial circumstances.

Green Mountain Care Board takes action to respond to COVID-19 needs

The Green Mountain Care Board unanimously approved a bulletin this week that allows the board to take expedited action on new health care projects needed in response to the COVID-19 crisis. The bulletin allows the board to act in less time than a normal review would require and allows the board to exercise its discretion to review applications for the projects without notice and opportunity for public hearing or intervention by any party. H.742, which is awaiting the governor’s signature, grants this flexibility, but the board chose to pass the bulletin as an emergency stop gap measure to address hospitals that need certificate of need approval immediately.

The board declined to vote on hospital budget guidance, with Chair Kevin Mullin stating that “taking a vote on budget guidance today would be a waste of people’s time and would provide confusion to hospitals on the timeline when they need to focus on the crisis.” GMCB staff is working up different scenarios for the upcoming fiscal year, and once they have authority granted by H.742, the board will likely shift budget deadline dates.