House embarks on remote voting
The House took historic action on Thursday, approving a rule change to allow legislators to vote remotely. The legislators are now using an app, Everbridge, to cast their votes from their living rooms, bedrooms, kitchen tables, and porches. The technical issues that vexed lawmakers as they became accustomed to using Zoom for committee meetings was magnified by the large number of members participating on Thursday, and compounded by the new technology that they were using.
For those viewing the proceedings, only a portion of the legislators were visible onscreen, and the relentless online meeting refrain to “mute oneself” was spoken by the House Speaker on many occasions, most notably after an anonymous legislator let some colorful language fly during the voting process. Those unable to make the app work, or who had issues with their remote connections, called the House Clerk to register their vote, or voted by video roll call. Despite the clunky process, the body passed five COVID-19 related bills.
Although the ability of the House to meet remotely now is critical for the state’s response to the crisis, the viability of the House to continue meeting remotely to handle more contentious and complex legislation is questionable. It is unclear if there is an intention of continuing to meet remotely to consider issues unrelated to the COVID-19 crisis.
Senate panel delays vote on incentive pay proposal
The Senate Appropriations Committee reviewed the latest proposal on Friday to address the issue of essential workers who continue to work, risking exposure to the COVID-19 virus, but who are in a worse financial position than individuals who hold similar jobs choose not to work and receive unemployment benefits. Senate President Tim Ashe said the next step is a discussion with the Scott administration and House leadership on Monday to get a read on where they are at. He has briefed them a number of times and the Senate needs a signal that they are part of this cause.
The voluntary program would be employer-based and would require employees to meet certain criteria. Employers would have to verify employee information. The Joint Fiscal Office provided a preliminary cost estimate of $89 million for the program. The committee agreed that eligible employees would include frontline workers earning $25 an hour or less as a base wage. Grant payments to eligible employees would be $1000 a month for up to three months. The list of eligible workers include health care providers, child care facilities, ambulance services, grocery stores, pharmacies, mortuaries, and certain retail entities.
The committee spent considerable time discussing how to address licensed professionals employed by nursing homes and home health agencies who make more than $25 an hour and who are providing direct patient care and are at high risk, but would be precluded from eligibility. The committee agreed to exclude from the wage cap covered employers who receive reimbursement for services through the Agency of Human Services through a rate setting process, a grant, or as established by rule.
The proposal includes language that the state will only expend the funds to support the program in the absence of a specific federal program that supports eligible employees and employers. Any federal program that offers the same benefits will allow the state to shut down this grant program and use the community reinvestment funds elsewhere.
Ashe said states are starting to see restrictive guidance from the Trump administration about the use of these funds, which has created a lot of uncertainty. The Trump administration has said the funds can be used for “hazard” pay. Ashe said, “So in some ways having a first proposal out to use a significant number of dollars for hazard pay sticks out like sore thumb even though it is precisely what some of these funds were meant to do…but it puts us in a slight disadvantage because people are likely to say ‘let’s not do anything and reserve the money because there may be some other use we prefer later.’ But at a certain point you have to start making choices and with this particular set of employees I think it is critically important that we step up.”
Panel hears update on drug supply shortages
The Senate Health and Welfare Committee continued its discussion on Thursday on the availability of medications that are used to treat specific chronic diseases that have been diverted for the treatment of COVID-19 patients. Legislative counsel Jennifer Carbee provided the committee with an overview of what other states have done related to the use of Hydroxychloroquine, Chloroquine, and Azithromycin, a drug often used in conjunction with hydroxychloroquine. Carbee said in general, states are directing pharmacists to use discretion and their professional judgment when filling these prescriptions. Carbee said several states have provisions that hydroxychloroquine not to be used as prophylaxis, that there be quantity limits when pharmacists fill a prescription, and that pharmacists restrict newly established prescriptions.
Blue Cross Blue Shield of Vermont Director of Pharmacy and Vendor Management Brian Murphy addressed steps that his organization has taken to prevent the stockpiling of five specific drugs that have potential indications for COVID-19. He said any new prescriptions for Hydroxychloroquine, Chloroquine, Azithromycin, Cellectra, and Albuterol now require a prior authorization. BCBSVT will approve prescriptions for any existing user of those drugs. Any new prescription for those specific drugs for non-COVID indications will be approved. Murphy said BCBSVT will remove these restrictions and prior authorization requirements once the pandemic ends.
Vermont Retail Druggist President Jeffrey Hochberg said most of these drugs are very difficult to get at this point in time. At the end of March pharmacies across the country saw a huge uptick in volume – large amounts of prescriptions going out the door and supplies being quickly depleted in central warehouses across the country. Hochberg said the bigger concern is that every single drug is going to have a supply problem, in particular generic drugs, which are 90 percent of Vermont’s volume. He predicts that there will be more drug shortages throughout the summer. Hochberg also urged caution regarding two drugs in particular – Azithromycin and Albuterol. These drugs have numerous indications and the state should be careful what kind of stops are put in place on the insurance side and the adjudication process. His presentation can be found here.
Office of Professional Regulation Director Lauren Hibbert reviewed the Emergency Regulatory Order issued on April 10 with the committee. It requires Vermont pharmacies and pharmacists to employ enhanced drug utilization review to curb inappropriate prescribing of drugs believed to be under investigation for COVID-19 indications. Hibbert said the intent is to make sure that a pharmacist reviews a prescription for a documented diagnosis, that the drug is reasonably indicated for the diagnosis (not prophylaxis for COVID-19), and that the diagnosis and drug are plausibly within the prescribers scope of practice. There have been reports that prescribers are prescribing to themselves or their immediate family.
Judiciary committee reviews impact of support services for released prisoners
The Senate Judiciary Committee took testimony on Wednesday on the impact of support services for released prisoners. Committee chair Dick Sears, D-Bennington, wants to ensure better outcomes and reentry at release through advance planning and cooperation across systems. People who are reentering their communities from incarceration will have to adjust to these changes all at once. Sears referenced the Council of State Governments Justice Center’s seven key questions to be asked in advance of the release of individual to a community. He is concerned that when individuals are released the services needed will be disjointed or not available.
Department of Corrections Director of Field Services Dale Crook said operating the DOC in this environment has been very challenging. In an attempt to limit the spread of COVID-19, the department has taken a thoughtful approach to community releases and expanded the use of furloughs. This approach had reduced the state’s incarcerated population to 1385 from 1670. The reduction has allowed DOC to provide isolation and quarantine rooms. Any new offender entering the system is automatically quarantined for 14 days before being sent to the general population. The state has also minimized face-to-face contacts with offenders.
Peter Mallary, Vice President of Government Relations and Community Outreach for the Vermont Association for Mental Health and Addiction Recovery, said his members are trying to use technology at its most effective level possible. Every day they have a recovery check-ins to reach out to people to give them help and direction. VAMH is also responsible for “recovery coaches” for the state. Recovery coaches are certified peer and ally workforce in the fields of addiction and mental health, and provide services for people in recovery. Mallary said VAMH will host its first virtual academy in early May. He said the need for coaches doing the peer-to- peer work is important now more than ever. The 12 recovery centers provide places for safety and support. Given the current state, the center and its clients face some real challenges in this atmosphere with meeting places closed. The centers have done remarkable work with technology, but staff is more burdened than ever trying to do outreach and peer-to-peer work.
Department of Mental Health Deputy Commissioner Mourning Fox said staffing continues to be an issue in all areas of the department’s work. However, most traditional referral avenues through the department of corrections continue for adult outpatient programs. Fox said the designated mental health agencies continue to do assessments and intakes for adult outpatient services as well as for community and rehabilitative treatment services for those with more serious and persistent mental health illnesses. Most of the assessments and meetings are conducted through telehealth at this time to reduce direct contact between individuals, but that becomes a barrier for individuals who do not have access to smart phones or tablets.
Fox did offer some positive news. The Collaborative Solutions in Integration Project in Washington County continues to have some of its case management services done face-to-face while still observing social distancing. Fox said having that ability to have face-to-face case management meetings has proven to be extremely helpful. Additionally, the Agency of Human Services Pathways Vermont Housing First Program saw its highest number of individuals placed in housing since they came to Vermont. The program immediately ends homelessness by helping individuals coming out of corrections or individuals with mental health needs to locate independent housing. The ability to avoid congregate housing helps decrease the risk of spreading COVID-19.
Panel passes EMS bill
The House Government Operations committee passed S.182 on Thursday, a bill related to emergency medical services and public safety in response to COVID-19.
The bill:
o Eliminates the need for EMS credentialing; o Extends licensing from one to three years;
o Requires health insurers to reimburse ambulance services directly;
o Allows for sheriffs to access emergency needs fund for COVID-19 needs; and
o Extends plumbers and electricians licenses.
Health committee reviews health care services to farm workers
The House and Senate Health Care committees met jointly on Wednesday to take up the issue of health care services available to Vermont’s immigrant farm workers.
Addie Strumolo, Deputy Commissioner of the Department of Vermont Health Access, told the legislators that DVHA has put temporary flexibilities in place to ease Medicaid enrollment, and opened a special enrollment period for Qualified Health Plans in order to allow uninsured Vermonters to secure coverage. Since March 20, 5000 households have enrolled in Medicaid, and 237 households have enrolled in QHP’s. The enrollment rate for QHP’s is not much different than the usual rate outside of open enrollment. However, undocumented immigrants are not eligible for Medicaid, and legal immigrants are subject to a five year bar. Medicaid can pay for emergency services on behalf of people who do not qualify for coverage solely based on immigration status, and DVHA is assuming that COVID-19 treatment is an emergency service. Several states have acted to explicitly expand the definition of “emergency medical condition” to include testing and screening for COVID-19.
Migrant Justice’s Will Lambek asked the committees to take similar action to ensure that COVID-19 related treatment costs will be reimbursed for Vermont’s undocumented immigrant farm workers. Lambek stressed that it will take only one person to get saddled with bills for the rest of the community to find out and not seek testing or treatment. He urged the legislators to remove barriers for treatment for the almost entirely uninsured population, saying that in this crisis, it’s not just an issue of equity and fairness, it’s an issue of health and safety for the entire state. Dairy worker Jose Ignacio De La Cruz described the tight living conditions on the farm he works at, with five to seven people living in one trailer and sharing bedrooms. It’s impossible to socially distance while living or working. He said “if one of us gets sick, we’re all going to get sick.” De La Cruz asked for the dairy workers to be treated like the other essential workers in the state, and for Medicaid coverage to be expanded to cover their pandemic related health care costs.
The Open Door Clinic, one of the state’s nine free clinics, described a case in Addison County where an undocumented worker who was hospitalized with a presumptive case of COVID-19, did not qualify for emergency Medicaid because he was unable to claim his children in Mexico as dependents and his income looked relatively high for his “household of one.” He also did not qualify for full coverage of his hospital stay from the hospital patient financial assistance program. Migrant Justice’s Lambek asked the legislators to look at ways to address the issue.
Georgia Maheras, Vice President of Policy and Programs for Bi-State Primary Care Association, described the work of Bridges to Health, a grant funded program run collaboratively by Bi-State and the UVM Extension Center that is focused on health outreach to the immigrant farm community. Bridges to Health regional care coordinators work with FQHCs, free clinics, Planned Parenthood clinics, and hospitals across Vermont to ensure that workers receive timely medical care. The program now provides services to approximately 49 percent of Vermont’s migrant farmworkers each year. During the crisis, in-person farm-visits by Bridges to Health staff have been temporarily suspended, but staff are performing drop-offs of supplies to meet health and education needs and are sharing COVID-19 information from the Vermont Department of Health, and the Centers for Disease Control, and other credible sources. Telephonic care coordination services are continuing.
The two committees will continue to look into the issue of Medicaid eligibility for farm workers and will reach out to the agriculture committees and the Agency of Agriculture to collaborate on finding solutions.
House appropriations begins review of CARES funding
The House Appropriations Committee heard testimony Wednesday from Joint Fiscal Office Chief Legislative Fiscal Officer Steve Klein, Moody’s Analytics Director Dan White, JFO Associate Fiscal Officer Maria Belliveau, and State Treasurer Beth Pearce. Klein told the committee that the $1.25 billion in Corona Relief Funds have arrived. The latest bill does not include language to allow the money to be used as revenue replacement. Klein shared the final plan for how to spend the money that was agreed upon by the Joint Fiscal Committee. The JFC proposes to allow $60 million go to emergency response expenses already made by the Administration, $150 million would be available for a quick response related to the emergency, and the remaining $1.09 billion would be appropriated through the normal legislative channel. For the quick response funds, the idea is that the Administration could request funds and the JFC would approve the request or decline it. The Administration could then pursue the request through the normal route of appropriation. Rep. Mary Hooper, D-Montpelier, was not in favor of expedited funding requests and would rather everything be appropriated by the legislature.
Moody’s Dan White explained that this unprecedented situation is difficult to predict. White detailed some of the results from Moody’s recent COVID-19 Stress-Test, which tests the amount of fiscal stress that states may be asked to absorb due to the pandemic. To provide some context, White said the country saw around 600,000 claims in unemployment in one week during the Great Depression, but the country has seen around 7 million during this pandemic.
White said that Vermont is doing very well in many respects, saying that the state has prepared well with the Rainy Day fund and will fare much better than other states that have no such fund. Rep. Kitty Toll, D-Danville, said that Vermont’s total reserves are usually between 12 and 18 percent of the general fund. White said that the reserves would be sufficient to get through a recession, but it may require closer to 20 percent to get through this pandemic unscathed. White said that Vermont is “in the middle of the pack” in terms of revenue loss. If all of Vermont’s reserves were used, only a five percent change in the budget would need to be made. White did not recommend using all of the reserves. However, not using all of the reserves will result in an even bigger impact.
JFO’s Belliveau gave the committee the latest COVID-19 Fiscal Update, showing that the projected revenue loss is the same for all funds, excepting the education fund. Due to a correction in sales tax data, the loss dropped from $89 to $69 million, and the FY 2020 to FY 2021 shift dropped from $51 to $42 million. To address the issues with the funds, the treasurer is requesting the legislature extend her ability of interfund borrowing this year, starting May 15 and ending August 15. Pearce explained that this will be at no cost to the tax payers. While both options would come at a cost, Pearce also explained that the state could use a line of credit or revenue anticipation notes. On Thursday, the committee voted on S.340, the bill that would allow for this temporary extension.
Health committees review DFR emergency rule on health insurance coverage
The House and Senate Health Care committees met jointly on Friday to review the Department of Financial Regulation’s emergency rule relating to health insurance coverage requirements during the COVID-19 crisis. The rule requires health insurers to waive cost-sharing requirements directly related to COVID-19 diagnosis, treatment, and prevention for fully funded insurance plans. Insurers must cover medically necessary testing, provider office visits to determine if testing is necessary, medically necessary in-patient or outpatient treatment, and medically necessary ambulance transport of members diagnosed with or suspected of having COVID-19 to and from treatment, recovery, or isolation areas with no cost sharing. If preventative treatment such as a vaccine is developed, insurers will be required to cover it with no cost share for their members. The rule is retroactive to March 13th, the date that the governor made the state of emergency declaration.
Vermont’s three biggest insurers – Blue Cross/Blue Shield of Vermont, MVP Health Care and CIGNA – were complying with most of the requirements of the rule before it was issued. They are now all fully in compliance, and although Employee Retirement Income Security Act (ERISA) restrictions exempt self-insured plans from the requirements of the rule, BCBSVT reported that a majority of their self-insured plans are following it.
Act 91 of 2021 also asked the department to look into requiring insurers to cover all prescription drugs without cost-sharing during the crisis, but DFR declined to include that in the rule after determining that it was not feasible. Several legislators asked about the possibility of waiving cost-sharing for maintenance medications for chronic disease treatment in order to prevent patients from ending up in the emergency department or hospital with expensive treatment needs. BCBSVT Director of Government and Media Affairs Sarah Teachout responded that eliminating cost-sharing for prescription drugs leads into an increase in people moving to brand name drugs and an increase in prescription drugs overall. Teachout also noted that they are limited by what they can do by the Internal Revenue Service for high-deductible health plans, and there are also concerns about drug shortages. All of the insurers have broadened their refill policies to allow for less frequent fills.
Legislators also asked for confirmation that a positive COVID-19 test is not required for the waiver of cost-sharing for treatment services. DFR responded that there is no requirement in the rule for a positive COVID-19 test. BCBSVT will confirm that there is no cost-sharing if a provider makes a clinical COVID-19 diagnosis and codes appropriately, but the patient either isn’t tested or has a negative test result.
Green Mountain Care Board
The Green Mountain Care Board met on Wednesday to receive a report from OneCare Vermont on its response to the COVID-19 pandemic and to vote on BlueCross BlueShield of Vermont proposed non-standard qualified health plans.
OneCare Vermont Chief Executive Officer Vicki Loner told the board that they are continuing to work to assure stability, predictability and flexibility in payments and programs to support providers. Fixed payments continue to flow, changes in the care coordination payment structure are delayed, and innovation grantees were offered the chance to pause. OneCare Vermont is also returning collected Medicare value-based incentive funds to hospitals and has stopped collecting funds to provide cash flow. For May and June, OneCare will pay all primary care practices their Population Health Management payment in advance to make cash available to these practices sooner. OneCare is also working with the state, the Center for Medicare and Medicaid Innovation Center and Health and Human Services to correct an unintentional miscalculation of Coronavirus Aid, Relief, and Economic Security Act funding for hospitals and independent primary care practices. Loner said that they will also continue to advocate for changes from payer partners to hold providers harmless from the impact of the pandemic.
OneCare deployed a new care coordination identification tool to help providers identify Vermonters who are most vulnerable during the COVID-19 crisis. The tool uses criteria developed by the World Health Organization, Centers for Disease Control, and Johns Hopkins and is aimed at keeping patients safe and out of the hospital, developing emergency plans, helping them with prescription needs, identifying social needs, and helping to support their management of chronic conditions. Thirty organizations are using it and reporting back that they are finding it very useful, and it has helped them identify people who are not able to or willing to pick up their prescriptions or go out and shop for food.
The Board also approved BCBSVT’s proposed non-standard qualified health plans, which include benefit enhancements for members with a diabetes or heart disease diagnosis. The insurer developed the new benefits, which include nutritional counseling and wellness drugs, based on feedback from customer service and clinical staff about what types of barriers challenged customers to manage their chronic conditions.
At the end of the meeting, Board Chair Kevin Mullin told the board that he is considering proposing a delay the submission of hospital budgets until the middle of the summer, and have it be a simple submission. The board would approve 3.5 percent increases to the 2020 budgets, and not engage in budget enforcement for the year. Although the question of two year budgets was raised, general counsel said that it does not have the authority to do one. Board member Maureen Usifer responded that she has been working with GMCB on this year’s budget process, and has engaged with several hospital CFOs who reviewed and supported a scaled down Profit & Loss balance sheet sample. Usifer said that she “wasn’t a hundred percent there for no enforcement for 2020.” She suggested that the board could delay the budget submissions until mid-summer, but then engage in “touchpoints” during the year to ensure that hospitals are financially viable and stable in the long term. The board may discuss the issue at the May 6 board meeting.