Good morning. House appropriations committee meeting on the top of our agenda is the, we're going to start out with the budget of the department of Vermont health access and we have with us. We're doing a joint committee meeting with the house health committee. So welcome all of you. It's nice to see you. Thank you. Thank you. We have. Here and we also have commissioner Gus. Gus. Fun. I can't say it because I'm on YouTube. I'm sorry, Corey. We have the commissioner here of diva with his team. And yesterday. The other committee of jurisdiction did hear that we are working off. This is a restated budget working off the 20. And we are working to get you the ups and downs from the January proposal and the ups and downs. From the restated budget. As well as refreshing everyone's minds as we go along of any possible language or changes that we were doing from the governor's recommend. So with that, Corey, we. Thank you. Thank you. Now from 830. 830 through 930. And then we have 15 minutes for committee discussion. So I'm hoping we can get through in an hour and welcome. And if you'd like to introduce your team, that would be great. But before we start representative. I have a couple of comments you would like to make. No, just great to be here jointly with you. Let's proceed. Nice to have you. Commissioner. Let's. Yeah. Good morning, Corey. Good morning to both committees. I want to say good to see you. I don't know if you all feel is about how you feel about being back on the screens, but good morning. And I will mention from the department. I have a question. Is our financial director. She's on. For any sort of technical questions related to. Interdepartmental transfers. Groups, anything that, you know, gets. Detailed enough that it's beyond my scope and Sarah Clark from the agency is on as well. You know, in case you have any bigger picture. Probably global commitment questions, but. I think we're, we'll get going. I, before I start, I think. As Laura Said. Madam chair. That we have, we have narratives and we have the ups downs. That are standard to look at. So it's really up to the committee, how you would like to walk through this. If you know of initiatives that were put on the table from January and you're prepared to say this is still in place. This is still in place. This was an initiative, but we changed it. This one's off the table as much as you can help us relate back to the January budget would be helpful. If not, you know, we will fill in those gaps. The two budgets and up at natural stopping points at different sections to ask for questions from committee members from either appropriations or health care. I would like you to lead the discussion so we know the changes and where the 21 budget is going in your department from you. The, it looks like Teresa has the narrative up and let's let's work off that then the, you know, the big picture is, is, of course, we always have program and administration on this sheet program is the first segment we're going to talk about the, you know, the overarching element that's different to there's two things that are different, especially in program for us at diva and at Medicaid is that with the pandemic. We essentially stopped doing redeterminations. And we're not removed in there were there were no people being terminated from Medicaid there are no people being terminated from Medicaid that continues today. Along with the economy, let's call it a slow down and that the non redetermination activity. We are picking up in a slowly but surely fashion, Medicaid members population is growing, not at a rate that is in other states it's been a really large expansion of population ours has been just kind of slow and steady. The last number I heard had in my head was is about 8000 I think it since maybe back to February we're up about 10,000. But that's like the sort of ballpark of slow but steady increase we've had we haven't had any real, you know, in one month time, a large addition of individuals. So that's one piece more people. Second piece that you will see in the numbers the second piece is that the 6.2 federal match increase, due to cares act is really the offset, all of that so there's more federal dollars offsetting the, the program increases. So, yeah, excuse me, I'm sorry commissioner, there's a lag around talking and when you hear it. I just wanted to the 6.2 is the f map bump. Okay, I just for for other legislators we talked a lot about the additional f map bump that has put us below I think we're below 40% now for our match, which is significant and this is the piece of money that is bringing in the extra $19 million per quarter. As long as we're still in the state of emergency as determined on the federal level and and this budget is built off an additional 19 million for the second quarter we're in a state of emergency now so we got the bump. We got the bump back in the 20 budget, and we got the bump for the first quarter of the 21, and this budget is built on the assumption that we will get that f map bump for the second for the second quarter of the 21 is that correct. Yeah and I would actually say a little more than it's more than an assumption the current state of emergency, or public health emergency, state of emergency goes until October 23 which is into the second quarter. And the sort of the CARES Act says the 6.2 will continue to the end of the, the quarter that the public health emergency ends in. Presently, it's October 23. I did have this conversation a little bit with folks who were saying what do you know about what's coming from the federal landscape in terms of funding and future opportunities. That's not a question that anyone can probably answer with any sort of certainty but you know, being asked, I think one of the places we landed in that conversation so you're up to speed is. I think I think I'd answer with a question do we think that the public health emergency in the United States will be under wraps by late October, and probably a lot of people would say no so there's a potential that if there's another extension that the f map would extend to $13 million in federal dollars that you're talking about. Madam chair would extend into another quarter and that would, you know, obviously, intersect with wherever revenues are at that time general fund, you know, all the other pieces but I wouldn't say that's good news but that is a piece, as you budget that we I was asked to move forward, what could happen what could change. So, the, to the end of the calendar year is actually not it's not an assumption I think we're, we're pretty good on that. And there's a possibility a strong possibility we would get it in the third quarter as well, but the budget is not does not reflect it so that would be a budget adjustment issue. That's true. Okay, thank you. Yeah. Okay, the trees if you could just move up a little bit more and we these are the basically the factors that lead to the increase of population and then, and things we've done so the first piece are related to the cares act those first two bullets, extending and then not ending coverage in the emergency unless a customer requested, that's just something we're actually really seeing right now like we. There are people that have other forms of coverage, but unless they actually say I want to end my Medicaid coverage we are not authorized to do so. We're kind of that's, you know a little insight to the daily daily operations where we're trying to navigate that and see how that, how we can appropriately broach that conversation if necessary. Then the second part is pieces that have been done in the state of Vermont by diva by Medicaid related to these populations that they, they do have a an impact on budget. So, you know the offset or the reason we do it is to protect health insurance for for monitors so I guess let's move on to the next one. These are just a little bit in terms of enrollment numbers for background you will see about a 10,000 overall increase from go back this is. Yeah, you, you don't get you're not getting the monthly increases sorry not go back, go down, you can keep going by it if there's questions on this I'm, we're happy to talk about. So next thing is clawback. It's three four, I mean I think I've been in on budget, maybe seven or eight times in my time here. I've always come in to tell you that the clawback was an increasing cost. This time, it's a decrease so the 6.2 reduces the clawback impact to our budget by $3 million and I mean by budget. This reduces state contributions by 3 million so that is an assist to the general fund all of the everything F map just again for context, everything that we get from the federal government is money that doesn't need to come from the general fund, and either it allows us to as a state who in your committee and the legislature to look at those dollars in a different way, possibly or make up for lost or depressed tax revenues or general fund revenues to the state in this. Yes, just for just for clarification within the 19, you know the 19 to 20 million FBF map bump does that include this $3 million of clawback, or is this additional on top of the 19. I asked Lisa specifically my I think I believe it's all included. It would be additional it's not part of the ages global commitment. That's even better news for us. The next is, this is a policy conversation we were having during the session. This states that we have an up in our budget because of delaying the implementation of a preferred drug list management of the HIV AIDS medications. I'm glad that the House Health Care Committee is on they were, you know very involved in reviewing this with both the department and stakeholders, and this is in our in our budget. As an increase because the it was a two $1.2 million decrease for a 12 month implementation so we are projecting in this budget that we would begin this change on one one of the next calendar year so mid fiscal year and then that means that the projected savings would be less that's why it's an up and not a down. And again, intersects with what you stated off the top. Madam chair is that, you know, we're, we're not working off last year's budget so that it's a down it's enough because the up was higher in the previous government govrack so I'll pause this one is often a conversation not often but it we have always paused to just see if there are any questions but are, I'll say it this way are there is language that needs to change that we would be have as a proposal, and have had as a proposal and I, I'm going to say with openness to a further conversation that I believe this was on a path to being okay and approved by okay with the stakeholders and approved by the legislative committees. But I, but I won't assume that but it is in our budget if it if we don't move forward with this, we would have to find the additional dollars. And to stop her questions, especially you know why do we have to have this delay, and I will turn it representative Lippert has a question. And I want a refresher of how close we were to accepting this proposal bill. Well, my memory is that our committee supports this. We did as the commissioner said we reviewed, we took testimony from stakeholders. And I'm honestly surprised that it wasn't in the q one budget I'm operating on the assumption that this had been in place, but apparently not. Well thank thank you. Chair Lippert, I, it, the language was never finalized for approval so we did not proceed. And that's the explanation. Where's the finalized language needing approval in the appropriations process. I'm believing now that it has to fall into the, to the, but I don't actually I'm not up on where what is going to be taken up by the legislature but we would need this language in order to it in the restatement language that was submitted to the legislature by finance and management. And we will send out Teresa will send the full packet of language out its color coded and it's really easy to follow. So just, if I can just be clear that you, you, you need who needs, who needs something from our committee or do you need anything from our committee at this point. House appropriations will want it in a very quick informal memo. We can do that very quickly. Thank you for the testimony we've done the debate and we're in support of this. Right, but I want you to approve the new language which you haven't seen there's some tweaks to the language. So I want to find the new language. Thank you. We'll be in the budget. Okay. So Teresa, if you'd send up the language to all the, all the house members that would be really helpful and anyone wants to listen in at 10 o'clock on Monday. Matt Riven from the administration will be in to walk through all of the language changes with our committee. So if, if anyone wants to jump in or ask Teresa for a link or jump in on YouTube that would that you may find it helpful. Thank you. Thank you both. Are you still or are you? No, no. And, and Charlie, but we will offer the follow up to if you want to have a conversation with us about what the language looks like. So I would just request that if someone could articulate very clearly what the change in language is, because we had reviewed the previous language so that we're not having to sort out what the Will do that. If there are changes with what's the change other than the timeframe. Right. Thank you. Okay, and then the next is again, addition, the F map increase hitting our dish and chip populations and this is what that, what that totals to it's $842,000 of general fund revenue that will not be needed. So that's the program side up in people so up in cost, but with the bump in F map. Due to the public health emergency and the cares act we are using more federal dollars than state dollars on on our entire population so it more than offsets the increase in population and utilization. I don't see any questions on the change in dish and chip it's just related to the F map bump. So, yeah, when you see, if you look at the, the ups downs in your sheets on the in the different, you know, fund sources, you know the, the, the payment and then, you know, match non waiver. There are places where these different populations fall. And so, you know, that's just the identification of two of those expenditures. Okay, so I'm going to move to administration now. This is very simple. We have been in the state of a hiring freeze for a while now and continuation of those freezes produce this in terms of savings or non expenditures and not sure I would necessarily just call them savings but they are by not having not any conditions. We're not spending as much on salary and fringe. You can move up the page. Thank you. The contract changes. These are, yep. I was muted so I couldn't jump in. Are you with the hiring freeze are you are do you have the capabilities of doing all the work you need to do is this putting any strain or stress on the agency to to get work especially with the Medicaid population increasing. The operationally. It's a great question. The operationally with the with not doing redeterminations and not doing a lot of basically a lot of the things that we normally do. I will say it's, it's, it's okay. The public health emergency ends, and we, and we move into open enrollment or sorry, we move into starting restarting redeterminations. The workload would probably be greater than what is necessary to manage that but we would be in a different situation at that time so we'll, I think it's not knowing when the public health emergency ends. It's not knowing when redetermination starts, you know, trying to predict anything related to that is very difficult. So we have, you know, it's, it's a good question because it's the same horizon we're looking at. When there's an assumption I guess that we're going to have to cross that bridge when the public health emergency ends and we restart determinations and that could be a conversation in early 21 or it could be next fiscal year it's hard to know when that starts but you're, you're really on to think about what we're looking forward to operationally. When we have to start to work again, the people will be, you know, we'll, we'll do what we have to do. I mean, the governor has often said we're going to take what we have in revenues and and and and money to expend and and match that accordingly and it it may affect how well we're able to execute, but you know we'll, we'll have those conversations all along with you with the administration and with the legislature. Thank you Corey, so if there is pressure you can address it in budget adjustment or in the 22 budget proposal. I mean, forward looking, I mean, it feels like, I mean, this, this kind of meeting in August aside, it feels like we are regularly coming to the legislature to talk about what's, what's new and that would be something that would be a change. So yes, you're those are the next two stopping points in in our budgeting is BA and and the next budget cycle correct. Sorry. Before we move on to the contract changes to anybody does anyone have a question from either committee. I don't worry so let's move on to contract changes. Yeah. Okay, so the first is a increase to our Wex health contract. The entity as you, I'm sure know this has been on in and out of our budget for a while. We are really really really close to executing on the transference of the premium processing responsibility to the insurers. And as you see in the explanation the pandemic delayed us, what I would, I would characterize as weeks and just put us up against the open enrollment timeframe where we just couldn't execute. We had essentially people and resource limitations that didn't allow us to get the premium collection activity transferred over for 2021. It's a calendar year start for this activity. And so, you know we're projecting for this savings now to be a year later. It's unfortunate but it you know the, the few weeks or, you know, a couple months that we got delayed on this project produces a one year delay so we have to continue to have it in our, our budget I mean on the, on the, I guess if you want to put a silver lining on it, it is a it's a lot of political and we have a bit of time to make sure we get it right. I will say it that way I'm looking for some positivity to it but it's, it is unfortunate that the, the pandemic really hit us when it did because we were on a path where we were going to achieve.  The next is the a macmas contract increase this is another one this is a little bit like the, the PDL conversation, we had in our gov rec for FY 21, an $817,000 down. We still have a down, but it's not the 817 it's 500 and 6500,000 less than the 817. Is that I say that right I think I did. So where it's still a down but it produces an up in this because we're working off the gov rec. So basically what happened is the budget was built late in 19. While we were, I would, would not say we were necessarily in the negotiations yet but the, the recommendation was based off annual. To maximus and by our annual expenditures over the last few years. This was sort of a, the 817 was a recognition based on our contract based on what we had actually spent in minutes. We could conceivably reduce our maximum budget by 817,000 the, the, excuse me the total contract is for higher than that. We didn't, we had, we were, we were becoming more and more efficient, I would say with our call center in terms of the process improvements. And so what ends it up happening was a negotiation that, that began really in earnest probably February of this calendar year so after the budget was introduced and proposed. Long story short, it was going that maximus had a about a million dollar increase to the, to the max of the budget we had to make some changes but negotiated pretty, you know, in good faith both with maximus and the state but got that number still below the original contract and so this kind of identifies where that contract is at now it doesn't really have any kind of prediction of what our utilization of minutes will be. We're, we'll have to see that. You know, there's a lot of, you know, a budget to budget the actuals are the actuals in this conversation because to the same conversation we had about staffing if we restart determinations. So now maximus call center has been very manageable in terms of calls, but if we start doing the redeterminations we would expect calls to jump back up. So, again, we can budget off our contract and that's what this does, but really knowing what our utilization over the next nine months is going to be a bit more of a challenge than that, and something that a little bit like if we start redeterminations before be a will come in and maybe have a something to tell you then, or it will be in the 22 budget how we would, what we would be seeing and would have that conversation that but just a little bit of a foreshadow into an explanation of the how the contract looks like this and that it is still a down from FY 20, but budget but it is and it manifests itself as enough because of it's not as much of a down from the government. Thank you commissioner. We do have one question representative felt us and then representative. Please. Marty. Yes, thank you. I realize you have a contract and so there's nothing that can be done about that now and this is just an additional observation. We've seen obviously you use Maximus and and do well used Maximus and I think there are other departments that use Maximus for call center usage is back in the beginning before you began working with Maximus did we have some more comprehensive looks at other possible vendors. It just kind of irks me that we're spending all this money to outside vendors when I would hope there would be a local vendor who could help us do this. Can you give me a little background on how that got started. It's interesting because the conversation before we began was about how long everybody's been doing this in on the committees. I think our relationship with Maximus goes back to the 90s. So I was not definitely not around that conversation time. I think, honestly, rep felt this. We would really be open to an examination of what is out there on the in the marketplace in terms of call centers. I will say Maximus has been a great partner the team that is in there is a team in Burlington there are people that are employed Vermonters that are employed by Maximus in the Burlington area. That team has worked really well with us through some pretty, some pretty difficult time so just a comment to the relationship with that entity first of all the second thing that was in principle I I don't have no disagreement with you. I think we we keep running into the theoretical of hey it would be great to put this out to bid and see what else is out there. And then, you know, then there's a pandemic then there's a, you know, there's always just something coming along that makes it well let's get through this next time period, and then we will get to, you know, that examination of the of the marketplace in a year in two years. I'll just say that as sort of the issue with how I agree but it operationally it becomes a little difficult. Okay, I understand. It's just an issue that has been raised to me on two occasions. Thanks very very reasonable and something that is actually I mean on the, it's on the whiteboard examining and we have eight or nine agreements at diva that we are constantly monitoring and, you know, re upping. So it's a it isn't just a Maximus conversation it's one of these conversations that we have on a regular basis with all of our vendors and then sometimes we'll put something out to bid and only the one vendor will will put a bid in so you know it's it's I appreciate the comment and and and really want you to hear that we are very interested in that sort of activity at diva. Thank you. Thank you Marty representative Blippert. First, just a quick note of jar and I took me a few minutes I think I understand what gov rec is and I think it's the governor's recommended budget, the governor's recommended that way. Thank you. But it's a little bit of appropriations and diva maybe should be translated for others who are participating early listening in. And in terms of Maximus. I'll just, I'll just second representative felt us is comment that some of us that while it appears from what you said that there's a good relationship with Maximus, I think, many, many legislators do not feel similarly about the relationship with the government and the labor and the enormous amount of money that's being paid to Maximus and compared to the results that Vermonters received as a result. So one of my questions is because it didn't occur to me till just today, because in but in joint fiscal committee we also, there was approval to use CRF dollars I think to contract with Maximus for the agency of commerce and community as well. Is there, is there a single contract with Maximus or does each department of state government set contract and negotiate separately. We have our, we have our own contract with Maximus there was actually a question early on in the in the pandemic and the emergency could other departments sort of tag on to our contract and the examinations, you know, basically kind of turn back no I mean, part of the Maximus, I would say complicating factor is, as you know in in Medicaid, a dollar includes the state and the federal dollars so unwinding that for a state agency that's paying in with non national dollars, it got a little complicated so the simple answer to your question and each has its own relationship I mean it's different people to, of course. Okay, thank you. Thank you bill. Commissioner, could you tell me how long a contract that you signed a contract for how many years. I believe this one is five years. Lisa does that sound like the, the, the latest update is five years there are some, some, you know, opportunities for discontinuing relationships in any contract but it says it says a five year amendment with Maxima so it's, I'm sorry I didn't catch that but my question is, is there any requirement to put these contracts out to bid. It's, you know, like with other pieces in state government depending on what the threshold is, you know with studies and so forth we, we put them out to bid. Yeah, we, there is, there are, and in situations, especially this one. You know we asked for a waiver of that requirement, basically because of the risk that it would you know we were, we were in a position to be negotiating this very fairly closely to the time when we were. The risk of a changeover is up. And the risk of a changeover which is regardless of when we were negotiating the risk of a changeover is always something that's on our minds to. And, and so, yes, there is a requirement. Representative Lippert. This is, this is the increase. What is maybe Lisa commissioner can tell us what is the total contractual amount. Just over $7 million. Thank you annually. Right. Thank you. I think it's a great conversation to continue when we, when the 22 budget is brought before the legislature to look at contract negotiations and perhaps starting them earlier is there. Yeah, totally.  The theory and then there's what happens. And if you're looking for a two line explanation. Changes in leadership on the team, you know, and just not ready to. It's a big deal to put out an RFP and to, and to be able to really know what you're looking for know what, you know, know what the difference between one contract to another looks like. And in the, in mid last year we had some pretty significant leadership changes in the, in that unit in the team that manages that contract. And it felt like more risk to engage in something that, as I said to wrap up this as chair Lippert has discussed and your point is good. Chair tall that it felt like more risk to the, to the operation, then we could really stomach at the time given the new newness of the, of the leadership team that was really taking over at you. I can appreciate that. And as the team is seasoned that these are something that we hope that will be seriously looked at. Yeah, we just, we just hired a new director who came to us. I think he's in her second week now. So, I agree completely. Let's move on to the next contract please. Okay archetype contract increase is this one can get pretty wonky pretty quick but essentially we have a lot of reports that archetype produces for us. In the neighborhood I'll, I'll say 700 about that that have been produced by archetype over the over the years, about 130 of those are for CMS reporting that we need. Oh, it says sorry it says right here. So the others are for us to actually run our business. So their process reporting that are used for us to do the work that we need to do related to enrollment and eligibility and essentially what happened was Oracle was updating their system. So all of our work would not be able would not all of our reporting wouldn't work anymore. So that so this is goes back this conversation goes back. I want to say almost two years and ADS had proposed that they would take over the project of reporting and sort of reconstruct all of these reports by essentially I'll call it reverse engineering. Over time, a complicated nature of that effort this demonstrated itself to be too great. And so in February of this calendar year we implemented contingency to get archetype to update their business intelligence and the reporting to to function with the Oracle platform and to get really to share Lippert's point to use acronyms. And just so in case you've heard this, but this is the OBIE of the cut over. For any of you that have heard those terms before for those of you that don't it's just explained it it's an update, and we're moving from one system to another. And it's basically us relying continuing to rely on archetype for these reports that are that are necessary to do our work and to report CMS. And it's going to cost us, you know, more as it's shown here in the in the itemization, but the there's an offset to as we continue in this in our proposal we had in the proposal that we would reduce archetype there was a proposal to increase you payments to ADS. So, you know that there's a little bit of a, it isn't just a pure increase to archetype it's just we were trying to bring something in house to the state and it didn't. It didn't work the way that it was, I would say proposed by in by ADS and by. It was hoped for. How's that. So ADS partner with ADS in this change. Any of these technology projects with with is a partnership with ADS in that goes across state government but we, we work closely with their, you know, technical resources, and they are, you know, they come up with ideas of how they can. I'm sure you've heard this before reuse platforms and efforts across the different departments and produce a little bit like Cheryl effort was referring to does everybody have a different contract with Maximas. The goal is to be a little bit more. There's a word I can think of right now but to use to use elements of our business. There's a large state government in our in in in our business as well so I think that this was a little bit of that, trying to bring it in house and save some money and it just didn't pan out because it was too complicated. Thank you Corey, we have, we do have a question from representative Christensen. My memory may be hazy on all this, but I remember. I think it was last year of the year before where you mentioned a lot of these contracts we're going to go. We're recommended these companies were recommended by the federal government. And that we really, I don't remember them as being free, but the federal government was picking up the bulk of. Yeah, I know it isn't rep Christensen but you're in the right ball you're in the right ballpark the the there was a move. Again, you're you're you are going back a couple of years where a different form of procurement procurement was on the table. The federal government was recommending that we engage with a couple of different firms to really push that along. And so those are different contracts. Okay, thank you. It is related to integrated eligibility was related to integrated eligibility but that was yeah that's a couple years. Okay, thank you. Thank you. I don't see other questions so let's move on to the burns and associate. That's an increase in our burns and associates are our payment consultants really, really top notch experts in the field of healthcare reimbursement. We are engaged in payment reform activities across the agency, and the more these payment reform efforts take root in certain areas, the more other parts other departments within our agency are saying, you know we might have a good year to pay for healthcare differently or pay for services differently in your team, engage with with our team are, you know, our, our program teams and this is, you know, DMH this is Dale. I think staff and VDH are really looking at efforts all across and, and as these come forward. It does and get involved consultation with burns and associates at a higher level so their budget or their projection for their budget is an increase in in in the next in the next year for those reasons. Thank you. We'll see questions there. The next is a one time reduction to the DXC contract. DXC is our, our MMS system. That is the system that pays claims and rules providers really is the is the sort of system backbone to Medicaid. It is a fairly substantial contract. And when we knew we were in a resource downturn state revenue downturn general funds or pressures. We turn to a lot of our vendors that had fairly large contracts and essentially asked them. What can you do to contribute to a reduction in our contract and DXC stepped up so great appreciation to them for this. And it essentially is the, there isn't necessarily anything particular. There's a little bit of we have some money in our contract for change. I think there's a little bit of thought that that's a little bit of a place where we will save, but more than anything it's just them being good partners is how I would characterize that. Commissioner was department three percent target for savings. We were. I'm not sure what the reduction in our, I mean, there's our there's our overall and then there's the GF right that's the funkiness of our contract always. But we were what I will say though is that the, the 6.2 has created, you know, I'm not actually sure what the, what the percentage savings in GF that come from the increase in 6.2. But we were given the target what I end up what I think ended up happening was, you know, an appreciation from the agency that in this time, making sure that providers were not affected by the change in any way shape or form. As we are in the midst of a health pandemic. So not no change to provider. The other part is we don't really have flexibility in terms of changing services or population those are the other two places that you might make a change in a Medicaid program with the 6.2 bump we can't change that as part of the agreement so I appreciate that I was wondering if you were if you had a 3% target, even beyond the 6.2, the savings you're able to realize because of that. And I was wondering if this DXC contract. If that's if you were going out to these contracts to try to make the changes to reach that target. Was that in was that an individual. We were making the changes because we didn't know we were making these requests before we had a finalization of the art, the, you know, the conversation always goes the department the agency the administration. And before we even knew what we did know we were working off what we did know and what we did know was there were the general fund projections were for less money. And knowing that our expenditures come from begin with the general fund and receive a federal match that we, you know, we, we didn't want to not leave stones unturned I guess is how I would say. Thank you. Before we move to changes in operations. Are there any final questions on the contracts from any members. I'm not seeing any so we'll go down to your final changes. Okay, so these are internal service fund obligations reductions 122,000. I don't have a ton to say about them. If there are questions, I'm happy to either get the answer or have Lisa speak to them but I'm going to move on where Claire and all the budgets with the with the 5% reductions in ADS. And then I've already kind of explained this one was anticipation of ADS. We're taking over and billing us for budget, excuse me, business intelligence activities that's the reporting that architect does. And so that this is the, there's also some dollars in here you'll you'll note that it's not a one for one. In terms of the total spend, but we also had some spending authority that had been in our budget that we weren't spending on an annual basis that is essentially going away from the federal government so that's that sort of finds itself into our budget here. We had additional, you can call it savings but it was really just authority that lived in our budget in case we had the match rate, the federal state match to to and and the and the projects to to that are appropriate to to spend on. Thank you. A question from Representative Hooper. Thank you. Good morning everybody. Thank you for your presentation commissioner. I am wondering what you are concerned about looking forward. It strikes me that your budget is one of those places where as the distressed to the economy plays out that you're going to see the repercussions of it, and the federal emergency will go away. And so we won't have the F map bump, but you're going to have additional pressures and not have the adjustments from the feds. Can you help us think about how to make a big question and we'll deal with it in the future but how are you positioning yourself to address that. Yeah I mean I couldn't say it a lot better than what you just did I mean that's you've really hit the nail on the head I mean that's the agency of human you know the conflict or the day caught me whatever you want to say the opposing nature of when the economy falls general fund revenues fall for the state that's really you know to the state but when the economy. When the health and or depresses human service. You know is in the programs and services we provide are in greater need usually right so you basically characterize that in your question. That is the, you know the concern across. I think the administration agency human services for sure the other departments. It's ex I the simple answer is, you know, we have we have a we were not like the federal government we don't print money so as the revenues and expenditures continue to diverge or, or, as we move forward we will continue in as chair told mentioned earlier will continue to adapt to. Here's what we have in terms of funding and here's what we have in terms of expenditures and make proposals that can, you know, and with a zero, at least in projection right there's always how things actually go in between the times when we are discussing our budgeting but I don't have a, I don't have a silver bullet for you that says well we've got it under control I would just say that, you know we've managed both ups and downs in the state over the last little little greater than a decade and we would continue to do that I think Vermont shown itself to be very aware of the needs of the population in a downturn of the economy. I would also say it does appear and this is now we're into a little bit yeah I mean we are in this sort of look forward and and nothing is is for sure. The conversation going on at the federal level are definitely something that we're interested in of course right we what we do know about the 6.2 what we know about the, the, the public health emergency and this and the state of emergency as as currently those are things we can talk about but there's also this conversation going on about what's the next round from the federal government of support for local and state entities. I think we've all heard those stories impossible to predict where those go but that's another part of the of the of the process and being aware as we move forward. Are there things. Can you take advantage of CRF money that will position you to will put you in a better position to address the inevitable revenue decline so our can you for building out better systems it that sort of thing. I think you can be doing now with CRF that will. Yeah, so CRF. Increasingly not surprisingly probably to you all. CRF gets increasingly prescriptive as as how we can use it and I would say that just as a, as a proper anticipation by the state, let's call it. The administration has brought on a consultant to advise. You know the federal government is great about handing over money and then coming back and saying how did you spend it. And so we're doing everything we can to not be in a position in the future, have to give those dollars back. As you mentioned it, it does make me think about all the projects that have been underway for a long time so anything that we would want to do quickly. It seems like a tough one but it, you know, we're not we're not again again just like I said about the contracts with our vendors. I won't say there's any stone that we don't want to look under and say is there opportunity, or just, you know out of hand dismiss something so we're always open to that but we do have a finite amount of resources as it pertains to it with our partners with our own team of program managers. And so we're we have finite resources that if we, you know, it would have to be the juice on those kinds of activities would really have to be there for us, and not just be. We really think something might be good if we do this. That's just that would be another sort of generalized consideration I would throw in. I will say that in CRF, you know the obviously maybe for this is for those that haven't, you know, seen it but I'm sure you have provider stabilization efforts the hazard pay efforts. And we're all to try our, our best to make sure that in during a health care pandemic that our health care providers are not being exposed to extraordinary pressure. And of course, as utilization goes changes, I mean, in, in, in some areas I think that utilization is really back to, to normal whatever you want to call that. But I think that the amount of money that was set aside by the legislature is one example of where those CFR dollar CRF dollars are assisting really what we need as an as a Medicaid program or as a as diva, which is access to health care when needed. Thank you. Mary, did you have a follow up or. No, thank you. Representative Yacoboni. I think we're just about out of time unless I'm, but I'll try to be brief. What, what is your primary method for controlling per member per month expenditures. We have a fair number of efforts underway right with all of our different payment models, trying to produce better outcomes for and purchase differently. We have engaged with the the biggest of course being our relationship with the accountable care organization as part of the all pair model agreement. And, you know, looking to push delivery system reform so that there is greater alignment in the healthcare system and, and less and better incentives for providers to produce and to act on in those, you know, perspective payments that we are making. You know, on the perspective payment side, we've seen good results in terms of shadow like sort of shadow claims showing in that when we pay a perspective payment utilization is down. I think that is speaking to what our big sort of overarching goal is is to purchase health differently. We do still have some prior authorization and in place, which we've been exploring reduction of that because of the incentive changes. But prior authorization is also aimed towards patient safety so we don't want to completely give that up either. But I think that's a short answer wrap back a volunteer question which is purchasing health care different differently is really what and not having that incentive a fee for service as the primary incentive. Because we've seen it time and time again if you pay on a on a per click basis, you're going to get clicks, and you don't necessarily. And again that that might seem theoretical in this conversation but as you said, we really are focused on purchasing value value not volume. I guess and thank you. Not for today's agenda, but in terms of budgets and driving costs. We'll talk more in the future about the ACO and the relationship to helping with outcomes that seems to be significant investment we're making and I want to make sure it's working. Thank you. Absolutely. Yeah, no, it's a great comment. I appreciate it. It's, you know, we've always said that this is we there's a theory behind the case I think that if you go at the beginning, you say should we leave the health care system alone or should we try to, to change it, it, and, and we've tried a few different ways we've we've looked at different modeling and we've had things like the blueprint for a long time but there's a lot more health care system out there than just the primary care.  And this is our current best effort to get, you know, all of the different kinds of payers in a very diverse system of health care into a more aligned methodology, both for the payers and both for and the, and all the things that we have in our system. So, the examination of its effectiveness is, is something we're very interested in as well as we've always said this is a, this is definitely a test of a, of what would seem to most people I think a lot of people have talked to a sound sense of the fee for service. This is a national sort of perspective that the incentives of fee for service don't necessarily produce outcomes. So, you know, our efforts around an all payer system, and an accountable set of providers and a network is is something that we think is worth testing so I appreciate your, your vision towards evaluation because that's, that's on the list as well. Thank you commissioner. Dave, did you. Thank you Dave. Thank you. Thank you very much. We have two final questions and then when you finish with those questions Corey we're going over a bid on time so I want to be respectful of your time. What we're going to have to discuss is we've discussed them in January and February but if there are highlighted initiatives that are still in play that were have not been changed since the 2000s in January proposal. If you could just give us those topics and if you can't Dave and I will be working on finding those, but we have a quick, we have a question from representative page and then derpy. This might be a little bit of out of our scope, but it does go along with what representative Yacoboni said. Your response, your agency is responsible for, I guess, putting together plans for essential health benefits regarding various MVP and Blue Cross and Blue Shields, yet we see some of those costs going up. So how do you maintain, keep those costs down, and yet provide essential services that we need for Vermonters. Yeah, it's a, it's a great question I mean I think this is a long kind of conversation if I wanted to answer it in short form. But really, the costs, you're now in, you're now in the world of commercial insurance, qualified health plans are, you know, we do have an intersection with those they are the commercial insurers, paying for health care. And I think in terms of the population, how we keep those costs down I mean that that's the intersection with the all pair model in one aspect, wanting to get some greater alignment in terms of overall overall health care, and how it is executed on the delivery side by adjusting payment. A little bit of an editorial about it is the cost of those plans are the reflection of the in a simple format of reflection of the cost of health care in the state of Vermont. Those increases reflect increases. I will say this, oh that those increases and their necessity are up for debate right in front of the Green Mountain Care Board that's what the Green Mountain Care Board's job is to evaluate both the necessity of increases, the cost of increases in health care through the hospital budget process and the insurance rate review. And of course, there's another intersection where DFR is responsible for, you know, certifying that the solvency of those insurers is is adequate is would be protected for the rates that the Green Mountain Care Board approves so that we diva does have an intersection on the certification of the plans. We have not certified plans before. Last year I believe we certified all the plans that were that were priced and approved. And three years ago we didn't approve one because it had an impact on the lowest cost silver plan which is how we, how the federal subsidies get determined, and by not approving that plan we were able, I think to secure an increase in the federal subsidies that came to Vermonters within the, the, the FPLs that we're getting subsidies on qhp so we do have an intersection but the overall I mean I think you have a bigger question that is is a really good one, it's just, I mean this goes back almost to rep yakovon's question I mean the cost of health care in the state of Vermont the cost of health care in the country. What are we going to do about it and I think we're all asking the same questions, we're doing something about it in a on a, on the basis of an agreement that was signed in the end of 2016. And we're testing a model right now to see if it's going to really produce the kind of delivery system evolution that we're hoping for. It's a much larger question then then then we'll tackle at this point but a very important question and certainly one. We look forward to, to continuing and when we come back for the 22 budget but also initiatives that can be put in place. Thank you representative page did you have a follow up. Thank you. Representative derpy and then we'll close with representative leopard. Thanks, I know we're running running over so if this is a question that can't be answered quickly commissioner. I'll be happy to discuss it later with you but it's a cost question and I'm looking at the caseload section of the document that you had addressed earlier. Okay, tell me if I'm doing the math right about 15 million in additional spend, and about 1000 additional in the case load. So, which would come out to about 15,000 additional dollars per added caseload. I think you're, you might be, you might be missing a zero there my Sarah not if I'm, I think it's, we're closer to 10,000 in increases, is that what you say 10,000 or 1000 in the case load. I thought I was seeing 1000 and what I'm doing is comparing 100 the bottom, the bottom row, the two rate columns in the case load. Yeah, it is absolute. Go ahead. That's the average enrollment from state fiscal year 20 to what we project for 21. What we were seeing before the pandemic was a regular decline in our Medicaid population and had originally projected that that it would continue so that's the the actual decline pre pandemic was greater than what we had thought it would be in 20 in 21. As we head into 21 and the number Corey is referencing the commissioners referencing representative is has to do with the difference between actual enrollment in in in February as to today today. Does that make sense. Not, not entirely. I'm not going to pursue it right now, though, just, let's, let's talk about it. Let's talk about it later. Yeah, I also just say that this is the consensus for crap casting that happens on a rate. I don't know what the cadence is but it's a regular effort between JFO. I think it's a good consideration and a chess to come to the forecast agreement about populations with the with the projection for enrollment is and utilization. And just in terms of the dollars though so that I understand make sure I understand that piece of that, that's 15 million 15 million 121,000 represents the difference between what was in the recommended budget. And what we're, what you're now for, yeah, for program and for utilization and case. Case. And what they would use you. Okay, good. Thank you. There'll be follow up for you. Representative derpy and representative Lippert. Very just quickly. Commissioner, you mentioned that in the by virtue of not being doing redeterminations at this point, there are indeed Vermonters who continue on Medicaid but who actually have access to other insurance. Do you have any estimate of what the additional costs are to Medicaid, and are, is it primarily commercial insurance that is reaping the instead of them. Yeah, I don't I don't know that and I was a little bit more anecdotal than it was, you know, some sort of grouping of a population we just we did we don't know we we know we can't take people off we do know people are asking in in in some cases but this it's very anecdotal and not something that's a population or a pocket of individuals that we know of they move. I mean, it's not something that we could necessarily pull. Not something you're prepared to quantify. Okay. Question. So, just very quickly Corey without getting into the topics because we have heard, you know, the testimony and it's been debated back in January and February. Are there initiatives you could just remind us of that that exists in the budget that we need to make sure we've made our final decisions on. But I know that the preferred medication list for, you know, that was one the the other is the Wex, the premium processing that gets. Sorry. We've talked about the Wex, right. Yeah, no, I don't have any that we that are on I'm looking at the list now for administration and I don't see anything that we haven't talked about. I don't see anything from the, from the, the original proposal of 2021 so I'm not. I don't see anything on this list. As far as administration goes or program that would be a anything we didn't discuss, even our, our, our governor recommended budget for 21 was pretty good. We had the, we had that PDL and we had the transference of premium processing. So, we've, and we've covered those so for the committees of for the health care committee the things that we'll be looking for in the diva budget would be the that you look at the new language and make sure that language. Fits your needs the hiring freeze if you had any concerns about that, and then the changes in contract I think that we've gone through all of those questions. And then we have the typical changes with the internal service charges and, and then back in the 20 budget the natural pressures with salaries and fringes and, and we, and we will look through all of those. I think that this was one of the budgets that we were pretty close to being complete on and if there's any other language that you had out there that you want considered if you could as quickly as possible. Wonderful. Okay. And if someone from, if someone from diva could articulate to Jen Carby, or our staff, the specific changes in the HIV AIDS language. I'm just going to say that we'll, we will ASAP. The only, can I, I think Jen is on yes she is. Okay. The only other is replipper, the only other comment I have on the, on the Medicaid and other insurance is that we do have coordination of benefits unit that that's their job to make sure that Medicaid is the pair of last. And so, if it's not, if there is any significant amounts in that category that we would, we would assume that that would get at those numbers too so just, just to sort of add to that conversation a little bit maybe add a little bit of comfort that it isn't just lost Medicaid dollars. Questions offline. Please. Okay. I think that this brings us to a close representative lipid. Did you have any closing statements? Again, again, just to say I think this was a helpful process and possibly something we might want to think about in the future actually, rather than just seeing this as an interim step between our committees. I think this is actually a productive use of our time. I find it much more productive in it and we're not duplicating efforts and we're hearing each other's questions questions. I think it's, I think it's a valuable thing and I hope we might want to recommend it as a way to proceed in the future. Thank you. And represent not representative gusset on commissioner. Thank you for Lisa. Thank you for coming in and we are going to have to sign off as we have to come in new at 11 o'clock committee we are at 10 o'clock I boy my morning isn't going to stop at 10 o'clock we're coming back into here from commissioner Baker from the Department of Corrections. So thank you and we'll see you all in about less than 15 minutes. Thank you. Stop being the live stream now madam chair.


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Welcome to JSA TV the newsroom for tech and telecom professionals. I'm Jamie Scott Okutaya here in Honolulu. Take a look at this drone footage, care of X-Site modular, fabulous PTC 2019. Joining me here today Mr. Xenophon Giannis. He is the vice president of Nexus Guard. Zen, how are you? Good, great having a great time here. We're so honored that you're here on JSA TV. Thanks Jamie. I love being here. It's my first time. And we're glad to have you. Now Nexus Guard, just for our viewers who just may not already know yet, cyber security firm specialized in DDoS attack mitigation. Tell me a little bit more. So DDoS mitigation is a very crowded space but what Nexus Guard does that's really unique is that we're kind of a managed security service provider. We cater specifically to carriers, ISPs, data centers and network providers. So we help protect infrastructure so that to preserve their revenue and their their network and also help them productize services for their customers. I love that. So also you know I would say one of the ways that you're out there productizing for your customers you're releasing these fabulous reports. Really informative, informative stuff. You just released a report showing nearly two-thirds of DDoS attacks and just the third quarter of 2018 we're targeting communication service providers. Obviously a very sobering report for the folks here at PTC. Can you give us more details? Sure. Well if you think about it, if you're a company or an individual that's being targeted you are living on someone else's network. So everyone buys from a carrier, they buy from AT&T level 3 etc. And so if I'm trying to get to you as an attacker I the collateral damage is the carrier. So and if I can't take you down I'm going to try to flood the pipes of the carrier so that they shut you down. So in a way it's not necessarily the carrier that's targeted but they end up getting targeted because I'm going after the end user. So it's not so much the why they're targeting communication service providers it's the how and what can we do? Well the how is it changes daily right? So our threat report that we release tells you the trends that we see. So it's basically last year could have been UDP floods. This year it's NTP floods. We call them zero-day attacks those are the ones that are brand new because these hackers are smart. So how they have botnets they infect networks and computers and now cloud providers and send attacks from all over. And the why is or the what is what can these carriers and end users do to protect themselves and why should they do it? And I imagine that's where Nexus God comes in? Yes. So we can do two-fold right? We'll pretend protect your end users or enterprise customers but more importantly we can protect the carrier itself. So and we look at it on a two-phased approach. The carrier wants to protect their infrastructure so that their network doesn't go down. So if one customer gets hit not all customers are hit and and it preserves their revenue and their network resiliency. But on the other side you want to have be able to provide to the needy customers that need it for compliance or they've been hit or they're at high risk. They want to be able to say okay you Mr. Customer on a DDoS protected network but I'm going to make sure that your DDoS protected and I'm going to protect your IP space and your infrastructure so it can be a value add service that they can sell. And these these attacks these days so constant and so complicated. Right in the past the the carriers and ISPs what they would do is just go buy a bunch of hardware and try to solve the problem but there's two problems with that one the tax keep getting bigger so you have to buy more and more gear you have to pay maintenance on it and then you got to hire somebody that is actually on your staff probably one or two people that know how to run the gear because it's not your core competency. So one of the the the unique services that we provide as an MSSP is that you can use our software stack in your environment you're using our management our expertise we're updating the software where we're helping you manage it and then roll it out to your customers so it becomes not a big capex expenditure it becomes more of a operational expenditure and we become your security partner and that's what is a real benefit for the customers. That works that definitely works in our industry particularly we like the expertise to be on you. We do too. Alright well thank you Xen for joining us we so appreciate you and your and your time here again nexusguard guys nexusguard.com we have these quarterly reports are being released definitely take a look at them and thank you viewers for tuning in to JSA TV happy networking