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1 S.240
2 Introduced by Senators Hardy, Lyons, Bray, Campion, Clarkson, Gulick,
3 Harrison, Hashim, MacDonald, McCormack, Vyhovsky,
4 Watson, White and Wrenner
5 Referred to Committee on
6 Date:
7 Subject: Health; health insurance; Medicaid; Dr. Dynasaur
8 Statement of purpose of bill as introduced: This bill proposes to increase
9 eligibility for the Dr. Dynasaur program and for Dr. Dynasaur-like coverage to
10 include income-eligible young adults up to 26 years of age. The bill would
11 increase the income eligibility thresholds for adults in the Medicaid program
12 over time until they reach the same level as Dr. Dynasaur. The bill would
13 require increased reimbursement rates to providers for delivering primary care,
14 mental health, substance use disorder treatment, long-term care, and dental
15 services to Medicaid beneficiaries. The bill would modify the appointments to
16 and duties of the Clinical Utilization Review Board and increase the income
17 eligibility thresholds for Medicare Savings Programs. The bill would require
18 Dr. Dynasaur to cover mental health services for children and young adults
19 without a specific diagnosis if they have faced certain adverse life experiences.
20 The bill would direct the Agency of Human Service to develop a proposal for a
21 public option for small businesses to use to purchase health coverage for their VT LEG #372757 v.1
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1 employees and require the Agency to propose a schedule of sliding-scale cost-
2 sharing requirements for the Medicaid program. The bill would also require
3 the Agency to recommend modifications to specialty care reimbursement rates
4 and to report on potential changes to the structure of Vermont’s health
5 insurance markets.
6 An act relating to expanding access to Medicaid and Dr. Dynasaur
7 It is hereby enacted by the General Assembly of the State of Vermont:
8 Sec. 1. SHORT TITLE
9 This act shall be known and may be cited as the “Medicaid Expansion Act
10 of 2024.”
11 Sec. 2. FINDINGS
12 The General Assembly finds that:
13 (1) Medicaid is a comprehensive public health insurance program,
14 funded jointly by state and federal governments. Vermont’s Medicaid program
15 currently covers adults with incomes up to 133 percent of the federal poverty
16 level (FPL), children up to 19 years of age from families with incomes up to
17 312 percent FPL, and pregnant individuals with incomes up to 208 percent
18 FPL.
19 (2) States may customize their Medicaid programs with permission from
20 the federal government through waivers and demonstrations. Vermont is the VT LEG #372757 v.1
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1 only state in the nation that operates its entire Medicaid program under a
2 comprehensive statewide demonstration, called the Global Commitment to
3 Health, that offers the same services to residents in all regions of the State.
4 (3) Vermont’s unique Medicaid program provides comprehensive
5 coverage for a full array of health care services, including primary and
6 specialty care; reproductive and gender-affirming care; hospital and surgical
7 care; prescription drugs; long-term care; mental health, dental, and vision care;
8 disability services; substance use disorder treatment; and some social services
9 and supportive housing services.
10 (4) There are no monthly premiums for most individuals covered under
11 Vermont’s Medicaid program, and co-payments are minimal or nonexistent for
12 most Medicaid coverage. For example, the highest co-payment for
13 prescription drugs for a Medicaid beneficiary is just $3.00.
14 (5) Close to one-third of all Vermonters, including a majority of all
15 children in the State, have coverage provided through Vermont Medicaid,
16 making it the largest health insurance program in Vermont.
17 (6) In 2021, the six percent uninsured rate for Vermonters who had an
18 annual income between 251 and 350 percent FPL was double the three percent
19 overall uninsured rate. And for those 45 to 64 years of age, the estimated
20 number of uninsured Vermonters increased more than 50 percent over the
21 previous three years, from 4,900 uninsured in 2018 to 7,400 in 2021.
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1 (7) Cost is the primary barrier to health insurance coverage for
2 uninsured Vermonters. More than half (51 percent) of uninsured individuals
3 identify cost as the only reason they do not have insurance.
4 (8) During the COVID-19 public health emergency, the uninsured rate
5 for Vermonters with incomes just above Medicaid levels (between 139 and
6 200 percent FPL) fell from six percent in 2018 to two percent in 2021. This
7 drop was due in large part to the federal Medicaid continuous coverage
8 requirement, which allowed individuals to remain on Medicaid throughout the
9 pandemic even if their incomes rose above the Medicaid eligibility threshold.
10 A majority of Vermonters (56 percent) with incomes between 139 and
11 200 percent FPL were on Medicaid in 2021.
12 (9) The end of the public health emergency and the beginning of the
13 federally required Medicaid “unwinding” means that many of these
14 Vermonters are losing their comprehensive, low- or no-cost Medicaid health
15 coverage.
16 (10) Almost nine in 10 (88 percent) insured Vermonters visited a doctor
17 in 2021, compared with just 48 percent of uninsured Vermonters. Insured
18 Vermonters are also significantly more likely to seek mental health care than
19 uninsured Vermonters (34 percent vs. 21 percent).
20 (11) Marginalized populations are more likely than others to forgo
21 health care due to cost. Vermonters who are members of gender identity VT LEG #372757 v.1
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1 minority groups are the most likely not to receive care from a doctor because
2 they cannot afford to (12 percent). In addition, eight percent of each of the
3 following populations also indicated that they are unlikely to receive care
4 because of the cost: Vermonters under 65 years of age who have a disability,
5 Vermonters who are Black or African American, and Vermonters who are
6 LGBTQ.
7 (12) Many Vermonters under 65 years of age who have insurance are
8 considered “underinsured,” which means that their current or potential future
9 medical expenses are more than what their incomes can bear. The percentage
10 of underinsured Vermonters is increasing, from 30 percent in 2014 to
11 37 percent in 2018 and to 40 percent in 2021.
12 (13) Vermonters 18 to 24 years of age are the most likely to be
13 underinsured among those under 65 years of age, with 37 percent or
14 38,700 young adults falling into this category.
15 (14) The highest rates of underinsurance are among individuals with the
16 lowest incomes, who are just over the eligibility threshold for Medicaid.
17 Among Vermonters under 65 years of age, 43 percent of those earning 139–
18 150 percent FPL and 49 percent of those earning 151–200 percent FPL are
19 underinsured.
20 (15) Underinsured Vermonters 18 to 64 years of age spend on average
21 approximately 2.5 times more on out-of-pocket costs than fully insured VT LEG #372757 v.1
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1 individuals, with an average of $4,655.00 for underinsured adults compared
2 with less than $1,900.00 for fully insured individuals.
3 (16) Individuals with lower incomes or with a disability who turn
4 65 years of age and must transition from Medicaid to Medicare often face what
5 is known as the “Medicare cliff” or the “senior and disabled penalty” when
6 suddenly faced with paying high Medicare costs. Individuals with incomes
7 between $14,580.00 and $21,876.00 per year, and couples with incomes
8 between $19,728.00 and $29,580.00 per year, can go from paying no monthly
9 premiums for Medicaid or a Vermont Health Connect plan to owing hundreds
10 of dollars per month in Medicare premiums, deductibles, and cost-sharing
11 requirements.
12 (17) The Patient Protection and Affordable Care Act, Pub. L. No. 111-
13 148, allows young adults to remain on their parents’ private health insurance
14 plans until they reach 26 years of age. The same option does not exist under
15 Dr. Dynasaur, Vermont’s public children’s health insurance program
16 established in accordance with Title XIX (Medicaid) and Title XXI (SCHIP) of
17 the Social Security Act, however, so young adults who come from families
18 without private health insurance are often uninsured or underinsured.
19 (18) In order to promote the health of young adults and to increase
20 access to health care services, the American Academy of Pediatrics
21 recommends that coverage under Medicaid and SCHIP, which in Vermont VT LEG #372757 v.1
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1 means Dr. Dynasaur, be made available to all individuals from 0 to 26 years of
2 age.
3 Sec. 3. 33 V.S.A. § 1901 is amended to read:
4 § 1901. ADMINISTRATION OF PROGRAM
5 (a)(1) The Secretary of Human Services or designee shall take appropriate
6 action, including making of rules, required to administer a medical assistance
7 program under Title XIX (Medicaid) and Title XXI (SCHIP) of the Social
8 Security Act.
9 (2) The Secretary or designee shall seek approval from the General
10 Assembly prior to applying for and implementing a waiver of Title XIX or
11 Title XXI of the Social Security Act, an amendment to an existing waiver, or a
12 new state option that would restrict eligibility or benefits pursuant to the
13 Deficit Reduction Act of 2005. Approval by the General Assembly under this
14 subdivision constitutes approval only for the changes that are scheduled for
15 implementation.
16 (3) Income eligibility for Medicaid for an adult who is 26 years of age
17 or older but under 65 years of age and is not pregnant shall be as follows:
18 (A) until January 1, 2026, 133 percent of the federal poverty level for
19 the applicable family size;
20 (B) from January 1, 2026 until January 1, 2028, 185 percent of the
21 federal poverty level for the applicable family size;
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1 (C) from January 1, 2028 until January 1, 2030, 250 percent of the
2 federal poverty level for the applicable family size; and
3 (D) beginning on January 1, 2030, 312 percent of the federal poverty
4 level for the applicable family size.
5 (4) A manufacturer of pharmaceuticals purchased by individuals
6 receiving State pharmaceutical assistance in programs administered under this
7 chapter shall pay to the Department of Vermont Health Access, as the
8 Secretary’s designee, a rebate on all pharmaceutical claims for which State-
9 only funds are expended in an amount that is in proportion to the State share of
10 the total cost of the claim, as calculated annually on an aggregate basis, and
11 based on the full Medicaid rebate amount as provided for in Section 1927(a)
12 through (c) of the federal Social Security Act, 42 U.S.C. § 1396r-8.
13 (b) The Secretary shall make coverage under the Dr. Dynasaur program
14 established in accordance with Title XIX (Medicaid) and Title XXI (SCHIP) of
15 the Social Security Act available to the following individuals whose modified
16 adjusted gross income is at or below 312 percent of the federal poverty level
17 for the applicable family size:
18 (1) all Vermont residents up to 26 years of age; and
19 (2) pregnant individuals of any age.
20 (c) The Secretary may charge a monthly premium, in amounts set by the
21 General Assembly, per family for pregnant women and individuals, children,
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1 and young adults eligible for medical assistance under Sections
2 1902(a)(10)(A)(i)(III), (IV), (VI), and (VII) of Title XIX of the Social Security
3 Act, whose family income exceeds 195 percent of the federal poverty level, as
4 permitted under section 1902(r)(2) of that act. Fees collected under this
5 subsection shall be credited to the State Health Care Resources Fund
6 established in section 1901d of this title and shall be available to the Agency to
7 offset the costs of providing Medicaid services. Any co-payments,
8 coinsurance, or other cost sharing to be charged shall also be authorized and
9 set established by the Agency of Human Services as authorized by the General
10 Assembly.
11 (d)(1) To enable the State to manage public resources effectively while
12 preserving and enhancing access to health care services in the State, the
13 Department of Vermont Health Access is authorized to serve as a publicly
14 operated managed care organization (MCO).
15 ***
16 (3) The Agency of Human Services and Department of Vermont Health
17 Access shall report to the Health Care Reform Oversight Committee about
18 implementation of Global Commitment in a manner and at a frequency to be
19 determined by the Committee. Reporting shall, at a minimum, enable the
20 tracking of expenditures by eligibility category, the type of care received, and
21 to the extent possible allow historical comparison with expenditures under the VT LEG #372757 v.1
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1 previous Medicaid appropriation model (by department and program) and, if
2 appropriate, with the amounts transferred by another department to the
3 Department of Vermont Health Access. Reporting shall include spending in
4 comparison to any applicable budget neutrality standards.
5 (e) [Repealed.]
6 (f) The Secretary shall not impose a prescription co-payment for
7 individuals under age 21 26 years of age enrolled in Medicaid or Dr. Dynasaur.
8 ***
9 Sec. 4. 33 V.S.A. § 1901e is amended to read:
10 § 1901e. GLOBAL COMMITMENT FUND
11 ***
12 (c)(1) Annually, on or before October 1, the Agency shall provide a
13 detailed report to the Joint Fiscal Committee that describes the managed care
14 organization’s investments under the terms and conditions of the Global
15 Commitment to Health Medicaid Section 1115 waiver, including the amount of
16 the investment and the agency or departments authorized to make the
17 investment.
18 (2) In addition to the annual report required by subdivision (1) of this
19 subsection, the Agency shall provide the information set forth in subdivisions
20 (A)–(F) of this subdivision annually as part of its budget presentation. The
21 Agency may choose to provide the required information for only a subset of
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1 the Global Commitment investments in any one year, provided that the Agency
2 shall provide the information for not less than 20 percent of all of the
3 investments in any one year and shall rotate the investments on which it reports
4 such that it provides the information set forth in subdivisions (A)–(F) of this
5 subdivision for each investment at least once every five years. The
6 information to be provided shall include:
7 (A) a detailed description of the investment;
8 (B) which Vermonters are served by the investment;
9 (C) the cost of the investment;
10 (D) the efficacy of the investment;
11 (E) the amount of return on the investment, if applicable; and
12 (F) where in State government the investment is managed, including
13 the division or office responsible for the management.
14 Sec. 5. 33 V.S.A. § 1905b is added to read:
15 § 1905b. MEDICAID REIMBURSEMENT RATES FOR CERTAIN
16 SERVICES
17 The Department of Vermont Health Access shall reimburse providers for
18 delivering primary care, mental health, substance use disorder treatment, and
19 long-term care services in amounts that are greater than or equal to 125 percent
20 of the Medicare reimbursement rates then in effect for delivering the sam