Senate Health and Welfare holds Medicaid 101 briefing on Global Commitment waiver and funding

The Senate Health and Welfare committee on Thursday, January 16 heard a Medicaid 101 briefing from Nolan Langwell of the Joint Fiscal Office and Ashley Ferlina, director of Medicaid policy for the Agency of Human Services, reviewing how Vermont’s Medicaid program is structured, funded and authorized by the state’s 1115 waiver known as the Global Commitment to Health.

The briefing emphasized the program’s scale and budgetary weight: presenters said roughly 197,000 Vermonters have received Medicaid services and that Medicaid accounted for about $2.3 billion in total expenditures in fiscal year 2024. Nolan Langwell noted, “Some of the data is still outdated,” and the presenters said several slides relied on the most recent available figures, some of which are from 2021.

The committee was shown how federal matching funds drive Medicaid financing in Vermont. Ashley Ferlina explained that “1115 waivers allow the explicit waiving of certain provisions of the Social Security Act,” and that Vermont’s Global Commitment waiver — in place since 2005 and set to run through the end of 2027 — lets the state receive federal participation for services and populations that would otherwise be outside standard Medicaid rules. For the majority of Vermont programs, presenters gave a federal match of roughly 58.81 percent (with a corresponding state share of about 41.3 percent); the children’s program (CHIP) was described as roughly 70/30, and the Affordable Care Act expansion population as receiving a 90/10 federal match.

Presenters outlined two main functions of the waiver: 1) access to federal dollars for services not normally allowed under the Social Security Act (examples cited included marketplace subsidies through Vermont Health Connect, a wraparound mental health benefit and prescription assistance for some Medicare beneficiaries), and 2) delivery flexibility, including the state’s use of a public managed-care arrangement through the Department of Vermont Health Access (DVHA) rather than contracting with a private managed care organization.

The committee heard details about services and pilots funded through waiver authorities and reinvested savings. Ferlina listed current and planned programs that rely on the waiver, including a community rehabilitation and treatment expansion benefit for mental health, a palliative care program through the Department of Health for terminal children, and a substance-use disorder expansion benefit planned for 2026 that would extend treatment for people above Medicaid income limits up to 225 percent of the federal poverty level. She said the state recently launched a permanent supportive housing pilot and, as of Jan. 1, 2025, has authority to pay up to six months of rent and medical respite for eligible individuals.

A distinctive feature of Vermont’s Global Commitment is the investments account, funded from in-year savings under the public managed care construct. Ferlina told the committee that investments permit the state to reinvest savings into services and programs that Medicaid would not otherwise pay for (examples cited included the public health lab, 211, hospital diversion and transitional housing supports). She said the waiver caps investments and that the current list includes 69 investments totaling about $120 million in the year discussed. The agency has contracted with the University of Chicago to develop evaluation approaches for those investments and with the University of Massachusetts to build infrastructure for Medicaid program data and monitoring.

Committee members asked about the waiver’s future. Presenters said the waiver must be renewed every five years; the current Global Commitment authorization runs through the end of 2027, and staff said they will begin negotiating renewal terms with federal officials well before that date. Ferlina and Langwell told the committee they are concerned some elements of the waiver could face challenges under future federal review and are preparing to negotiate defensively.

Several senators raised budget and reimbursement questions, including how Medicaid reimbursement levels affect commercial payers and providers; committee members signaled plans to bring additional experts to future hearings. Presenters agreed to post briefing materials, the list of Global Commitment investments and a short memo summarizing the current waiver terms to the committee’s document repository.

The presentation was educational rather than action-oriented: there were no formal votes or policy decisions recorded during this session. The committee recessed after the briefing.