Committee hears Medicaid 101 briefing, including Global Commitment waiver, investments and new supports

The House Health Care Committee received a detailed briefing on Medicaid coverage, financing and the state's Section 1115 demonstration waiver — the Global Commitment to Health — at its Jan. 15 meeting.

Nolan Langewell of the Legislative Fiscal Office and Ashley Berliner, director of Medicaid policy at the Agency of Human Services (AHS), told members the Medicaid population accounts for roughly one-quarter of Vermont residents and represents a substantial share of state health spending. "Today, we're gonna be talking about the pie chart part of the pie chart that's Medicaid, which is a 24%." Berliner said. Committee discussion referenced a prior expenditure analysis and more recent budget figures showing Medicaid accounted for about $2.3 billion of gross spending in fiscal year 2024.

Why it matters: Medicaid is a major portion of Vermont's health budget and state finances. Committee members pressed officials on federal matching rules, program eligibility and how waiver authority changes what the state can fund with federal dollars.

Key facts and program features explained to the committee:

- Coverage and eligibility: Medicaid requires Vermont residence and lawful presence; financial eligibility is income-based. Before the Affordable Care Act (ACA), categorical tests (pregnancy, parent, aged, blind or disabled) applied. The ACA created the "new adult" expansion group, allowing low-income adults to qualify without a categorical condition.

- Federal matching and risk: The federal government provides varying matches (FMAP). The ACA-era match for the expansion adult group is commonly referred to as 90/10 in the briefing; officials said the 90/10 rate is written as permanent in statute but noted administrations can propose changes.

- State spending and budget shares: Presentations used FY24 budget figures: an $8.7 billion gross state budget with roughly $2.3 billion for Medicaid. Officials said the state's general fund contribution to Medicaid is about $734 million (gross state dollars to draw federal match) for that period.

- Global Commitment (Section 1115) waiver: Berliner described Vermont's Global Commitment to Health as a comprehensive Section 1115 demonstration in place since 2005 and currently authorized through Dec. 31, 2027. The waiver waives portions of the Social Security Act to allow the state to operate certain programs differently, draw federal dollars for specified services and use savings for reinvestment subject to federal approval and budget-neutrality requirements.

- Waiver-enabled services and recent amendments: The waiver permits Vermont to draw federal match for marketplace subsidies up to 300% of FPL, funds wraparound benefits such as community rehabilitation and treatment (for severe mental illness) and a pharmacy wraparound for elderly individuals. The state cited recent additions and amendments: a substance use disorder wraparound expansion benefit planned for 2026 (with a 225% FPL income ceiling for the initial phase), a permanent supportive housing benefit "turned on" effective Jan. 1 (pre-tenancy and tenancy supports), and a waiver amendment authorizing up to six months of rent and six months of medical respite (authority provided but state funding not yet appropriated).

- Reentry services for incarcerated individuals: The committee was told a 2024 waiver amendment allows Medicaid-funded reentry services — including some Medicaid-covered care inside correctional facilities up to 90 days pre-release — and that the state is working on implementation details; Berliner said the state planned to activate that authority on "11/26" (as stated in the briefing) and is coordinating with the Department of Corrections on operational steps.

- Investments and evaluation: The Global Commitment demonstration also permits the state to reinvest savings into a defined set of "investments." Officials said Vermont currently lists 69 investments and that the state has roughly $20 million of headroom available in the investment cap at present. A contract with the University of Chicago will evaluate investments; the state's first-pass review found many investments lack sufficient evaluation data, and the evaluation contract will prioritize investments that can be meaningfully assessed and scaled.

- Delivery model and management: Berliner and Langewell explained Vermont's managed, waiver-enabled structure: AHS and the Department of Vermont Health Access (DVHA) serve as public payers under the Global Commitment construct, enabling payment and delivery flexibilities that differ from typical state plan Medicaid administration.

Committee members asked clarifying questions about income thresholds for disability-related eligibility, which the speakers said still require meeting income criteria in many cases, and about where wraparound housing services can and cannot be used (officials said Medicaid cannot pay for new brick-and-mortar construction but can fund supportive services, certain rehabbing and tenant supports when beneficiaries meet homelessness/eligibility hooks; Medicaid may not supplant existing general-fund base programs).

No formal committee votes accompanied the briefing. Committee members requested additional materials, including the list of investments and anticipated reports from the University of Chicago contract.