Good morning everyone and welcome to this joint committee session of the government operations of fiscal policy committee and the health and human services committee. Today we have one item for the joint committee that is supplemental appropriation 25-58 to the FY 25 operating budget Montgomery County government Department of Health and Human Services. My Montgomery cares in the amount of 974,664 dollars the source of funds is General Funds Undesignated Reserves. And we also have an amendment to the FY25 operating budget resolution 20-526, Section G designation of entities for non-competitive contract awards, the primary care coalition of Montgomery County, Maryland. Today we are joined by Council Member Albinas who chairs HHS committee and we have Council Member Luthe who is virtual. I'll first turn over to my co-chair, CPS, any opening remarks before turning over to staff. Well good morning everyone. It's good to see you. So I think we should just get started. We got a pack day today. Great. Ms. Clemens Johnson, do you want to start? Sure, I will. Good morning and thank you so much. We are discussing the supplemental appropriation for the Montgomery Cares program of $974,664. Montgomery Cares is a longstanding program within DHHS that provides access to medical services for uninsured adults in Montgomery County. Requirements are that you have to live in the county, be uninsured and make less than 250% of the federal poverty level. This supplemental is to request to help ensure that there is not a shortfall in the program. Similar to what was happening for care for kids, our clinics are experiencing influx of patients, therefore having more patient visits and are expending their budget quite quickly. So they are budgeted for 72,000 encounters at 102 dollars and 15 cents per encounter. They are suggesting that they are projected to reach 76,449 encounters. Therefore, they are requesting a budget of 77 encounters. So I would say that would be the largest need to ensure that the clinics do not have to close their doors. The other request include a support for specialty care. That is a other ancillary program that are part of the program. Specialty care, they are spending their budget at a very quick rate and so they are requesting additional funds to ensure that they can provide services throughout the end of the year. And then there is also a request to expand the Machemui CARES Network to include the Islamic Center of Maryland's CARE clinic. So in your packet I have detailed that the budget details didn't quite line up budgetarily in terms of the request. So if you see page five of your packet, I recommend the discussion questions that they receive clarity on the primary care amount that is requested. And then there's also received clarity on one part of the program that's requested for the MedBang program to council staff knowledge. That's support staff in the fact that this would be a month and a half with the funding I think just more information should be shared about how that funding would be used for six weeks. And also I would suggest that the council can what the committee consider talking about the addition of the clinic and why that is needed at this time. I will share that the addition of the clinic is recommended in the FY26 Public Health Services budget that will be discussed in the HHS committee meeting today. So there would be an opportunity to have further discussion about them joining the networks in. I can answer any additional questions. And that's it. Great. With the OK of my co-chair, why don't we first take questions or clarifying points on the additional primary care encounters and specialty care requests and then talk about the ICM? Is that OK? Great. Does anyone have any questions about the additional funds for the primary care encounters or the specialty care request at this time? Councilmember Albinas. Thank you. So more of a comment than a question, but obviously we're going to be looking at the overall reimbursement rate and making appropriate adjustments as part of the FY 26 budget as has been recommended by the county executive. I'm sure that all of my colleagues and I agree that we greatly understand and see the writing on the wall with regards to the additional need. And that is only going to increase over the coming once as adjustments are made to Medicare and Medicaid, which are going to significantly disrupt our overall public health care infrastructure. That coupled with the challenges at DHHS at the national level and the reductions that are being made and potentially significant policy shifts with things such as vaccinations have created just an absolutely unsettling, troubling, and frankly scary time. And so it obviously makes sense for us to continue to do what we need to do to support our local constituents, particularly those that for whatever reason are not eligible for federal aid aid. And so I very much support this, this appropriation, but would love to hear a little bit more about how this will be connected to the broader recommendation of the enhanced reimbursement rates. And do you think the enhanced reimbursement rates may, I would assume, put you in a pitter position to not have to request a supplemental appropriation moving forward. We know that greatly disrupts the budget. It greatly disrupts the operations of clinics Just kind of team it up and letting you comment on that Good morning council president Stewart and council member sitting as a joint committee this morning Just want to tee it up for our public health team when we talk about our public health systems and our HHS enterprise. I know we've had at least 10 supplemental requests this year. And last year, I advised the council that given the budget reductions and what we forecast at the fiscal level for the federal and the state budget constraints, we are at a time now where we need supplements to support our healthy human services Enterprise. Specifically, our safety net providers who are at risk as far as keeping their doors open and also looking at supporting those who are at risk and are underserved. And so what we have in this supplement is a request that looks at not only the Medicaid and Medicare billing rate, but also the Healthy Human Human Services as a business enterprise. If you look at the Health and Human Services and all the services that we provide, look at it akin to a small operating hospital. And I know early on when Council member Freetz and talked about the infrastructure and our ability to have staff and resources, this is part of that enterprise. And so what you will have this morning, and see this morning, especially for this particular supplement, is our team will lay out all the questions that you have and provide those granular level details. I'll stop there with those opening remarks and turn it over to our great public health team. And I don't have a ton more to add before I turn it over to Dr. Rogers, but I do think when we talk about the additional funding, just making sure that we're decoupling the reimbursement rate from the increased encounter rate, particularly for this supplemental, so I just want to make that point of clarification. And then I will turn it over to Dr. Rogers. Good morning. I would say two things, Councilman Albernol's and to Dr. Astros point, the couple in the encounters versus a reimbursement, two distinct but interrelated items. And the FY25 supplement on that you have before you, you will see that we have budgeted for 6,000 additional Montgomery cares adult primary care encounters. That's because we are seeing increased utilization across our safety net clinics. More patients are engaging with the system, which we want them to do at the primary care so that they can avoid unnecessary emergency department utilization. And then so in FY 26 budget, which we talk about later that account executive recommended you'll see that we maintain that that's that funding for increased utilization into FY26. We don't anticipate that utilization will decrease in the coming fiscal year. We think that it will maintain. So we have budgeted funds. And then for the reimbursement rate, that's a FY26 recommended budget item that we would address later. So the supplemental does not include any funding for the increased reimbursement rate. Thank you, I appreciate it. First, I have Council Member Lutti. Hi, sorry, I had a little trouble unmuting. I just had a quick question. I don't know if Miss Clem and Johnson could clarify this or our friends from DHS. In the packet it had indicated that there was a change in the eligibility criteria that went into effect on April 1st of this year. And so could you just speak to what that change was and how that may impact things moving forward? Yes, thank you for that question. As Council may very well know, the Maryland General Assembly passed the access to care at which will go on to effect on January 1, 2026, that will allow undocumented immigrants to be eligible for health care covers from the Maryland health connection, they'll be able to purchase a qualified health plan. Prior to April 1st, part of the Montgomery Kids eligibility requirements was not eligible for or enrolled in a qualified health plan. And so what the new law does in the state of Maryland, in effect, it renders nearly all, if not 100% of our Montgomery kids, patients and eligible. We also know that individuals who will become eligible for the access to care at Croft, our health plan will not be eligible for federal subsidies or any type of cost-sharing reductions, which means that the coverage that they will be, have access to will be unaffordable. So access doesn't always mean that you can afford a plan. And so what the county executive decided to do was to ensure that our undocumented residents of Montgomery County can still have access to quality affordable health care. We change the eligibility criteria for Montgomery care so that individuals can remain eligible for the program. And so as long as a person attests to not be an uninsured, for example, they may be deemed that a qualified health plan is unaffordable. So therefore, they choose not to enroll into a qualified health plan. They will still be considered uninsured. Now these individuals, of course, they still won't be eligible for Medicaid and the clinics also take ample steps to make sure that individuals not enrolled in Medicaid by checking the enrollment verification system. So there are a number of checks and balances to ensure that we still have the right people enrolled in right coverage that they are eligible for. And so we made that policy change to ensure that our undocumented residents can still have access to quality affordable health care. Thank you for that because yes, I know you're 100% correct that even though there's technically now an eligibility ability, if you will, based on the state law change, that doesn't mean that the folks in need would meet the, you know, path, they may still be under the economic pressure and still otherwise qualify for Montgomery care. So thank you for that, I appreciate it. Thank you, Council Member Lutke, Councilmember Katz. Thank you very much Madam President. Dr. Bridges first of everybody thank you all for everything you do we sincerely appreciate it. But Dr. Bridges you mentioned the real concern in that some of our medical providers are having difficulty struggling to keep their doors open and I think that's certainly something that's very, very true and very realistic. So if they don't keep their doors open, AirNeed doesn't go away, but we still have the need there as there are plan V. How do we make certain that we can go forward and take care of people who are having health risks that are not only risk for themselves but risk for the community at large? Thank you. Thank you, Council Member Cass for that. One of the strengths that we have at the Department of Health Human Services and I ask my colleagues who are the table this morning to add and enhance that. but we have like primary care coalition in our next is Montgomery hospital system. But we're all at risk. All of the system is at risk when a clinic closes because again we support and underserved this advantage. Often disenfranchised community who rely on our system as a safety net system, safety net providers and when there's a tear in that fabric, there's a likelihood of things falling through the crack. And what are those things? Well, and of course at this point in their area especially, there are people who never thought that they would be without medical insurance, who are either already are or will be without medical insurance. And that is a very scary situation for everyone involved. So again, thank you for everything you do and I yield back. Thank you, Council Member Sale. Thank you Madam Chair and thank you to our HHS team. We know that right now things are very uncertain even for our recently displaced workers, those uninsured and our immigrant community. And so I'm glad to see that we are forecasting the needs and ensuring that no one will be turned away for service and also I'm glad to see I see M here. Ensuring that we are providing culturally competent care is also of the utmost importance in our majority community of color. So thank you all. I just wanted to highlight a few questions. Given the federal administration's position towards budget cuts and plans to further reduce the budget by about 40 billion, especially connected to our health programs and services. How are we assessing the efficiency of the primary care coalition model? And when was the last time that evaluation was completed? That's a great question, Councilmember Sales. I do not know the last time the primary care coalition's contract was evaluated. I've been with the county for five years and to my knowledge, well, I know it has not been evaluated. And so I would probably. So that that would be my response as far as an evaluation. The system as itself, so the couple, the primary care coalition is a contractor, which we would need to work with the directors office and our contract management team to talk about and evaluation. I know each vendor has a contract monitoring report that is done at the end of each fiscal year, which to make sure that they are complete and certain tasks throughout the year. But I think I understand what you're saying as far as evaluation. The system has been evaluated as a Montgomery Cares. We did a network adequacy study that the department authorized a couple years ago to determine to really gauge access to CARE across our population. That is whether or not our patients can access the right clinics when they need to, whether or not the clinics have the right operating hours, how far they have to travel to different clinics if there are gaps within services that we need to offer. So we've done a valuation of the system as a whole. Okay. Can I just add a couple more points? I think when we talk about Montgomery Cares as a system, it's actually quite a great value to the county. The average cost per participant is $515 per person per year, which if you think about the health insurance premiums that you pay just out of your paycheck, not even what the county subsidizes, is quite a great value as Dr. Rogers mentioned, then that work at Quesy study. When we look at our clinics, 88% of patients surveyed received forms and they're preferred language, 67% of patients surveys, surveyed received interpretation services. Folks, I think 91% expressed high satisfaction with their providers, most our patients are within a 15-minute drive from their clinic. The clinics really are what I call the Magic or the Secret Sauce of the Montgomery Care's program in terms of providing quality care they perform on par with Medicaid heaters measures. So the network adequacy study looked at all of that. The program itself is truly a great value for the investment that the county puts in. Thank you. Dr. Rogers just mentioned the impact on our emergency room wait times. Council member sales, if I may, we have only about seven minutes left for this session, and then you all are going to go in deep on this in HHS. So it was making your recommendation. We're just making a recommendation on the supplement for the FY25 budget that we have before us, but then you all are going to go to the seventh floor. Upstairs at seven minutes to dig in deep on the HHS FY25, a 26 budget Montgomery cares and other things. So just want to just do a time check just because of the cascading effect of now all our budget committee meetings. Yes. So I will yield and continue the conversation of stairs. You know, I'm going to definitely support this budget appropriation. We want to make sure that no one gets turned away and just wanted to better understand some of the terminology versus unique patients versus the actual visits that patients are having. And I will yield my time. Thank you. Thank you so much. And so I'm not hearing any objections to the part of the supplemental regarding the additional primary care encounters and the specialty care requests and just want to add as my colleagues have said thank you to the work we're doing. Dr. Bridges we hear you loud and clear the number of supplemental HHS how to do this year and I know the chair of HHS has also heard that as we're entering into our FY26 deliberations. So Ms. Johnson, those pieces of the supplemental, I think we are seeing recommendation to the full council. And then we wanted to speak about the ICM request and I'll turn it over to chair of HHS. Thank you. I guess just fundamentally, there's only a few months left in this fiscal year. So the big question is why, why provide services for just the two or three months as opposed to waiting for the FY26. And then secondarily, there were some discrepancies in the description and in some of the numbers that I would ask Ms. Clemens Johnson to elaborate on. But if we could just start with that fundamental issue of why supplemental for two or three months versus waiting for FY26, because we will have a much deeper dive in just about about 35, 40 minutes on this overall subject, the great work that I see I'm doing, how it connects to all of the various clinics, the need that we know is expanding, but just wanted to ask that fundamental question first. Thank you, Council Member Alvin, so we actually submitted the supplement of requests a couple of months ago to forecast and take us through the end of this fiscal year It was presented to council and as you indicated unfortunately there are only a couple of months left to go in this fiscal year But we went through a series of what if scenarios beginning last year and so we wanted to present it to council earlier Unfortunately, it didn't get to council in a timely manner We submitted because we track the team tracks expenditures and utilization very closely and we want to be good fiscal stewards of our budget. It was submitted in December. So it's like Dr. Bridger said, it's just a little delayed getting to you guys. If I could jump in, Grace Pederson from OMB, this supplement all was tied to fiscal 26 affordability decisions, including the ability to expand to ICM. So that full program was evaluated in the budget deliberation process. So it was presented to council as a full package of what will be affordable for the program, including the C's recommendation for fiscal 26. And I just want to clarify that the council did not receive this in December. So I just said, clarify that the HHS department may have put this in, but the council had not received this. We just received this recently. Correct, yes. I just, just for everybody watching, we were not holding this up. This was when we received this, we moved as quickly as possible to hold the public hearing and follow our processes for the supplemental. Sure. Absolutely. And I'm doing it. And we went through a series of Q and A's by OMB for the justification. So that caused some of the delay in making sure that we provided OMV with all of the information that they needed to process the supplement. This is Clemens Johnson. If you could elaborate on some of the discrepancies you noted in the request. Yes. So I will go through the chart on, not chart, excuse me, the detail on page four to five. So we will start with the primary care amount, the state it budget, the numbers just aren't correct. The rate is one, oh, two, 15 for encounters, and that translates to a number of visits, one, oh, two, 15 plus 100, I mean, time to 100. You know, so the number was 694.61 visits. So I did some math and said, well, this would be the rated with either it's 700 visits because the request for the number of visits wasn't included. There was just the dollar amount. So ideally, the information should have been presented that we want 6,000 visits at a rate of 102. I mean, you know, not like the primary care, but for it should be just more clearly laid out. So I'm not sure how they got to that number. I think some of the work that they have been doing is looking at things as a percentage of things, but for us, 5 plus 5 plus equal 10. So that is what I was requesting more information for. Additionally, behavioral health is pretty clear. They either behavioral health this funding would go into the PCC contract, and it would either support encounters, behavioral health encounters that happen at the clinic, or it would support the behavioral health staff. So there is a question about that, but I was a bit more clear on behavioral health, because I know I can happen in encounters in which the provider provides those. And then the question mainly was on MedBang, the 21,293, my knowledge of the program is that we really pay for the staff and the staff do the work to help support the patients. And so my question was what would the 21,000 be used for? And then also community pharmacy, that's very clear. They use the money for the purchase of medication. So I didn't question that. So I did give out a general recommendation that we just not add the clinic for the next. I mean, if this goes through, then the money would be approved like May 5th or one of those weeks. So this would literally be like six weeks of funding. So that, you know, that the committee could consider not funding it and just consider maybe talking about it during the FY26 Public Health Services budget. Because we just need clarity and I don't know that we have time to come back and revisit this unless the department can provide details about what the budget numbers are. So we've only got a few minutes left. So I would like for you all to respond to those very understandable questions. And then also, while HHS submitted in December, it is the practical reality that the, in the best case scenario, the funding would go out for just a little less than two months. And there are a lot of questions regarding the overall operation, how it fits within the system that we certainly are going to get to this morning. So I'd love to hear a super compelling reason why we should be making this recommendation the full council as opposed to having a broader deliberation through the committee process within FY26. Well, I can answer the budget question and let the direct that give you the super compelling reason. But on average, and Montgomery here... within FY26. Well, I can answer the budget question and let the direct that give you the super compelling reason. But on average, a Montgomery Kieres recipient receives 2.7 visits and so the department worked with the Primary Care Coalition to develop a budget for ICM and so the behavioral health because we're adding more patients, they're going to need more bandwidth, more staff to do the work and so it would Fun a point to FTE behavior health care manager in addition to med bank again because we're taking all more patients They had to administer more medication. It would fund a point to five FTE client service specialist for the med bank program and then for community pharmacy, the funding is going to be used to purchase medications. And then again, in a primary care line, using the $102.15 in counter rate, when you times that by the average number of visits per person, across 267 individuals who we receive in services at ICM, which is, it is projected, that's how we get the total for the primary care reimbursement rate. And so the 123,000 is without the primary care coalitions and direct costs. And then when you fact the end direct for the primary care coalition, we get at 136,000 and then I'll turn to the director. Thank you, Dr. Roderick. So the compelling need is to expand and increase capacity in the community. The long-term gain would be to fund it in FY26. And so looking realistically at where we are physically, to get into more detail in our HHS committee session. But short-termly, it may be advantageous to consider it in FY 26 and then provide any support that we can through our community partnerships to the community center and the interim. Thank you. And OMB. And OMB's understanding is that conversations have been ongoing with the ICM provider all year to see whether this would be feasible. So the May start date was what was anticipated when they could realistically get this off the ground. It's just a coincidence of when it falls in the fiscal year but we have been working with them to get it off the ground. That's correct. So that's not the executive branch isn't trying to fit this in at the end of the year. That's just when the provider is going to be able to start accepting patients and bringing them on board. And with the exceptional increase in enrollment in the program that was seen as a strength to have a new provider as soon as possible. Get online. So given those comments which I appreciate, I would recommend Madam President that we comply with the or go forward with the staff recommendation which is that we have a fuller conversation as part of the FY26 budget plan which we're having in literally an hour and that you know while all things being equal given the circumstances that's probably the more appropriate approach as noted by Dr. Briggers. Council Member Sales thank you how many clinics are up county? Yeah. Do you do? Do you do the work? We do hear the music. It's all in to you. The works 25. Your microphone. Sorry. I'm sure he'll do the math, but I will say there's 12 entities with over 25 sites around the county. I think majority are of the more than I wrong. Yeah, because I think there's mercy health clinic. There's I see him as newly suggested. Who else is right there? I'm going to say about four or five. Thank you, sit Upcanny, like I'm right here. Okay, thank you. Great, so we have a recommendation from our co-chair that joint committees move forward with the staff recommendation of funding the supplemental at $851,152 and the funding for the new clinic, ICM, is included in conversations that the HHS committee will have regarding FY26 budget. Any objections to that? Councilmember sales? Yes, I'm just looking at 267 patients who won't be seeing and how we're going to contend with that for how many more months it's just April. So that's until two months that patients are going to have to go somewhere else. I don't know if they're in the middle of their care or not and so I don't support delaying this funding. Okay. Council Member Cassia. Can we clarify are you saying that those patients would not be seen? Can I just note really quick that the clinic is not currently part of the network. So they are seeing patients I see them as a clinic right now by themselves. They are requesting to join my gum recures. So we're not talking about patients that are part of the my gum recures network now. any patient part of the network is currently being seen. This is a suggestion of adding a clinic. So they are operating by themselves as a clinic and serving the patients that they are choosing to. And this would be going forward. This would be going forward. They would be joining the network to be reimbursed for the patients, I guess, that they are currently saying. Thank you. Who may be eligible? And I agree with the chair of HHS that if we're talking about adding a new clinic to the network, having the HHS committee have a fuller conversation of that, I think, is appropriate. Understanding there is a need and understanding, as we've all said here, where we are right now, but that is a big step for us. And so I understand that the department has been looking at this and OMB, but I'd request that the HHS committee do the due diligence of really having a full conversation. And when we're talking about a supplemental of this amount at this time in the budget year that we do the supplemental for Montgomery Cares now. Council member, Regent. Thank you. We all are huge supporters of ICM who does incredible work with all visited multiple times and have seen it, it leverages a significant amount of volunteer support from the incredible talent that we have in the community, which is a deal that we can replicate in many ways. I have a little bit of heartburn on this one. I'm going to defer to the co-chairs on this on their views. But we wanna see this, well, at least I can speak for myself. I wanna see this expansion, you know, in terms of the timing and where we are in the budget year and the recommendation that has come from the co-chairs, I'm gonna defer, but ultimately, as Council Member Sales noted, there are patients, there are needs, there is a partner that is willing and able to do it, that is, you know, doing incredible work. There have been ongoing discussions. I do think a May start date with a July 1 fiscal year is a challenging dynamic for us to grapple with, but ultimately I just want to be very clear that what work that is being done and the potential partnership and expansion here is something that really deserves significant deep dive. Unfortunately, we're not in a position to do that level of deep dive here, which is why I'm deferring, but I just want to be very clear on that. Thank you. Councilmember Luki, did you want to speak? I saw your hand up and then down. Yes, I just wanted to say, I definitely support ICM. I do believe there are some logistical and practical hiccups present right now. ICM provides a valuable service to our up county community and they have been expanding their services over time. I certainly will support them joining the coalition, but I think that's the subsequent discussion. we're going to have upstairs and I believe that there are some unresolved issues now that make us not able to move forward with these unanswered questions. Great thank you. Since there's potentially a slight difference of opinion I'd like to take a formal vote so do I have a motion to accept the staff recommendation on this supplemental council member Alvin Osmoo do I have a second council member cats mood all those in favor of supporting the staff recommendation on the supplemental please raise your hand I have one two three four five those opposed abstaining abstaining. Abstain, abstain, abstain. Mr. Johnson, did you get that? All right. All right, you all are going upstairs. Because it's budget time. So HHS's upstairs will take a two minute break and government operations and fiscal policy will begin here at 9.40.