Quality, Resource Allocation, and Cost Containment

V.S.A. tit. 18, ch. 221, subch. 1

in effect

18 V.S.A. § 9401 Policy

9401. Policy (a) It is the policy of the State of Vermont that health care is a public good for all Vermonters and to ensure that all residents have access to quality health services at costs that are affordable. To achieve this policy, it is necessary that the State ensure the quality of health care services provided in Vermont and, until health care systems are successful in controlling their costs and resources, to oversee cost containment. (b) It is further the policy of the State of Vermont that the health care system should: (1) maintain and improve the quality of health care services offered to Vermonters; (2) utilize planning, market, and other mechanisms that contain or reduce increases in the cost of delivering services so that health care costs do not consume a disproportionate share of Vermonters’ incomes or the monies available for other services required to ensure the health, safety, and welfare of Vermonters; (3) encourage regional and local participation in decisions about health care delivery, financing, and provider supply; (4) utilize planning, market, and other mechanisms that will achieve rational allocation of health care resources in the State; (5) facilitate universal access to preventive and medically necessary health care; (6) support efforts to integrate mental health and substance abuse services with overall medical care. Added 1991, No. 160 (Adj. Sess.), § 1, eff. May 11, 1992; amended 1995, No. 180 (Adj. Sess.), § 7; 2009, No. 49, § 8; 2009, No. 128 (Adj. Sess.), § 8, eff. May 27, 2010; 2023, No. 6, § 225, eff. July 1, 2023.

18 V.S.A. § 9402 Definitions

9402. Definitions As used in this chapter, unless otherwise indicated: (1) “Commissioner” means the Commissioner of Financial Regulation or the Commissioner’s designee. (2) “Community report” means the hospital report prepared under section 9405a of this title. (3) “Department” means the Department of Financial Regulation. (4) [Repealed.] (5) “Expenditure analysis” means the expenditure analysis developed pursuant to section 9383 of this title. (6) “Health care facility” means all institutions, whether public or private, proprietary or nonprofit, that offer diagnosis, treatment, inpatient, or ambulatory care to two or more unrelated persons, and the buildings in which those services are offered. The term shall not apply to any facility operated by religious groups relying solely on spiritual means through prayer or healing but includes all institutions included in subdivision 9432(8) of this title, except health maintenance organizations. (7) “Health care provider” means a person, partnership, or corporation, other than a facility or institution, licensed or certified or authorized by law to provide professional health care service in this State to an individual during that individual’s medical care, treatment, or confinement. (8) “Health insurer” means any health insurance company, nonprofit hospital and medical service corporation, managed care organizations, and, to the extent permitted under federal law, any administrator of an insured, self-insured, or publicly funded health care benefit plan offered by public and private entities. (9) “Health maintenance organization” means any person certified to operate a health maintenance organization by the Commissioner pursuant to 8 V.S.A. chapter 139. (10) “Health Resource Allocation Plan” means the plan published by the Green Mountain Care Board in accordance with subsection 9405(b) of this title. (11) “Home health agency” means a for-profit or nonprofit health care facility providing part-time or intermittent skilled nursing services and at least one of the following other therapeutic services made available on a visiting basis, in a place of residence used as a patient’s home: physical, speech, or occupational therapy; medical social services; home health aide services; or other non-nursing therapeutic services, including the services of nutritionists, dieticians, psychologists, and licensed mental health counselors. (12) “Home health services” means activities and functions of a home health agency, including nurses, home health aides, physical therapists, occupational therapists, speech therapists, medical social workers, or other non-nursing therapeutic services directly related to care, treatment, or diagnosis of patients in the home. (13) “Hospital” means an acute care hospital licensed under chapter 43 of this title. (14) “Managed care organization” means any financing mechanism or system that manages health care delivery for its members or subscribers, including health maintenance organizations and any other similar health care delivery system or organization. (15) “Health care spending estimate” means the spending estimate established in accordance with section 9383 of this title. (16) “State Health Improvement Plan” means the plan developed under section 9405 of this title. (17) “Green Mountain Care Board” or “Board” means the Green Mountain Care Board established in chapter 220 of this title. Added 1991, No. 160 (Adj. Sess.), § 1, eff. May 11, 1992; amended 1995, No. 180 (Adj. Sess.), § 8; 2003, No. 53, §§ 2, 26; 2005, No. 57, § 3, eff. June 13, 2005; 2007, No. 27, § 11; 2009, No. 49, § 9; 2011, No. 48, § 19; 2011, No. 171 (Adj. Sess.), § 13, eff. May, 16, 2012; 2015, No. 54, § 33; 2017, No. 167 (Adj. Sess.), §§ 3, 10, eff. May 22, 2018.

18 V.S.A. § 9403 Statewide Health Care Delivery Strategic Plan

9403. Statewide Health Care Delivery Strategic Plan (a) The Agency of Human Services, in collaboration with the Green Mountain Care Board, the Department of Financial Regulation, the Vermont Program for Quality in Health Care, the Office of the Health Care Advocate, the Health Care Delivery Advisory Committee established in section 9403a of this title, the Vermont Steering Committee for Comprehensive Primary Health Care established pursuant to section 9403b of this title, and other interested stakeholders, shall lead development of an integrated Statewide Health Care Delivery Strategic Plan as set forth in this section. (b) The Plan shall: (1) Align with the principles for health care reform expressed in section 9371 of this title. (2) Identify existing services and promote universal access across Vermont to high-quality, cost-effective acute care; primary care, including primary mental health services; chronic care; long-term care; substance use disorder treatment services; emergency medical services; nonemergency medical services; nonmedical services and supports; and hospital-based, independent, and community-based services. (3) Define a shared vision and shared goals and objectives for improving access to and the quality, efficiency, and affordability of health care services in Vermont and for reducing disparities in access resulting from demographic factors or health status, including benchmarks for evaluating progress. (4) Identify the resources, infrastructure, and support needed to achieve established targets, which will ensure the feasibility and sustainability of implementation. (5) Provide a phased implementation timeline with milestones and regular reporting to ensure adaptability as needs evolve. (6) Promote accountability and continuous quality improvement across Vermont’s health care system through the use of data, scientifically grounded methods, and high-quality performance metrics to evaluate effectiveness and inform decision making. (7) Provide annual targets for the total cost of care across Vermont’s health care system. Using these total cost of care targets, the Plan shall identify appropriate allocations of health care resources and services across the State that balance quality, access, and cost containment. The Plan shall also establish targets for the percentages of overall health care spending that should reflect spending on primary care services, including mental health services, and on preventive care services, which targets shall be aligned with the total cost of care targets. (8) Build on data and information from: (A) the transformation planning resulting from 2022 Acts and Resolves No. 167, Secs. 1 and 2; (B) the expenditure analysis and health care spending estimate developed pursuant to section 9383 of this title; (C) the State Health Improvement Plan adopted pursuant to subsection 9405(a) of this title; (D) the Health Resource Allocation Plan published by the Green Mountain Care Board in accordance with subsection 9405(b) of this title; (E) hospitals’ community health needs assessments and strategic planning conducted in accordance with section 9405a of this title; (F) hospital and ambulatory surgical center quality information published by the Department of Health pursuant to section 9405b of this title; (G) the statewide quality assurance program maintained by the Vermont Program for Quality in Health Care pursuant to section 9416 of this title; (H) the 2020 report determining the proportion of health care spending in Vermont that is allocated to primary care, submitted to the General Assembly by the Green Mountain Care Board and the Department of Vermont Health Access in accordance with 2019 Acts and Resolves No. 17, Sec. 2; (I) the 2024 report on Blueprint for Health payments to patient-centered medical homes, submitted to the General Assembly by the Agency of Human Services in accordance with 2023 Acts and Resolves No. 51, Sec. 5; and (J) such additional sources of data and information as the Agency and other stakeholders deem appropriate. (9) Identify: (A) opportunities to improve the quality of care across the health care delivery system, including exemplars of high-quality care to stimulate best practice dissemination; (B) gaps in access to care, as well as unnecessary duplication of services, including circumstances in which service closures or consolidations may result in improvements in quality, access, and affordability; (C) opportunities to reduce administrative burdens; (D) federal, State, and other barriers to achieving the Plan’s goals and, to the extent feasible, how those barriers can be removed or mitigated; (E) priorities in steps for achieving the goals of the Plan; (F) barriers to access to appropriate mental health and substance use disorder services that meet standards of quality, access, and affordability equivalent to other components of health care; (G) opportunities to integrate health care services for individuals in the custody of the Department of Corrections as part of Vermont’s health care delivery system; (H) enhancements in quality reporting and data collection to provide a more current and accurate picture of the quality of health care delivery across Vermont; and (I) systems to ensure that reported data is shared with and is accessible to the health care professionals who are providing care, enabling them to track performance and inform improvement. (c) State agencies shall cooperate with all reasonable requests from the Agency of Human Services for data and other information and assistance needed for the Agency to prepare and update the Plan pursuant to this section. (d)(1) In 2025 and 2026, the Agency of Human Services shall engage with stakeholders; collect and analyze data; gather information obtained through the processes established in 2022 Acts and Resolves No. 167, Secs. 1 and 2; and solicit input from the public. (2) In 2027, the Agency shall prepare the Plan. (3) On or before January 15, 2028, the Agency shall provide the Plan to the House Committees on Health Care and on Human Services and the Senate Committee on Health and Welfare. (4) The Agency shall prepare an updated Plan every three years and shall provide it to the General Assembly on or before December 1 of every third year, beginning on December 1, 2030. Added 2025, No. 68, § 8, eff. June 12, 2025.

18 V.S.A. § 9403a Health Care Delivery Advisory Committee

9403a. Health Care Delivery Advisory Committee (a) There is created the Health Care Delivery Advisory Committee to: (1) establish health care affordability benchmarks; (2) evaluate and monitor the performance of Vermont’s health care system and its impacts on population health outcomes; (3) collaborate with the Agency of Human Services and other interested stakeholders in the development and maintenance of the Statewide Health Care Delivery Strategic Plan developed pursuant to section 9403 of this title; (4) consider the recommendations of the Vermont Steering Committee for Comprehensive Primary Health Care established pursuant to section 9403b of this title; (5) advise the Green Mountain Care Board on the design and implementation of an ongoing evaluation process to continuously monitor current performance in the health care delivery system; and (6) provide coordinated and consensus recommendations to the General Assembly on issues related to health care delivery, including primary care, and population health. (b)(1) The Advisory Committee shall be composed of the following 18 members: (A) the Secretary of Human Services or designee; (B) the Chair of the Green Mountain Care Board or designee; (C) the Chief Health Care Advocate from the Office of the Health Care Advocate or designee; (D) two members of the Vermont Steering Committee for Comprehensive Primary Health Care, selected by the Steering Committee; (E) one representative of commercial health insurers offering major medical health insurance plans in Vermont, selected by the Commissioner of Financial Regulation; (F) two representatives of Vermont hospitals, selected by the Vermont Association of Hospitals and Health Systems, who shall represent hospitals that are located in different regions of the State and that face different levels of financial stability; (G) one representative of Vermont’s federally qualified health centers, selected by Bi-State Primary Care Association; (H) one representative of physicians, selected by the Vermont Medical Society; (I) one representative of independent physician practices, selected by HealthFirst; (J) one representative of advanced practice registered nurses, selected by the Vermont Nurse Practitioners Association; (K) one representative of Vermont’s designated and specialized service agencies, selected by Vermont Care Partners; (L) one preferred provider from outside the designated and specialized service agency system, selected by the Commissioner of Health; (M) one Vermont-licensed mental health professional from an independent practice, selected by the Commissioner of Mental Health; (N) one representative of Vermont’s home health agencies, selected jointly by the VNAs of Vermont and Bayada Home Health Care; (O) one representative of long-term care facilities, selected by the Vermont Health Care Association; and (P) one representative of small businesses, selected by the Vermont Chamber of Commerce. (2) The Advisory Committee shall consult with and solicit input from the Health Equity Advisory Commission; physician assistants, physical therapists, and other health care professionals who are not members of the Advisory Committee; Vermont’s free clinic programs; the Vermont Program for Quality in Health Care; and other relevant stakeholders. (3) The Secretary of Human Services or designee shall be the Chair of the Advisory Committee. (4) The Agency of Human Services shall provide administrative and technical assistance to the Advisory Committee. (c) Members of the Advisory Committee shall not receive per diem compensation or reimbursement of expenses for their participation on the Advisory Committee. Added 2025, No. 68, § 9, eff. June 12, 2025.

18 V.S.A. § 9403b Vermont Steering Committee for Comprehensive Primary Health Care

9403b. Vermont Steering Committee for Comprehensive Primary Health Care (a) There is created the Vermont Steering Committee for Comprehensive Primary Health Care to inform the work of State government, including the Blueprint for Health and the Office of Health Care Reform in the Agency of Human Services, as it relates to access to, delivery of, and payment for primary care services in Vermont. (b) The Steering Committee shall be composed of the following members: (1) the Chair of the Department of Family Medicine at the University of Vermont Larner College of Medicine or designee; (2) the Chair of the Department of Pediatrics at the University of Vermont Larner College of Medicine or designee; (3) the Associate Dean for Primary Care at the University of Vermont Larner College of Medicine or designee; (4) the Executive Director of the Vermont Child Health Improvement Program at the University of Vermont Larner College of Medicine or designee; (5) the President of the Vermont Academy of Family Physicians or designee; (6) the President of the American Academy of Pediatrics, Vermont Chapter, or designee; (7) a member of the Green Mountain Care Board’s Primary Care Advisory Committee, selected by the Green Mountain Care Board; (8) the Executive Director of the Blueprint for Health; (9) a primary care clinician who practices at an independent practice, selected by HealthFirst; (10) a primary care clinician who practices at a federally qualified health center, selected by Bi-State Primary Care Association; (11) a primary care physician, selected by the Vermont Medical Society; (12) a primary care physician assistant, selected by the Physician Assistant Academy of Vermont; (13) a primary care nurse practitioner, selected by the Vermont Nurse Practitioners Association; (14) a mental health provider who practices at a community mental health center designated pursuant to section 8907 of this title, selected by Vermont Care Partners; (15) a licensed independent clinical social worker, selected by the National Association of Social Workers, Vermont Chapter; and (16) a psychologist, selected by the Vermont Psychological Association. (c) The Steering Committee shall: (1) engage in an ongoing assessment of comprehensive primary care needs in Vermont; (2) provide recommendations for recruiting and retaining high-quality primary care providers, including on ways to encourage new talent to join Vermont’s primary care workforce; (3) develop proposals for sustainable payment models for primary care; (4) identify methods for enhancing Vermonters’ access to primary care; (5) recommend opportunities to reduce administrative burdens on primary care providers; (6) recommend mechanisms for measuring the quality of primary care services delivered in Vermont; (7) provide input regarding comprehensive primary health care for the Statewide Health Care Delivery Strategic Plan as it is developed, updated, and implemented pursuant to section 9403 of this title; (8) consult with the Green Mountain Care Board in the event that the Board develops reference-based pricing for primary care providers as permitted under subdivision 9376(e)(5) of this title; and (9) offer additional recommendations and guidance to the Blueprint for Health, the Office of Health Care Reform, the General Assembly, and others in State government on ways to increase access to primary care services and to improve patient and provider satisfaction with primary care delivery in Vermont. (d) The Steering Committee shall receive administrative and technical assistance from the Agency of Human Services. (e)(1) The Executive Director of the Blueprint for Health shall call the first meeting of the Steering Committee to occur on or before September 1, 2025. (2) The Steering Committee shall select a chair from among its members at the first meeting. (3) A majority of the membership of the Steering Committee shall constitute a quorum. (f) Members of the Steering Committee shall not receive per diem compensation or reimbursement of expenses for their participation on the Steering Committee. Added 2025, No. 68, § 9a, eff. June 12, 2025.

18 V.S.A. § 9404 Administration

9404. Administration (a) The Commissioner and the Green Mountain Care Board shall supervise and direct the execution of all laws vested in the Department and the Board, respectively, by this chapter, and shall formulate and carry out all policies relating to this chapter. (b) The Commissioner and the Board may: (1) apply for and accept gifts, grants, or contributions from any person for purposes consistent with this chapter; (2) adopt rules necessary to implement the provisions of this chapter; and (3) enter into contracts and perform such acts as are necessary to accomplish the purposes of this chapter. (c) [Repealed.] (d) There is hereby created a special fund to be known as the Green Mountain Care Board Regulatory and Administrative Fund pursuant to 32 V.S.A. chapter 7, subchapter 5, for the purpose of providing the financial means for the Green Mountain Care Board to administer its obligations, responsibilities, and duties as required by law, including pursuant to 8 V.S.A. § 4026, chapters 220 and 221 of this title, and 33 V.S.A. chapter 18. All fees, fines, penalties, and similar assessments received by the Board in the administration of its obligations, responsibilities, and duties shall be credited to the Fund. The Fund may also be used by the Department of Health to administer its obligations, responsibilities, and duties as required by chapter 221 of this title. Added 1991, No. 160 (Adj. Sess.), § 1, eff. May 11, 1992; amended 1995, No. 180 (Adj. Sess.), §§ 10, 38(a); 1999, No. 49, § 222; 2013, No. 79, § 36; 2015, No. 54, § 34; 2015, No. 68 (Adj. Sess.), § 67; 2025, No. 11, § 22, eff. Sept. 1, 2025.

18 V.S.A. § 9405 State Health Improvement Plan; Health Resource Allocation Plan

9405. State Health Improvement Plan; Health Resource Allocation Plan (a) The Secretary of Human Services or designee, in consultation with the Chair of the Green Mountain Care Board and health care professionals and after receipt of public comment, shall adopt a State Health Improvement Plan that sets forth the health goals and values for the State. The Secretary may amend the Plan as the Secretary deems necessary and appropriate. The Plan shall include health promotion, health protection, nutrition, and disease prevention priorities for the State; identify available human resources as well as human resources needed for achieving the State’s health goals and the planning required to meet those needs; identify gaps in ensuring equal access to appropriate mental health care that meets standards of quality, access, and affordability equivalent to other components of health care as part of an integrated, holistic system of care; and identify geographic parts of the State needing investments of additional resources in order to improve the health of the population. Copies of the Plan shall be submitted to members of the Senate Committee on Health and Welfare and the House Committee on Health Care. (b) The Green Mountain Care Board, in consultation with the Secretary of Human Services or designee, shall publish on its website the Health Resource Allocation Plan identifying Vermont’s critical health needs, goods, services, and resources, which shall be used to inform the Board’s regulatory processes, cost containment and statewide quality of care efforts, health care payment and delivery system reform initiatives, and any allocation of health resources within the State. The Plan shall identify Vermont residents’ needs for health care services, programs, and facilities; the resources available and the additional resources that would be required to realistically meet those needs and to make access to those services, programs, and facilities affordable for consumers; and the priorities for addressing those needs on a statewide basis. The Board may expand the Plan to include resources, needs, and priorities related to the social determinants of health. The Plan shall be revised periodically but not less frequently than once every four years. (1) In developing the Plan, the Board shall: (A) consider the principles in section 9371 of this title, as well as the purposes enumerated in sections 9401 and 9431 of this title; (B) identify priorities using information from: (i) the State Health Improvement Plan; (ii) emergency medical services resources and needs identified by the EMS Advisory Committee in accordance with subsection 909(f) of this title; (iii) the community health needs assessments required by section 9405a of this title; (iv) available health care workforce information; (v) materials provided to the Board through its other regulatory processes, including hospital budget review, oversight of accountable care organizations, issuance and denial of certificates of need, and health insurance rate review; and (vi) the public input process set forth in this section; (C) use existing data sources to identify and analyze the gaps between the supply of health resources and the health needs of Vermont residents and to identify utilization trends to determine areas of underutilization and overutilization; and (D) consider the cost impacts of fulfilling any gaps between the supply of health resources and the health needs of Vermont residents. (2) The Green Mountain Care Board shall convene the Green Mountain Care Board General Advisory Committee established pursuant to subdivision 9374(e)(1) of this title to provide recommendations to the Board during the Board’s development of the Plan. (3) The Board shall receive and consider public input on the Plan at a minimum of one Board meeting and one meeting of the Advisory Committee and shall give interested persons an opportunity to submit their views orally and in writing. (4) The Board shall include reproductive health care services and gender-affirming health care services, as those terms are defined in 1 V.S.A. § 150, in its Plan analysis. (5) As used in this section: (A) “Health resources” means investments into the State’s health care system, including investments in personnel, equipment, and infrastructure necessary to deliver: (i) hospital, nursing home, and other inpatient services; (ii) ambulatory care, including primary care services, mental health services, health screening and early intervention services, and services for the prevention and treatment of substance use disorders; (iii) home health services; and (iv) emergency care, including ambulance services. (B) “Health resources” may also include investments in personnel, equipment, and infrastructure necessary to address the social determinants of health. Added 1991, No. 160 (Adj. Sess.), § 1, eff. May 11, 1992; amended 1995, No. 180 (Adj. Sess.), § 11; 2003, No. 53, § 3; 2007, No. 27, § 6; 2011, No. 48, § 20; 2011, No. 139 (Adj. Sess.), § 16, eff. May 14, 2012; 2011, No. 171 (Adj. Sess.), § 9, eff. May 16, 2012; 2013, No. 79, § 37; 2017, No. 167 (Adj. Sess.), § 4, eff. May 22, 2018; 2017, No. 200 (Adj. Sess.), § 16; 2019, No. 14, § 55, eff. April 20, 2019; 2019, No. 166 (Adj. Sess.), § 28, eff. Oct. 1, 2020; 2023, No. 15, § 9, eff. May 10, 2023.

18 V.S.A. § 9405a Public participation and strategic planning

9405a. Public participation and strategic planning (a) Each hospital shall have a protocol for meaningful public participation in its strategic planning process for identifying and addressing health care needs that the hospital provides or could provide in its service area. Needs identified through the process shall be integrated with the hospital’s long-term planning. Each hospital shall post on its website a description of its identified needs, strategic initiatives developed to address the identified needs, annual progress on implementation of the proposed initiatives, opportunities for public participation, and the ways in which the hospital ensures access to appropriate mental health care that meets standards of quality, access, and affordability equivalent to other components of health care as part of an integrated, holistic system of care. Hospitals may meet the community health needs assessment and implementation plan requirement through compliance with the relevant Internal Revenue Service community health needs assessment requirements for nonprofit hospitals. (b) When a hospital is working on a new community health needs assessment, the hospital shall post on its website information about the process for developing the community needs assessment and opportunities for public participation in the process. Added 2003, No. 53, § 4; amended 2005, No. 71, § 77a; 2007, No. 27, § 4; 2011, No. 48, § 21; 2015, No. 152 (Adj. Sess.), § 1, eff. May 31, 2016; 2017, No. 200 (Adj. Sess.), § 17; 2019, No. 14, § 56, eff. April 20, 2019.

18 V.S.A. § 9405b Hospital community reports and ambulatory surgical center quality reports

9405b. Hospital community reports and ambulatory surgical center quality reports (a) The Commissioner of Health, in consultation with representatives from hospitals, other groups of health care professionals, and members of the public representing patient interests, shall adopt rules establishing a statewide comparative hospital quality report. Hospitals located outside this State that serve a significant number of Vermont residents, as determined by the Commissioner of Health, shall be invited to participate in the community report process established by this section. The report shall include: (1) Measures of quality, including process and performance measures, that are valid, reliable, and useful, including comparisons to appropriate national benchmarks for high quality and successful results. (2) Measures of patient safety that are valid, reliable, and useful, including comparisons to appropriate industry benchmarks for safety. (3) Measures of hospital-acquired infections that are valid, reliable, and useful, including comparisons to appropriate industry benchmarks. (4) Valid, reliable, and useful information on nurse staffing, including comparisons to appropriate industry benchmarks for safety. This information may include system-centered measures such as skill mix, nursing care hours per patient day, and other system-centered measures for which reliable industry benchmarks become available. (5) Measures of the hospital’s financial health, including comparisons to appropriate national benchmarks for efficient operation and fiscal health. (6) A summary of the hospital’s budget, including revenue by source, the one-year and four-year capital expenditure plans, the depreciation schedule for existing facilities, and quantification of cost shifting to private payers. (7) Data that provides valid, reliable, useful, and efficient information for payers and the public for the comparison of charges for higher volume health care services. (b) Each hospital shall publish on its website: (1) the hospital’s process for achieving openness, inclusiveness, and meaningful public participation in its strategic planning and decision making; (2) the hospital’s consumer complaint resolution process, including identification of the hospital officer or employee responsible for its implementation; (3) information on membership and governing body qualifications; a listing of the current governing body members, including each member’s name, town of residence, occupation, employer, and job title, and the amount of compensation, if any, for serving on the governing body; and means of obtaining a schedule of meetings of the hospital’s governing body, including times scheduled for public participation; and (4) a link to the comparative statewide hospital quality report. (c) The Commissioner of Health shall publish the statewide comparative hospital quality report on a public website and shall update the report at least annually beginning on June 1, 2017. (d) The Commissioner of Health shall publish or otherwise make publicly available on its website each ambulatory surgical center’s performance results from quality reporting programs offered by the Centers for Medicare and Medicaid Services and shall update the information at least annually. (e) The Green Mountain Care Board may assess and collect from general hospitals licensed under chapter 43 of this title expenses incurred by the Commissioner of Health in administering hospital community reports and ambulatory surgical center quality reports under this section. Added 2003, No. 53, § 5; amended 2005, No. 71, § 77b; 2005, No. 153 (Adj. Sess.), § 1; 2005, No. 215 (Adj. Sess.), § 327; 2007, No. 27, § 5; 2011, No. 48, § 22; 2013, No. 79, § 38; 2015, No. 11, § 22; 2015, No. 152 (Adj. Sess.), § 2, eff. May 31, 2016; 2019, No. 55, § 5, eff. Jan. 1, 2020; 2023, No. 113 (Adj. Sess.), § E.345.1, eff. July 1, 2024.

18 V.S.A. § 9405c Notice of acquisition

9405c. Notice of acquisition (a) As used in this section: (1) “Acquire” means a purchase or transfer through which a hospital will own or control the business of a medical practice. (2) “Hospital” means a general hospital or hospital facility licensed under chapter 43 of this title. (3) “Medical practice” means a business through which one or more physicians practice medicine. (b) Each hospital shall provide notice to the Office of the Attorney General at least 90 days or as soon as practicable prior to the effective date of a transaction through which the hospital will acquire a medical practice. The notice shall include at least the following information: (1) the name and address of the hospital acquiring the medical practice and contact information for a representative of the hospital; and (2) the name and address of the medical practice being acquired and contact information for a representative of the medical practice. (c) Information provided to the Office of the Attorney General pursuant to this section is exempt from public inspection and copying under the Public Records Act and shall be kept confidential except to the extent necessary to allow the Office to perform an inquiry into potentially anticompetitive practices. Added 2015, No. 143 (Adj. Sess.), § 2.

18 V.S.A. § 9405d Hospital service eliminations; notice required

9405d. Hospital service eliminations; notice required (a)(1)(A) A hospital that is considering eliminating any of the following services shall provide a preliminary notice of intent to the Agency of Human Services, the Green Mountain Care Board, and the Office of the Health Care Advocate as set forth in subdivision (B) of this subdivision (1): (i) emergency department services; (ii) primary care services, including closing a site at which primary care services are provided; (iii) obstetrics; (iv) perinatal care; (v) inpatient psychiatric services; (vi) treatment for substance use disorder, including medication for opioid use disorder; (vii) dialysis, including closing a site at which dialysis services are provided; or (viii) inpatient pediatric services. (B) The information to be provided by the hospital in its preliminary notice of intent shall include: (i) the rationale for the proposed elimination; (ii) the financial impacts on the hospital both of maintaining the service and of eliminating the service; and (iii) a description of all possible alternatives to the proposed elimination that were considered and the reasons they were not pursued. (2) The Agency of Human Services shall evaluate the information provided by the hospital in its preliminary notice of intent pursuant to subdivision (1) of this subsection, the financial impact of the proposed elimination on Vermont’s health care system, and the impact of the proposed elimination on access to health care services in the region. (3)(A) The Agency and the Green Mountain Care Board may consult with a hospital that has submitted a preliminary notice of intent pursuant to subdivision (1) of this subsection (a) regarding the proposed elimination in order to explore opportunities to maintain the service or otherwise to address the circumstances that prompted the proposed elimination. (B) A hospital that is considering eliminating any service other than those listed in subdivisions (1)(A)(i)–(viii) of this subsection (a) may choose to provide a preliminary notice of intent to the Agency of Human Services and the Green Mountain Care Board that includes the information described in subdivision (1)(B) of this subsection (a) and to engage with the Agency and the Board in the consultation process set forth in subdivision (A) of this subdivision (3). (4) All information and materials related to a preliminary notice of intent and related consultation pursuant to this subsection, including all materials provided by the hospital to the Agency or the Board, shall be exempt from public inspection and copying under the Public Records Act and shall be kept confidential, except that the Agency and the Board shall provide access to information and materials related to the proposed elimination of a service described in subdivisions (1)(A)(i)–(viii) of this subsection to the Office of the Health Care Advocate, which shall not further disclose this confidential information. (b)(1) If a hospital elects to proceed with the proposed elimination of a service described in subdivisions (a)(1)(A)(i)–(viii) of this section after engaging in the processes set forth in subsection (a) of this section, then within 90 days after the hospital provided the preliminary notice of intent required by subdivision (a)(1) of this section or upon the conclusion of the confidential consultation process set forth in subdivisions (a)(3) and (4) of this section, whichever occurs first, the hospital shall provide a notice of intent to the Agency of Human Services, the Green Mountain Care Board, the Office of the Health Care Advocate, and the members of the General Assembly who represent the hospital service area. (2) The notice of intent required by subdivision (1) of this subsection shall: (A) explain the rationale for the proposed elimination; (B) set forth a proposed timeline for the proposed elimination and a transition plan; (C) be provided not less than 60 days prior to the effective date of the proposed elimination; (D) be posted on the hospital’s website; and (E) be published in a newspaper of general circulation in the hospital service area within 10 days after notice is provided pursuant to subdivision (1) of this subsection (b). (3) In addition to the notice of intent required by subdivision (1) of this subsection, the hospital shall conduct a public engagement process, including holding one or more public hearings in the county in which the hospital is located and soliciting and responding to public comments, regarding the proposed service elimination. The public engagement process shall continue for not less than 30 days following the notice required pursuant to subdivision (1) of this subsection. The hospital shall provide a summary of the community’s response to the proposal, including the public comments received, to the Agency of Human Services, the Green Mountain Care Board, and the Office of the Health Care Advocate following the conclusion of the public engagement process. (c) If a hospital elects to proceed with eliminating a service described in subdivisions (a)(1)(A)(i)–(viii) of this section after completing the processes set forth in subsections (a) and (b) of this section, then within five business days after making the decision to proceed, the hospital shall notify the Agency of Human Services to inform the Agency’s health care system transformation efforts and the Statewide Health Care Delivery Strategic Plan and the Green Mountain Care Board to enable the Board to review the impact on the hospital’s budget pursuant to subdivision 9456(e)(2) of this title. Added 2025, No. 146 (Adj. Sess.), § 1, eff. June 16, 2026.

18 V.S.A. § 9406 Reporting on participation in 340B drug pricing program [Repealed effective January 1, 2031]

9406. Reporting on participation in 340B drug pricing program [Repealed effective January 1, 2031] (a) Annually on or before January 31, each hospital participating in the federal 340B drug pricing program established by 42 U.S.C. § 256b shall submit to the Green Mountain Care Board, in a form and manner prescribed by the Board, a report detailing the hospital’s participation in the program during the previous hospital fiscal year, which report shall be posted on the Green Mountain Care Board’s website and which shall contain at least the following information: (1)(A) For prescription drugs that the hospital or any entity acting on behalf of the hospital obtained through the 340B program and dispensed or administered to patients during the previous calendar year: (i) the aggregated acquisition cost for all such prescription drugs; and (ii) the aggregated payment amount that the hospital received for all such prescription drugs, with information reported separately for each of the following distribution channels: (I) dispensed drugs from an in-house pharmacy; (II) dispensed drugs from a contract pharmacy; (III) administered drugs paid separately; and (IV) administered drugs paid by bundled payments. (B) For administered drugs for which payment was bundled with payment for other services, as set forth in subdivision (A)(ii)(IV) of this subdivision (1), the hospital shall estimate the payment amount by comparing the actual acquisition cost for a drug to the wholesale acquisition cost for that drug. (2) The aggregated payment amount that the hospital made to pharmacies with which the hospital contracted to dispense drugs to its patients under the 340B program during the previous hospital fiscal year. (3) The aggregated payment amount that the hospital made to any other outside vendor for managing, administering, or facilitating any aspect of the hospital’s 340B drug program during the previous hospital fiscal year. (4) A description of the ways in which the hospital uses revenue from its participation in the 340B program to benefit its community through programs and services funded in whole or in part by revenue from the 340B program, including services that support community access to care that the hospital could not continue without this revenue. (5) A description of the hospital’s internal review and oversight of its participation in the 340B program in compliance with the U.S. Department of Health and Human Services, Health Resources and Services Administration’s 340B program rules and guidance. (b) In addition to the vendor information required pursuant to subdivision (a)(3) of this section, each hospital shall also provide to the Board a list of the names of all vendors that managed, administered, or facilitated any aspect of the hospital’s 340B program during the previous calendar year, along with a brief description of the work performed by each vendor. The vendor information reported pursuant to this subsection shall be exempt from public inspection and copying under the Public Records Act and shall be kept confidential, except that the Board shall provide the information to the Office of the Health Care Advocate, which shall not further disclose this confidential information. Added 2025, No. 55, § 2, eff. June 11, 2025; repealed by 2025, No. 55, § 3, eff. Jan. 1, 2031.

18 V.S.A. § 9407 Outpatient prescription drugs; limitations on hospital charges

9407. Outpatient prescription drugs; limitations on hospital charges (a)(1) A hospital shall not submit a claim to a health insurer for reimbursement of a prescription drug administered in an outpatient or office setting in an amount that exceeds 120 percent of the average sales price (ASP), as calculated by the Centers for Medicare and Medicaid Services, for any drug for which the hospital charged any health insurer more than 120 percent of the ASP in effect as of April 1, 2025. (2) For any prescription drug administered in an outpatient or office setting for which a hospital charged a health insurer 120 percent or less of the ASP in effect as of April 1, 2025, the hospital shall not charge the health insurer a greater percentage of the ASP, as calculated by the Centers for Medicare and Medicaid, for that drug than the percentage of the ASP that the hospital charged the health insurer as of April 1, 2025. (3) A hospital shall update the ASP for each drug annually on January 1 and July 1 based on the Centers for Medicare and Medicaid Services’ ASP calculations for the most recent calendar quarter. (b)(1) The purpose of this section is to reduce health care costs. A hospital shall not charge or collect from the patient or health insurer any amount for a prescription drug administered in an outpatient or office setting that exceeds the amounts set forth in subsection (a) of this section or increase the amounts the hospital charges for other prescription drugs, procedures, tests, imaging, or other health care goods or services in an effort to offset revenue reduced as a result of implementing this section. (2) If a hospital demonstrates to the Green Mountain Care Board in its budget submissions pursuant to subchapter 7 of this chapter that the price cap set forth in subsection (a) of this section is having a negative impact on access to care, the quality of care, or the sustainability of rural health care services, or a combination of these, the hospital may propose to increase the commercial reimbursement rates for one or more of its service lines, such as primary care, and the Board shall consider both the demonstrated impact and the proposed increase to reimbursement rates. (c) The provisions of this section shall remain in effect unless and until the Green Mountain Care Board establishes a different reference-based price pursuant to section 9376 of this title that applies to prescription drugs administered in an outpatient or office setting. (d) This section shall not apply to: (1) an independent hospital that is designated as a critical access hospital and that is not affiliated with another hospital or hospital network based in or outside Vermont; and (2) a non-critical access hospital that is participating in the Rural Community Hospital Demonstration program through the Centers for Medicare and Medicaid Services. Added 2025, No. 55, § 4, eff. Jan. 1, 2026; amended 2025, No. 74 (Adj. Sess.), § 84, eff. Mar. 5, 2026.

18 V.S.A. § 9408 Common claims forms and procedures

9408. Common claims forms and procedures Not later than January 15, 1993, the Commissioner shall adopt by rule uniform health insurance claims forms and uniform standards and procedures for the processing of claims, including electronic claims forms submission. Added 1991, No. 160 (Adj. Sess.), § 1, eff. May 11, 1992; amended 1995, No. 180 (Adj. Sess.), § 14; 2023, No. 6, § 226, eff. July 1, 2023.

18 V.S.A. § 9408a Uniform provider credentialing

9408a. Uniform provider credentialing (a) Definitions. As used in this section: (1) “Credentialing” means a process through which an insurer or hospital makes a determination, based on criteria established by the insurer or hospital, concerning whether a provider is eligible to: (A) provide health care services to an insured or hospital patients; and (B) receive reimbursement for the health care services. (2) “Health care services” means health-care-related services or products rendered or sold by a provider within the scope of the provider’s license or legal authorization, including hospital, medical, surgical, dental, vision, and pharmaceutical services or products. (3) “Insured” means an individual entitled to reimbursement for expenses of health care services under a policy issued or administered by an insurer. (4) “Insurer” has the same meaning as in subdivision 9402(8) of this title. (5) “Provider” has the same meaning as in subdivision 9402(7) of this title. (b) The Department shall prescribe the credentialing application form used by the Council for Affordable Quality Healthcare (CAQH), or a similar, nationally recognized form prescribed by the Commissioner, in electronic or paper format, which must be used beginning January 1, 2007 by an insurer or a hospital that performs credentialing. The Commissioner may grant a hospital an extension to the implementation date for up to one year. (c) An insurer or a hospital shall notify a provider concerning a deficiency on a completed credentialing application form submitted by the provider not later than 30 business days after the insurer or hospital receives the completed credentialing application form. (d) A hospital shall notify a provider concerning the status of the provider’s completed credentialing application not later than: (1) 60 days after the hospital receives the completed credentialing application form; and (2) every 30 days after the notice is provided under subdivision (1) of this subsection, until the hospital makes a final credentialing determination concerning the provider. (e) [Repealed.] (f) An insurer shall act upon and finish the credentialing process of a completed application submitted by a provider within 60 calendar days after receipt of the application. An application shall be considered complete once the insurer has received all information and documentation necessary to make its credentialing determination as provided in subsections (b) and (c) of this section. Added 2005, No. 191 (Adj. Sess.), § 56; amended 2007, No. 70, § 30; 2007, No. 203 (Adj. Sess.), § 30, eff. June 10, 2008; 2015, No. 152 (Adj. Sess.), § 3; 2023, No. 6, § 227, eff. July 1, 2023.

18 V.S.A. § 9409 Health care provider bargaining groups

9409. Health care provider bargaining groups (a) The Green Mountain Care Board may approve the creation of one or more health care provider bargaining groups, consisting of health care providers who choose to participate. A bargaining group is authorized to negotiate on behalf of all participating providers with the Secretary of Administration, the Secretary of Human Services, the Green Mountain Care Board, or the Commissioner of Labor with respect to any matter in this chapter; chapter 13, 219, 220, or 222 of this title; 21 V.S.A. chapter 9; and 33 V.S.A. chapters 18 and 19 with respect to provider regulation, provider reimbursement, administrative simplification, information technology, workforce planning, or quality of health care. (b) The Green Mountain Care Board shall adopt by rule criteria for forming and approving bargaining groups and criteria and procedures for negotiations authorized by this section. (c) The rules relating to negotiations shall include a nonbinding arbitration process to assist in the resolution of disputes. Nothing in this section shall be construed to limit the authority of the Secretary of Administration, the Secretary of Human Services, the Green Mountain Care Board, or the Commissioner of Labor to reject the recommendation or decision of the arbiter. Added 1991, No. 160 (Adj. Sess.), § 1, eff. May 11, 1992; amended 1995, No. 180 (Adj. Sess.), §§ 15, 38(a); 2005, No. 103 (Adj. Sess.), § 3, eff. April 5, 2006; 2011, No. 171 (Adj. Sess.), § 24, eff. May 16, 2012; 2015, No. 152 (Adj. Sess.), § 5.

18 V.S.A. § 9410 Health care database

9410. Health care database (a)(1) The Board shall establish and maintain a unified health care database to enable the Board to carry out its duties under this chapter, chapter 220 of this title, and Title 8, including: (A) determining the capacity and distribution of existing resources; (B) identifying health care needs and informing health care policy; (C) evaluating the effectiveness of intervention programs on improving patient outcomes; (D) comparing costs between various treatment settings and approaches; (E) providing information to consumers and purchasers of health care; and (F) improving the quality and affordability of patient health care and health care coverage. (2) [Repealed.] (b) The database shall contain unique patient and provider identifiers and a uniform coding system and shall reflect all health care utilization, costs, and resources in this State and health care utilization and costs for services provided to Vermont residents in another state. (c) Health insurers, health care providers, health care facilities, and governmental agencies shall file reports, data, schedules, statistics, or other information determined by the Board to be necessary to carry out the purposes of this section. Such information may include: (1) health insurance claims and enrollment information used by health insurers; (2) information relating to hospitals filed under subchapter 7 of this chapter (hospital budget reviews); and (3) any other information relating to health care costs, prices, quality, utilization, or resources required by the Board to be filed. (d) The Board may by rule establish the types of information to be filed under this section and the time and place and the manner in which such information shall be filed. (e) [Repealed.] (f) The Board shall adopt a confidentiality code to ensure that information obtained under this section is handled in an ethical manner. (g) Any person who knowingly fails to comply with the requirements of this section or rules adopted pursuant to this section shall be subject to an administrative penalty of not more than $1,000.00 per violation. The Board may impose an administrative penalty of not more than $10,000.00 each for those violations the Board finds were willful. In addition, any person who knowingly fails to comply with the confidentiality requirements of this section or confidentiality rules adopted pursuant to this section and uses, sells, or transfers the data or information for commercial advantage, pecuniary gain, personal gain, or malicious harm shall be subject to an administrative penalty of not more than $50,000.00 per violation. The powers vested in the Board by this subsection shall be in addition to any other powers to enforce any penalties, fines, or forfeitures authorized by law. (h)(1) All health insurers shall electronically provide to the Board in accordance with standards and procedures adopted by the Board by rule: (A) their health insurance claims data, provided that the Board may exempt from all or a portion of the filing requirements of this subsection data reflecting utilization and costs for services provided in this State to residents of other states; (B) cross-matched claims data on requested members, subscribers, or policyholders; and (C) member, subscriber, or policyholder information necessary to determine third-party liability for benefits provided. (2) The collection, storage, and release of health care data and statistical information that are subject to the federal requirements of the Health Insurance Portability and Accountability Act (HIPAA) shall be governed exclusively by the regulations adopted under in 45 C.F.R. Parts 160 and 164. (3)(A) The Board shall collaborate with the Agency of Human Services and participants in the Agency’s initiatives in the development of a comprehensive health care information system. The collaboration is intended to address the formulation of a description of the data sets that will be included in the comprehensive health care information system, the criteria and procedures for the development of limited-use data sets, the criteria and procedures to ensure that HIPAA compliant limited-use data sets are accessible, and a proposed time frame for the creation of a comprehensive health care information system. (B) To the extent allowed by HIPAA, the data shall be available as a resource for insurers, employers, providers, purchasers of health care, and State agencies to continuously review health care utilization, expenditures, and performance in Vermont. In presenting data for public access, comparative considerations shall be made regarding geography, demographics, general economic factors, and institutional size. (C) Consistent with the dictates of HIPAA, and subject to such terms and conditions as the Board may prescribe by rule, the Vermont Program for Quality in Health Care shall have access to the unified health care database for use in improving the quality of health care services in Vermont. In using the database, the Vermont Program for Quality in Health Care shall agree to abide by the rules and procedures established by the Board for access to the data. The Board’s rules may limit access to the database to limited-use sets of data as necessary to carry out the purposes of this section. (D) Notwithstanding HIPAA or any other provision of law, the comprehensive health care information system shall not publicly disclose any data that contain direct personal identifiers. For the purposes of this section, “direct personal identifiers” include information relating to an individual that contains primary or obvious identifiers, such as the individual’s name, street address, e-mail address, telephone number, and Social Security number. (i) On or before January 15, 2018 and every three years thereafter, the Commissioner of Health shall submit a recommendation to the General Assembly for conducting a survey of the health insurance status of Vermont residents. The provisions of 2 V.S.A. § 20(d)(expiration of required reports) shall not apply to the report to be made under this subsection. (j)(1) As used in this section, and without limiting the meaning of subdivision 9402(8) of this title, the term “health insurer” includes: (A) any entity defined in subdivision 9402(8) of this title; (B) any third-party administrator, any pharmacy benefit manager, any entity conducting administrative services for business, and any other similar entity with claims data, eligibility data, provider files, and other information relating to health care provided to a Vermont resident, and health care provided by Vermont health care providers and facilities required to be filed by a health insurer under this section; (C) any health benefit plan offered or administered by or on behalf of the State of Vermont or an agency or instrumentality of the State; and (D) any health benefit plan offered or administered by or on behalf of the federal government with the agreement of the federal government. (2) The Board may adopt rules to carry out the provisions of this subsection, including criteria for the required filing of such claims data, eligibility data, provider files, and other information as the Board determines to be necessary to carry out the purposes of this section and this chapter. Added 1991, No. 160 (Adj. Sess.), § 1, eff. May 11, 1992; amended 1995, No. 180 (Adj. Sess.), §§ 16, 38(a); 2005, No. 71, § 312; 2005, No. 122 (Adj. Sess.), § 14; 2005, No. 191 (Adj. Sess.), § 57; 2007, No. 15, § 22; 2007, No. 70, § 25; 2007, No. 80, § 19; 2009, No. 42, § 33; 2009, No. 61, § 3; 2009, No. 156 (Adj. Sess.), § I.27; 2011, No. 48, § 27, eff. Oct. 1, 2011; 2013, No. 79, § 40, eff. June 7, 2013; 2013, No. 142 (Adj. Sess.), § 35; 2015, No. 54, § 35; 2021, No. 167 (Adj. Sess.), § 5, eff. June 1, 2022; 2023, No. 6, § 228, eff. July 1, 2023.

18 V.S.A. § 9411 Interactive price transparency dashboard

9411. Interactive price transparency dashboard (a) The Green Mountain Care Board shall develop and maintain a public, interactive, Internet-based price transparency dashboard that allows consumers to compare health care prices for certain health care services across the State. Using data from the Vermont Healthcare Claims Uniform Reporting and Evaluation System (VHCURES) established pursuant to section 9410 of this title, the dashboard shall provide the range of actual allowed amounts for selected health care services, showing both the amount paid by the health insurer or other payer and the amount of the member’s responsibility, and shall allow the consumer to sort the information by geographic location, by health care provider, by payer type, and by the specific health care procedure or health care service. The Board shall provide a link on the dashboard to the statewide comparative hospital quality report published by the Commissioner of Health pursuant to section 9405b of this title. (b) The Board shall update the information in the interactive price transparency dashboard at least annually. Added 2019, No. 159 (Adj. Sess.), § 2.

18 V.S.A. § 9412 Enforcement

9412. Enforcement (a) In order to carry out the duties under this chapter, in addition to the powers provided in this chapter, in chapter 220 of this title, and in Title 8, the Commissioner and the Board may examine the books, accounts, and papers of health insurers, health care providers, health care facilities, health plans, contracting entities, covered entities, and payers, as defined in section 9418 of this title, and may administer oaths and may issue subpoenas to a person to appear and testify or to produce documents or things. (b) In addition to any other power or duty authorized by law, the Commissioner of Financial Regulation shall, in the case of health insurers, enforce a violation of a provision of this subchapter or a rule adopted pursuant to a provision of this subchapter as a violation of a requirement of Title 8 relating to health insurers. Added 1991, No. 160 (Adj. Sess.), § 1, eff. May 11, 1992; amended 1995, No. 180 (Adj. Sess.), §§ 18, 38; 2009, No. 61, § 28; 2011, No. 171 (Adj. Sess.), § 14, eff. May 16, 2012.

18 V.S.A. § 9413 Health care quality and price comparison

9413. Health care quality and price comparison Each health insurer with more than 200 covered lives in this State shall establish an Internet-based tool to enable its members to compare the price of health care in Vermont by service or procedure, including office visits, emergency care, radiologic services, and preventive care such as mammography and colonoscopy. The tool shall include provider quality information as available and to the extent consistent with other applicable laws and regulations. The tool shall allow members to compare price by selecting a specific service or procedure and a geographic region of the State. Based on the criteria specified, the tool shall provide the member with an estimate for each provider of the amount the member would pay for the service or procedure, an estimate of the amount the insurance plan would pay, and an estimate of the combined payments. The price information shall reflect the cost-sharing applicable to a member’s specific plan, as well as any remaining balance on the member’s deductible for the plan year. Added 2015, No. 54, § 20, eff. July 1, 2016.

18 V.S.A. § 9414 Quality assurance for managed care

9414. Quality assurance for managed care (a) The Commissioner shall have the power and responsibility to ensure that each managed care organization provides quality health care to its members, in accordance with the provisions of this section. (1) In determining whether a managed care organization meets the requirements of this section, the Commissioner may review and examine, in accordance with subsection (e) of this section, the organization’s administrative policies and procedures, quality management and improvement procedures, utilization management, credentialing practices, members’ rights and responsibilities, preventive health services, medical records practices, grievance and appeal procedures, member services, financial incentives or disincentives, disenrollment, provider contracting, and systems and data reporting capacities. The Commissioner shall establish, by rule, specific criteria to be considered under this section. (2) A managed care organization shall, in plain language, disclose to its members: (A) any provision of its enrollment plan or provider contracts that may restrict referral or treatment options or that may require prior authorization or utilization review or that may limit in any manner the services covered under the members’ enrollment plan; (B) the criteria used for credentialing or selecting health care providers with whom the organization contracts; (C) the financial inducements offered to any health care provider or health care facility for the reduction or limitation of health care services; (D) the utilization review procedures of the organization, including the credentials and training of utilization review personnel; (E) whether the organization’s health care providers are contractually prohibited from participating in other managed care organizations or from performing services for persons who are not members of the managed care organization; (F) upon request, health care providers available to members under the enrollment plan. (3) A managed care organization shall not include any provision in a contract with a health care provider that prohibits the health care provider from disclosing to members information about the contract or the members’ enrollment plan that may affect their health or any decision regarding health care treatment. (4) The Commissioner or designee may resolve any consumer or provider complaint arising out of this subsection as though the managed care organization were an insurer licensed pursuant to Title 8. As used in this section, “complaint” means a report of a violation or suspected violation of the standards set forth in this section or adopted by rule pursuant to this section and made by or on behalf of a consumer or provider. (5) The Commissioner shall prepare an annual report on or before July 1 of each year providing the number of complaints received during the previous calendar year regarding violations or suspected violations of the standards set forth in this section or adopted by rule pursuant to this section. The report shall specify the aggregate number of complaints related to each standard and shall be posted on the Department’s website. (b)(1) A managed care organization shall ensure that the health care services provided to members are consistent with prevailing professionally recognized standards of medical practice. (2) A managed care organization shall participate in the Blueprint for Health established in chapter 13 of this title. If needed to implement the Blueprint, a managed care organization shall establish a chronic care program, which shall include: (A) appropriate benefit plan design; (B) informational materials, training, and follow-up necessary to support members and providers; and (C) payment reform methodologies. (3) Each managed care organization shall have procedures to ensure availability, accessibility, and continuity of care, and ongoing procedures for the identification, evaluation, resolution, and follow-up of potential and actual problems in its health care administration and delivery. (4) Each managed care organization shall be accredited by a national independent accreditation organization approved by the Commissioner. (c) Consistent with participation in the Blueprint for Health pursuant to subdivision (b)(2) of this section and the accreditation required by subdivision (b)(4) of this section, the managed care organization shall have an internal quality assurance program to monitor and evaluate its health care services, including primary and specialist physician services, and ancillary and preventive health care services, across all institutional and noninstitutional settings. The internal quality assurance program shall be fully described in written form; provided to all managers, providers, and staff; and made available to members of the organization. The components of the internal quality assurance program shall include the following: (1) a peer review committee or comparable designated committee responsible for quality assurance activities; (2) accountability of the committee to the board of directors or other governing authority of the organization; (3) participation by an appropriate base of providers and support staff; (4) supervision by the medical director of the organization; (5) regularly scheduled meetings; and (6) minutes or records of the meetings that describe in detail the actions of the committee, including problems discussed, charts reviewed, recommendations made, and any other pertinent information. (d), (e) [Repealed.] (f)(1) For the purpose of evaluating a managed care organization’s performance under the provisions of this section, the Commissioner may examine and review information protected by the provisions of the patient’s privilege under 12 V.S.A. § 1612(a) or otherwise required by law to be held confidential. (2) [Repealed.] (3) Any information made available under this section shall be furnished in a manner that does not disclose the identity of the protected person. The Commissioner shall adopt a confidentiality code to ensure that information obtained under this section is handled in an ethical manner. Information disclosed to the Commissioner under this section shall be confidential and privileged and shall not be subject to subpoena or available for public disclosure, except that the Commissioner is authorized to use such information during the course of any legal or regulatory action under this title against a managed care organization. (g)(1) In addition to any other remedy or sanction provided by law, after notice and an opportunity to be heard, if the Commissioner determines that a managed care organization has violated or failed to comply with any of the provisions of this section or any rule adopted pursuant to this section, the Commissioner may: (A) sanction the violation or failure to comply as provided in Title 8, including sanctions provided by or incorporated in 8 V.S.A. §§ 4726, 5108, and 5109, and may use any information obtained during the course of any legal or regulatory action against a managed care organization; (B) order the managed care organization to cease and desist in further violations; and (C) order the managed care organization to remediate the violation, including issuing an order to the managed care organization to terminate its contract with any person or entity that administers claims or the coverage of benefits on behalf of the managed care organization. (2) A managed care organization that contracts with a person or entity to administer claims or provide coverage of health benefits is fully responsible for the acts and omissions of such person or entity. Such person or entity shall comply with all obligations, under this title and Title 8, of the health insurance plan and the health insurer on behalf of which such person or entity is providing or administering coverage. (3) A violation of any provision of this section or a rule adopted pursuant to this section shall constitute an unfair act or practice in the business of insurance in violation of 8 V.S.A. § 4723. (h) Each managed care organization subject to examination, investigation, or review by the Commissioner under this section shall pay the Commissioner the reasonable costs of such examination, investigation, or review conducted or caused to be conducted by the Commissioner, at a rate to be determined by the Commissioner. All examinations conducted under this section shall be pursuant to and in conformity with 8 V.S.A. §§ 3573, 3574, 3575, and 3576, except that the Commissioner may modify or adapt those examination guidelines, principles, and procedures to be more appropriate or useful to the examination of managed care organizations. (i) [Repealed.] Added 1993, No. 30, § 19; amended 1995, No. 180 (Adj. Sess.), §§ 21, 38(a), (b); 1999, No. 38, § 22, eff. May 20, 1999; 2007, No. 142 (Adj. Sess.), §§ 2, 3, eff. May 14, 2008; 2007, No. 204 (Adj. Sess.), § 1; 2015, No. 54, § 36; 2015, No. 152 (Adj. Sess.), § 7; 2023, No. 6, § 229, eff. July 1, 2023.

18 V.S.A. § 9414a Annual reporting by health insurers

9414a. Annual reporting by health insurers (a) As used in this section: (1) “Adverse benefit determination” means a denial, reduction, modification, or termination of, or a failure to provide or make payment in whole or in part for, a benefit, including: (A) a denial, reduction, modification, termination, or failure to provide or make payment that is based on a determination of the member’s eligibility to participate in a health benefit plan; (B) a denial, reduction, modification, or termination of, or failure to make payment in whole or in part for, a benefit resulting from the application of any utilization review; and (C) a failure to provide coverage for an item or service for which benefits are otherwise provided because the item or service is determined to be experimental, investigational, or not medically necessary or appropriate. (2) “Claim” means a preservice review or a request for payment for a covered service that a member or the member’s health care provider submits to the insurer at or after the time that health care services have been provided. (3) “Concurrent review” means utilization review conducted during a member’s stay in a hospital or other facility, or during another ongoing course of treatment. (4) “Grievance” means a complaint submitted by or on behalf of a member regarding: (A) an adverse benefit determination; (B) the availability, delivery, or quality of health care services; (C) claims payment, handling, or reimbursement for health care services; or (D) matters relating to the contractual relationship between a member and the managed care organization or health insurer offering the health benefit plan. (5) “Independent external review” means a review of a health care decision by an independent review organization pursuant to 8 V.S.A. § 4063. (6) “Postservice review” means the review of any claim for a benefit that is not a preservice or concurrent review. (7) “Preservice review” means the review of any claim for a benefit with respect to which the terms of coverage condition receipt of the benefit in whole or in part on approval of the benefit in advance of obtaining health care. (8) “Utilization review” means a set of formal techniques designed to monitor the use, or evaluate the clinical necessity, appropriateness, efficacy, or efficiency, of health care services, procedures, or settings, including prescription drugs. (b) Health insurers with a minimum of 2,000 Vermont lives covered at the end of the preceding year or who offer insurance through the Vermont Health Benefit Exchange pursuant to 33 V.S.A. chapter 18, subchapter 1 shall annually report the following information to the Commissioner of Financial Regulation, in plain language, as an addendum to the health insurer’s annual statement: (1) the health insurer’s state of domicile and the total number of states in which the insurer operates; (2) the total number of Vermont lives covered by the health insurer; (3) the total number of claims submitted to the health insurer; (4) the total number of claims denied by the health insurer, including the total number of denied claims for mental health services, treatment for substance use disorder, and prescription drugs; (5) data regarding the number and percentage of denials of service by the health insurer based on utilization review, including utilization review at the preservice review, concurrent review, and postservice review levels and including denials of mental health services, services for substance use disorder, and prescription drugs broken out separately, including: (A) denials of service by the health insurer; (B) denials of service appealed to the health insurer at the first-level grievance and, of those, the total number overturned; (C) denials of service appealed to the health insurer at any second-level grievance and, of those, the total number overturned; (D) denials of service at the preservice level for which external review was sought and, of those, the total number overturned; (6) the total number of adverse benefit determinations made by the health insurer, including: (A) the total number of adverse benefit determinations appealed to the health insurer at the first-level grievance and, of those, the total number overturned; (B) the total number of adverse benefit determinations appealed to the health insurer at any second-level grievance and, of those, the total number overturned; (C) the total number of adverse benefit determinations for which external review was sought and, of those, the total number overturned; (7) [Repealed.] (8) the total number of claims denied by the health insurer as duplicate claims, as coding errors, or for services or providers not covered; (9) the percentage of claims processed in a timely manner; (10) the percentage of claims processed accurately, both financially and administratively; (11) the number and percentage of utilization review decisions meeting the timelines described in subdivisions (A)-(D) of this subdivision (11), including timeliness data for all utilization review decisions and timeliness data for physical health, mental health, substance use disorder, and prescription drug utilization review decisions broken out separately: (A) concurrent reviews within 24 hours; (B) urgent preservice reviews within 48 hours of receipt of the request; (C) nonurgent preservice reviews within two business days after receipt of request; and (D) postservice reviews within 30 days after receipt of request; (12) data regarding the number of grievances related to availability, delivery, or quality of health care services or matters relating to the contractual relationship between a member and the health insurer, including: (A) health care provider performance and office management issues; (B) plan administration; (C) access to health care providers and services; (D) access to mental health providers and services; and (E) access to substance use disorder providers and services; (13) the total number of claims, including separate numbers for claims related to mental health services, services for substance use disorder, and prescription drugs, denied by the health insurer on the grounds that the service was experimental, investigational, or an off-label use of a drug; was not medically necessary; or involved access to a provider that is inconsistent with the limitations imposed by the plan; (14) results of surveys evaluating health care provider satisfaction with the health insurer; (15) the health insurer’s actions taken in response to the prior year’s health care provider survey results; (16)(A) the titles and salaries of all corporate officers and board members during the preceding year; and (B) the bonuses and compensatory benefits of all corporate officers and board members during the preceding year; (17) the health insurer’s marketing and advertising expenses during the preceding year; (18) the health insurer’s federal and Vermont-specific lobbying expenses during the preceding year; (19) the amount and recipient of each political contribution made by the health insurer during the preceding year; (20) the amount and recipient of dues paid during the preceding year by the health insurer to trade groups that engage in lobbying efforts or that make political contributions; (21) the health insurer’s legal expenses related to claims or service denials during the preceding year; and (22) the amount and recipient of charitable contributions made by the health insurer during the preceding year. (c) Health insurers may indicate the extent of overlap or duplication in reporting the information described in subsection (b) of this section. (d) The Department of Financial Regulation shall create a standardized form using terms with uniform, industry-standard meanings for the purpose of collecting the information described in subsection (b) of this section, and each health insurer shall use the standardized form for reporting the required information as an addendum to its annual statement. To the extent possible, health insurers shall report information specific to Vermont on the standardized form and shall indicate on the form where the reported information is not specific to Vermont. (e)(1) The Department of Financial Regulation and the Office of the Health Care Advocate shall post on their websites links to the standardized form completed by each health insurer pursuant to this section. Each health insurer shall post its form on its own website. (2) The Department of Vermont Health Access shall post on the Vermont Health Benefit Exchange established pursuant to 33 V.S.A. chapter 18, subchapter 1 an electronic link to the standardized forms posted by the Department of Financial Regulation pursuant to subdivision (1) of this subsection. (f) The Commissioner of Financial Regulation may adopt rules pursuant to 3 V.S.A. chapter 25 to carry out the purposes of this section. Added 2011, No. 150 (Adj. Sess.), § 1; amended 2013, No. 79, § 40b; 2015, No. 152 (Adj. Sess.), § 8; 2023, No. 6, § 230, eff. July 1, 2023; 2025, No. 11, § 23, eff. Sept. 1, 2025.

18 V.S.A. § 9416 Vermont Program for Quality in Health Care

9416. Vermont Program for Quality in Health Care (a) The Commissioner of Health shall contract with the Vermont Program for Quality in Health Care, Inc. to implement and maintain a statewide quality assurance system to evaluate and improve the quality of health care services rendered by health care providers of health care facilities, including managed care organizations, to determine that health care services rendered were professionally indicated or were performed in compliance with the applicable standard of care, and that the cost of health care rendered was considered reasonable by the providers of professional health services in that area. The Commissioner of Health shall ensure that the information technology components of the quality assurance system comply with, and the Commissioner of Vermont Health Access shall ensure such components are incorporated into, the Statewide Health Information Technology Plan developed under section 9351 of this title and any other information technology initiatives coordinated pursuant to 3 V.S.A. § 3027. (b) The Vermont Program for Quality in Health Care, Inc. shall file an annual report with the Commissioner of Health. The report shall include an assessment of progress in the areas designated by the Commissioner of Health, including comparative studies on the provision and outcomes of health care and professional accountability. (c) Expenses incurred under this section by the Vermont Program for Quality in Health Care, Inc. shall be borne as follows: 35 percent by the hospitals, 15 percent by nonprofit hospital and medical service corporations licensed under 8 V.S.A. chapter 123 or 125, and 50 percent by health insurance companies licensed under 8 V.S.A. chapter 101 and health maintenance organizations licensed under 8 V.S.A. chapter 139. Expenses allocated under this section to persons licensed under 8 V.S.A. chapters 101 and 139 shall be billed based on premiums paid for health insurance coverage as defined in subsection 9415(b) of this title. Expenses allocated under this section shall not exceed 75 percent of the operating budget of the Vermont Program for Quality in Health Care, Inc. Added 1995, No. 180 (Adj. Sess.), § 21a; amended 2005, No. 215 (Adj. Sess.), § 329; 2007, No. 70, § 33; 2009, No. 61, § 4; 2011, No. 171 (Adj. Sess.), § 30, eff. July 1, 2013; 2017, No. 85, § F.10, eff. June 28, 2017.

18 V.S.A. § 9417 Tax-advantaged accounts for health-related expenses; administration; rulemaking

9417. Tax-advantaged accounts for health-related expenses; administration; rulemaking (a) As used in this section: (1) “Flexible spending account” or “FSA” has the same meaning as in 26 U.S.C. § 106(c)(2). (2) “Health reimbursement arrangement” or “HRA” means any account-based reimbursement arrangement funded solely by employer contributions that reimburses an employee, spouse, or dependents, or a combination thereof, for medical care expenses incurred by the employee, spouse, dependents, or a combination thereof, up to a maximum coverage amount set by the employer for a given coverage period and that is established pursuant to 26 U.S.C. §§ 105-106 and applicable guidance from the Internal Revenue Service. (3) “Health savings account” or “HSA” has the same meaning as in 26 U.S.C. § 223(d)(1). (b) Any entity administering one or more HRAs, HSAs, FSAs, or similar tax-advantaged accounts for health-related expenses, or a combination of these, in this State is subject to the jurisdiction of the Commissioner of Financial Regulation pursuant to 8 V.S.A. § 10 and all other applicable provisions. (c) The Commissioner of Financial Regulation shall adopt rules pursuant to 3 V.S.A. chapter 25 to license and regulate, to the extent permitted under federal law, entities administering or proposing to administer one or more HRAs, HSAs, FSAs, or similar tax-advantaged accounts for health-related expenses, or a combination of these, in this State. The rules shall include: (1) licensure or registration filing requirements; and (2) such requirements and qualifications for such entities as the Commissioner determines necessary to protect Vermont consumers and employers and to help ensure that funds are disbursed appropriately. (d) Following the adoption of rules pursuant to subsection (c) of this section, an entity making an initial application for a license or registration to administer HRAs, HSAs, FSAs, or similar tax-advantaged accounts for health-related expenses, or a combination of these, in this State shall pay to the Commissioner a nonrefundable fee of $600.00 for examining, investigating, and processing the application. Each such entity shall also pay a renewal fee of $600.00 on or before December 31 every three years following initial licensure. (e) This section shall not apply to an employer that self-administers one or more tax-advantaged accounts on behalf of its own employees. Added 2019, No. 54, § 1; amended 2021, No. 137 (Adj. Sess.), § 6, eff. July 1, 2022.

Source: Vermont General Assembly (legislature.vermont.gov)URL: https://legislature.vermont.gov/statutes/chapter/18/221Fetched: 10/21/2026