Health insurer participation; payments to practices
18 V.S.A. § 706
in effect706. Health insurer participation; payments to practices
(a) As set forth in 8 V.S.A. § 4025, health insurance plans shall be consistent with the Blueprint for Health as determined by the Commissioner of Financial Regulation.
(b)(1) Health insurers shall participate in the Blueprint for Health as a condition of doing business in this State as provided for in this section and in 8 V.S.A. § 4025.
(2) In order to facilitate development of the sustainable payment models necessary for the Blueprint’s success, health insurers shall submit to the Agency of Human Services at least quarterly, or more frequently upon the Agency’s request, all information that the Director of the Blueprint deems necessary to perform a comprehensive fiscal analysis of the total cost of care within Vermont and to implement one or more payment models that address health care capacity, volume, quality, and clinical outcomes.
(c)(1) The Blueprint payment reform methodologies shall include per-person per-month payments to participating practices, including medical homes and primary care providers, by each health insurer and Medicaid for their attributed patients and for contributions to the shared costs of operating Blueprint initiatives, including the community health teams. Per-person per-month payments to practices shall be:
(A) based on the official National Committee for Quality Assurance’s Patient Centered Medical Home (NCQA PCMH) score or another quality standard identified by the Director of the Blueprint in consultation with the Blueprint Payment Implementation Workgroup, to the extent practicable;
(B) provided in addition to a practice’s typical fee-for-service or other payments; and
(C) from health insurers, in amounts at least equal to Medicaid payments beginning in 2027.
(2) Consistent with recommendations of the Blueprint Executive Committee, the Director of the Blueprint may recommend to the Secretary of Human Services changes to the payment amounts or to the payment reform methodologies described in subdivision (1) of this subsection, including by providing for enhanced payment to health care professional practices, including medical homes and primary care practices; payment toward the shared costs for community health teams; or other payment methodologies required by the Centers for Medicare and Medicaid Services (CMS) for participation by Medicaid or Medicare. In formulating recommendations, the Director shall strive to achieve or maintain parity across payers and payment methodologies and to adjust payment methodologies annually as needed to adequately support practices in maintaining NCQA PCMH status or meeting other requirements for participation in Blueprint programs.
(3) Health insurers shall modify payment methodologies and amounts to health care professionals and providers as required for the establishment of the model described in sections 703–705 of this title and this section, including any requirements specified by the Centers for Medicare and Medicaid Services (CMS) in approving federal participation in the model to ensure consistency of payment methods in the model.
(4) In the event that the Secretary of Human Services is denied permission from the Centers for Medicare and Medicaid Services (CMS) to include financial participation by Medicare, health insurers shall not be required to cover the costs associated with individuals covered by Medicare.
(d) A health insurer may appeal a decision to require a particular payment methodology or payment amount to the Secretary of Human Services or designee, who shall provide a hearing in accordance with 3 V.S.A. chapter 25. A health insurer aggrieved by the decision of the Secretary or designee may appeal to the Superior Court for the Washington District within 30 days after the Secretary or designee issues a decision.
Added 2009, No. 128 (Adj. Sess.), § 13; amended 2011, No. 78 (Adj. Sess.), § 2, eff. April 2, 2012; 2011, No. 96 (Adj. Sess.), § 4, eff. May 2, 2012; 2015, No. 172 (Adj. Sess.), § E.306.2; 2019, No. 128 (Adj. Sess.), § 8; 2023, No. 6, § 105, eff. July 1, 2023; 2025, No. 11, § 15, eff. Sept. 1, 2025; 2025, No. 173 (Adj. Sess.), § 2, eff. June 18, 2026.
Source: Vermont General Assembly (legislature.vermont.gov)URL: https://legislature.vermont.gov/statutes/section/18/013/00706Fetched: 10/21/2026