Green Mountain Care Board

V.S.A. tit. 18, ch. 220, subch. 1

in effect

18 V.S.A. § 9371 Principles for health care reform

9371. Principles for health care reform The General Assembly adopts the following principles as a framework for reforming health care in Vermont: (1) The State of Vermont must ensure universal access to and coverage for high-quality, medically necessary health services for all Vermonters. Systemic barriers, such as cost, must not prevent people from accessing necessary health care. All Vermonters must receive affordable and appropriate health care at the appropriate time in the appropriate setting. (2) Overall health care costs must be contained, and growth in health care spending in Vermont must balance the health care needs of the population with the ability to pay for such care. (3) The health care system must be transparent in design, efficient in operation, and accountable to the people it serves. The State must ensure public participation in the design, implementation, evaluation, and accountability mechanisms of the health care system. (4) Primary care must be preserved and enhanced so that Vermonters have care available to them, preferably within their own communities. The health care system must ensure that Vermonters have 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. Other aspects of Vermont’s health care infrastructure, including the educational and research missions of the State’s academic medical center and other postsecondary educational institutions, the nonprofit missions of the community hospitals, and the critical access designation of rural hospitals, must be supported in such a way that all Vermonters, including those in rural areas, have access to necessary health services and that these health services are sustainable. (5) Every Vermonter should be able to choose his or her health care providers. (6) Vermonters should be aware of the costs of the health services they receive. Costs should be transparent and easy to understand. (7) Individuals have a personal responsibility to maintain their own health and to use health resources wisely, and all individuals should have a financial stake in the health services they receive. (8) The health care system must recognize the primacy of the relationship between patients and their health care practitioners, respecting the professional judgment of health care practitioners and the informed decisions of patients. (9) Vermont’s health delivery system must seek continuous improvement of health care quality and safety and of the health of the population and promote healthy lifestyles. The system therefore must be evaluated regularly for improvements in access, quality, and cost containment. (10) Vermont’s health care system must include mechanisms for containing all system costs and eliminating unnecessary expenditures, including by reducing administrative costs and by reducing costs that do not contribute to efficient, high-quality health services or improve health outcomes. Efforts to reduce overall health care costs should identify sources of excess cost growth. (11) The financing of health care in Vermont must be sufficient, fair, predictable, transparent, sustainable, and shared equitably. (12) The system must consider the effects of payment reform on individuals and on health care professionals and suppliers. It must enable health care professionals to provide, on a solvent basis, effective and efficient health services that are in the public interest. (13) Vermont’s health care system must operate as a partnership between consumers, employers, health care professionals, hospitals, and the State and federal government. (14) State government must ensure that the health care system satisfies the principles expressed in this section. Added 2011, No. 48, § 3, eff. May 26, 2011; amended 2017, No. 200 (Adj. Sess.), § 14; 2019, No. 14, § 53, eff. April 30, 2019.

18 V.S.A. § 9372 Purpose

9372. Purpose It is the intent of the General Assembly to create an independent board to promote the general good of the State by: (1) improving the health of the population; (2) reducing the per-capita rate of growth in expenditures for health services in Vermont across all payers while ensuring that access to care and quality of care are not compromised; (3) enhancing the patient and health care professional experience of care; (4) recruiting and retaining high-quality health care professionals; and (5) achieving administrative simplification in health care financing and delivery. Added 2011, No. 48, § 3, eff. May 26, 2011.

18 V.S.A. § 9373 Definitions

9373. Definitions As used in this chapter: (1) “Board” means the Green Mountain Care Board established in this chapter. (2) “Chronic care” means health services provided by a health care professional for an established clinical condition that is expected to last a year or more and that requires ongoing clinical management attempting to restore the individual to highest function, minimize the negative effects of the condition, prevent complications related to chronic conditions, engage in advanced care planning, and promote appropriate access to palliative care. (3) “Chronic care management” means a system of coordinated health care interventions and communications for individuals with chronic conditions, including significant patient self-care efforts, systemic supports for licensed health care practitioners and their patients, and a plan of care emphasizing prevention of complications, utilizing evidence-based practice guidelines, patient empowerment strategies, and evaluation of clinical, humanistic, and economic outcomes on an ongoing basis with the goal of improving overall health. (4) “Global payment” means a payment from a health insurer, Medicaid, Medicare, or other payer for the health services of a defined population of patients for a defined period of time. Such payments may be adjusted to account for the population’s underlying risk factors, including severity of illness and socioeconomic factors that may influence the cost of health care for the population. (5) “Green Mountain Care” means the public-private universal health care program designed to provide health benefits through a simplified, uniform, single administrative system pursuant to 33 V.S.A. chapter 18, subchapter 2. (6) “Health care professional” means an individual, partnership, corporation, facility, or institution licensed or certified or otherwise authorized by Vermont law to provide professional health services. (7) “Health care system” means the local, State, regional, or national system of delivering health services, including administrative costs, capital expenditures, preventive care, and wellness services. (8) “Health insurer” means any health insurance company, nonprofit hospital and medical service corporation, managed care organization, and, to the extent permitted under federal law, any administrator of a health benefit plan offered by a public or a private entity. The term does not include Medicaid or any other State health care assistance program financed in whole or in part through a federal program. (9) “Health service” means any treatment or procedure delivered by a health care professional to maintain an individual’s physical or mental health or to diagnose or treat an individual’s physical or mental condition, including services ordered by a health care professional, chronic care management, preventive care, wellness services, and medically necessary services to assist in activities of daily living. (10) “Integrated delivery system” means a group of health care professionals, associated either through employment by a single entity or through a contractual arrangement, that provides health services for a defined population of patients and is compensated through a global payment. (11) “Manufacturers of prescribed products” shall have the same meaning as “manufacturers” in section 4631a of this title. (12) “Payment reform” means modifying the method of payment from a fee-for-service basis to one or more alternative methods for compensating health care professionals, health care provider bargaining groups created pursuant to section 9409 of this title, integrated delivery systems, and other health care professional arrangements, manufacturers of prescribed products, medical supply companies, and other companies providing health services or health supplies for the provision of high-quality and efficient health services, products, and supplies while measuring quality and efficiency. The term may include shared savings agreements, bundled payments, episode-based payments, and global payments. (13) “Preventive care” means health services provided by health care professionals to identify and treat asymptomatic individuals who have risk factors or preclinical disease, but in whom the disease is not clinically apparent, including immunizations and screening, counseling, treatment, and medication determined by scientific evidence to be effective in preventing or detecting a condition. (14) [Repealed.] (15) “Wellness services” means health services, programs, or activities that focus on the promotion or maintenance of good health. (16) “Accountable care organization” and “ACO” means an organization of health care providers that has a formal legal structure, is identified by a federal taxpayer identification number, and agrees to be accountable for the quality, cost, and overall care of the patients assigned to it. (17) “Health care spending estimate” means the estimate established in accordance with section 9383 of this title. (18) “Net patient revenues” has the same meaning as in 33 V.S.A. § 1951. Added 2011, No. 48, § 3, eff. May 26, 2011; amended 2011, No. 171 (Adj. Sess.), § 6, eff. May 16, 2012; 2013, No. 79, § 20, eff. Jan. 1, 2014; 2013, No. 96 (Adj. Sess.), § 117; 2015, No. 113 (Adj. Sess.), § 3, eff. Jan. 1, 2018; 2017, No. 167 (Adj. Sess.), § 7, eff. May 22, 2018; 2019, No. 55, § 3a, eff. June 10, 2019.

18 V.S.A. § 9374 Board membership; authority

9374. Board membership; authority (a)(1) On July 1, 2011, the Green Mountain Care Board is created and shall consist of a chair and four members. The Chair and all of the members shall be State employees and shall be exempt from the State classified system. The Chair shall receive compensation equal to that of a Superior judge, and the compensation for the remaining members shall be two-thirds of the amount received by the Chair. (2) The Chair and the members of the Board shall be nominated by the Green Mountain Care Board Nominating Committee established in subchapter 2 of this chapter using the qualifications described in section 9392 of this chapter and shall be otherwise appointed and confirmed in the manner of a Superior judge. The Governor shall not appoint a nominee who was denied confirmation by the Senate within the past six years. (b)(1) The term of each member of the Board, including the Chair, shall be six years. (2) Any appointment to fill a vacancy shall be for the unexpired portion of the term vacated. (3) A member may serve more than one term. A member may be reappointed to additional terms subject to the requirements of section 9391 of this title. (4) Members of the Board may be removed only for cause. The Board shall adopt rules pursuant to 3 V.S.A. chapter 25 to define the basis and process for removal. (c)(1) No Board member shall, during his or her term or terms on the Board, be an officer of, director of, organizer of, employee of, consultant to, or attorney for any person subject to supervision or regulation by the Board, provided that for a health care practitioner, the employment restriction in this subdivision shall apply only to administrative or managerial employment or affiliation with a hospital or other health care facility, as defined in section 9432 of this title, and shall not be construed to limit generally the ability of the health care practitioner to practice his or her profession. (2) No Board member shall participate in creating or applying any law, rule, or policy or in making any other determination if the Board member, individually or as a fiduciary, or the Board member’s spouse, parent, or child wherever residing or any other member of the Board member’s family residing in his or her household has an economic interest in the matter before the Board or has any more than a de minimis interest that could be substantially affected by the proceeding. (3) The prohibitions contained in subdivisions (1) and (2) of this subsection shall not be construed to prohibit a Board member from, or require a Board member to recuse himself or herself from Board activities as a result of, any of the following: (A) being an insurance policyholder or from receiving health services on the same terms as are available to the public generally; (B) owning a stock, bond, or other security in an entity subject to supervision or regulation by the Board that is purchased by or through a mutual fund, blind trust, or other mechanism where a person other than the Board member chooses the stock, bond, or security; or (C) receiving retirement benefits through a defined benefit plan from an entity subject to supervision or regulation by the Board. (4) No Board member shall, during his or her term or terms on the Board, solicit, engage in negotiations for, or otherwise discuss future employment or a future business relationship of any kind with any person subject to supervision or regulation by the Board. (5) No Board member may appear before the Board or any other State agency on behalf of a person subject to supervision or regulation by the Board for a period of one year following his or her last day as a member of the Green Mountain Care Board. (d)(1) The Chair shall have general charge of the offices and employees of the Board but may hire a director to oversee the administration and operation. (2)(A) Except for final decisions in regulatory matters over which the Board has jurisdiction, a member of the Board, Board officer, or Board employee may perform any service that is within the Board’s jurisdiction and that the Board delegates to the member, officer, or employee. (B) The Board shall establish procedures to ensure that Board employees have appropriate supervision in their performance of delegated activities and that the Board remains informed regarding these activities. (e)(1) The Board shall establish a consumer, patient, business, and health care professional advisory group to provide input and recommendations to the Board. Members of such advisory group who are not State employees or whose participation is not supported through their employment or association shall receive per diem compensation and reimbursement of expenses pursuant to 32 V.S.A. § 1010, provided that the total amount expended for such compensation shall not exceed $5,000.00 per year. (2) The Board may establish additional advisory groups and subcommittees as needed to carry out its duties. The Board shall appoint diverse health care professionals to the additional advisory groups and subcommittees as appropriate. (3) To the extent funds are available, the Board may examine, on its own or through collaboration or contracts with third parties, the effectiveness of existing requirements for health care professionals, such as quality measures and prior authorization, and evaluate alternatives that improve quality, reduce costs, and reduce administrative burden. (f) In carrying out its duties pursuant to this chapter, the Board shall seek advice from the Office of the Health Care Advocate. The Office shall advise the Board regarding the policies, procedures, and rules established pursuant to this chapter. The Office shall represent the interests of Vermont patients and Vermont consumers of health insurance and may suggest policies, procedures, or rules to the Board in order to protect patients’ and consumers’ interests. (g) The Chair of the Board or designee may apply for grant funding, if available, to advance or support any responsibility within the Board’s jurisdiction. (h)(1)(A) Except as otherwise provided in subdivisions (1)(C) and (2) of this subsection (h), the expenses of the Board shall be borne as follows: (i) 40 percent by the State from State monies; (ii) 36 percent by the hospitals; and (iii) 24 percent by nonprofit hospital and medical service corporations licensed under 8 V.S.A. chapter 123 or 125, health insurance companies licensed under 8 V.S.A. chapter 101, and health maintenance organizations licensed under 8 V.S.A. chapter 139. (B) Expenses under subdivision (A)(iii) of this subdivision (1) shall be allocated to persons licensed under Title 8 based on premiums paid for health care coverage, which for the purposes of this subdivision (1) shall include major medical, comprehensive medical, hospital or surgical coverage, and comprehensive health care services plans, but shall not include long-term care, limited benefits, disability, credit or stop loss, or excess loss insurance coverage. (C) Amounts assessed pursuant to the provisions of sections 9382 and 9441 of this title shall not be assessed in accordance with the formula set forth in subdivision (A) of this subdivision (1). (2) The Board may determine the scope of the incurred expenses to be allocated pursuant to the formula set forth in subdivision (1) of this subsection if, in the Board’s discretion, the expenses to be allocated are in the best interests of the regulated entities and of the State. (3) If the amount of the proportional assessment to any entity calculated in accordance with the formula set forth in subdivision (1)(A) of this subsection would be less than $150.00, the Board shall assess the entity a minimum fee of $150.00. The Board shall apply the amounts collected based on the difference between each applicable entity’s proportional assessment amount and $150.00 to reduce the total amount assessed to the regulated entities pursuant to subdivisions (1)(A)(ii) and (iii) of this subsection. (4)(A) Annually on or before September 15, the Board shall report to the House and Senate Committees on Appropriations the total amount of all expenses eligible for allocation pursuant to this subsection (h) during the preceding State fiscal year and the total amount actually billed back to the regulated entities during the same period. The provisions of 2 V.S.A. § 20(d) (expiration of required reports) shall not apply to the report to be made under this subdivision (A). (B) The Board shall also present the information required by this subsection (h) to the Joint Fiscal Committee annually at its September meeting. (i)(1) In addition to any other penalties and in order to enforce the provisions of this chapter and empower the Board to perform its duties, the Chair of the Board may issue subpoenas, examine persons, administer oaths, and require production of papers and records. Any subpoena or notice to produce may be served by registered or certified mail or in person by an agent of the Chair. Service by registered or certified mail shall be effective three business days after mailing. Any subpoena or notice to produce shall provide at least six business days’ time from service within which to comply, except that the Chair may shorten the time for compliance for good cause shown. Any subpoena or notice to produce sent by registered or certified mail, postage prepaid, shall constitute service on the person to whom it is addressed. (2) Each witness who appears before the Chair under subpoena shall receive a fee and mileage as provided for witnesses in civil cases in Superior Courts; provided, however, any person subject to the Board’s authority shall not be eligible to receive fees or mileage under this section. (3) The Board may share any information, papers, or records it receives pursuant to a subpoena or notice to produce issued under this section with the Agency of Human Services or the Department of Financial Regulation, or both, as appropriate to the work of the Agency or Department, provided that the Agency or Department agrees to maintain the confidentiality of any information, papers, or records that are exempt from public inspection and copying under the Public Records Act. (j) A person who fails or refuses to appear, to testify, or to produce papers or records for examination before the Chair upon properly being ordered to do so may be assessed an administrative penalty by the Chair of not more than $2,000.00 for each day of noncompliance and proceeded against as provided in the Administrative Procedure Act, and the Chair may recommend to the appropriate licensing entity that the person’s authority to do business be suspended for up to six months. Added 2011, No. 48, § 3, eff. May 26, 2011; amended 2011, No. 171 (Adj. Sess.), § 5, eff. May 16, 2012; 2013, No. 79, § 35b, eff. Jan. 1, 2014; 2013, No. 79, § 37a; 2015, No. 113 (Adj. Sess.), § 9, eff. May 17, 2016; 2017, No. 154 (Adj. Sess.), § 23, eff. May 21, 2018; 2017, No. 167 (Adj. Sess.), § 13, eff. May 22, 2018; 2017, No. 167 (Adj. Sess.), § 17; 2019, No. 88 (Adj. Sess.), § 67, eff. March 4, 2020; 2021, No. 137 (Adj. Sess.), § 5, eff. July 1, 2022; 2023, No. 134 (Adj. Sess.), § 4, eff. May 30, 2024; 2023, No. 113 (Adj. Sess.), § E.345, eff. July 1, 2024; 2025, No. 27, § E.345, eff. July 1, 2025; 2025, No. 62, § 3, eff. July 1, 2025; 2025, No. 68, § 11, eff. June 12, 2025.

18 V.S.A. § 9375 Duties

9375. Duties (a) The Board shall execute its duties consistent with the principles expressed in section 9371 of this title. (b) The Board shall have the following duties: (1) Oversee the development and implementation, and evaluate the effectiveness, of health care payment and delivery system reforms designed to control the rate of growth in health care costs; promote seamless care, administration, and service delivery; and maintain health care quality in Vermont, including ensuring that the payment reform pilot projects set forth in this chapter are consistent with such reforms. (A) Implement by rule, pursuant to 3 V.S.A. chapter 25, methodologies for achieving payment reform and containing costs that may include the participation of Medicare and Medicaid, which may include the creation of health care professional cost-containment targets, reference-based pricing, global payments, bundled payments, global budgets, risk-adjusted capitated payments, or other uniform payment methods and amounts for integrated delivery systems, health care professionals, or other provider arrangements. (i) The Board shall work in collaboration with providers to develop payment models that preserve access to care and quality in each community. (ii) The rule shall take into consideration current Medicare designations and payment methodologies, including critical access hospitals, prospective payment system hospitals, graduate medical education payments, Medicare dependent hospitals, and federally qualified health centers. (iii) The payment reform methodologies developed by the Board shall encourage coordination and planning on a regional basis, taking into account existing local relationships between providers and human services organizations. (B) Prior to the initial adoption of the rules described in subdivision (A) of this subdivision (1), report the Board’s proposed methodologies to the House Committee on Health Care and the Senate Committee on Health and Welfare. (C) In developing methodologies pursuant to subdivision (A) of this subdivision (1), engage Vermonters in seeking ways to equitably distribute health services while acknowledging the connection between fair and sustainable payment and access to health care. (D) Nothing in this subdivision (1) shall be construed to limit the authority of other agencies or departments of State government to engage in additional cost-containment activities to the extent permitted by State and federal law. (2) [Repealed.] (3) Review and approve the Health Care Workforce Development Strategic Plan created in chapter 222 of this title. (4) Publish on its website the Health Resource Allocation Plan identifying Vermont’s critical health needs, goods, services, and resources in accordance with section 9405 of this title. (5) Set rates for health care professionals pursuant to section 9376 of this title, to be implemented over time beginning with reference-based pricing as soon as practicable, but not later than hospital fiscal year 2027, and make adjustments to the rules on reimbursement methodologies as needed. (6) Approve, modify, or disapprove requests for health insurance rates pursuant to 8 V.S.A. § 4026, taking into consideration the requirements in the underlying statutes; changes in health care delivery; changes in payment methods and amounts, including implementation of reference-based pricing; protecting insurer solvency; and other issues at the discretion of the Board. (7) Review and establish hospital budgets pursuant to chapter 221, subchapter 7 of this title, including establishing standards for global hospital budgets that reflect the implementation of reference-based pricing and the total cost of care targets determined in collaboration with federal partners and other stakeholders or as set by the Statewide Health Care Delivery Plan developed pursuant to section 9403 of this title, once established. Beginning not later than hospital fiscal year 2028, to the extent that resources are available, the Board shall establish global hospital budgets for one or more Vermont hospitals that are not critical access hospitals. By hospital fiscal year 2030, to the extent that resources are available, the Board shall establish global hospital budgets for all Vermont hospitals. (8) Review and approve, approve with conditions, or deny applications for certificates of need pursuant to chapter 221, subchapter 5 of this title. (9) Review and approve, with recommendations from the Commissioner of Vermont Health Access, the benefit package or packages for qualified health benefit plans and reflective health benefit plans pursuant to 33 V.S.A. chapter 18, subchapter 1. The Board shall report to the House Committee on Health Care and the Senate Committee on Health and Welfare within 15 days following its approval of any substantive changes to the benefit packages. (10) Develop and maintain a method for evaluating systemwide performance and quality, including identification of the appropriate process and outcome measures: (A) for determining public and health care professional satisfaction with the health system; (B) for utilization of health services; (C) in consultation with the Department of Health and the Director of the Blueprint for Health, for quality of health services and the effectiveness of prevention and health promotion programs; (D) for cost-containment and limiting the growth in health care expenditures; (E) for determining the adequacy of the supply and distribution of health care resources in this State; (F) to address access to and quality of mental health and substance abuse services; and (G) for other measures as determined by the Board. (11) Develop the health care spending estimate pursuant to section 9383 of this title. (12) [Repealed.] (13) Adopt by rule pursuant to 3 V.S.A. chapter 25 such standards as the Board deems necessary and appropriate to the operation and evaluation of accountable care organizations pursuant to this chapter, including reporting requirements, patient protections, and solvency and ability to assume financial risk. (14) [Repealed.] (15) Collect and review data from each community mental health and developmental disability agency designated by the Commissioner of Mental Health or of Disabilities, Aging, and Independent Living pursuant to chapter 207 of this title, which may include data regarding a designated or specialized service agency’s scope of services, volume, utilization, payer mix, quality, coordination with other aspects of the health care system, and financial condition, including solvency. The Board’s processes shall be appropriate to the designated and specialized service agencies’ scale and their role in Vermont’s health care system, and the Board shall consider ways in which the designated and specialized service agencies can be integrated fully into systemwide payment and delivery system reform. (c) The Board shall have the following duties related to Green Mountain Care: (1) Prior to implementing Green Mountain Care, consider recommendations from the Agency of Human Services, and define the Green Mountain Care benefit package within the parameters established in 33 V.S.A. chapter 18, subchapter 2, to be adopted by the Agency by rule. (2) When providing its recommendations for the benefit package pursuant to subdivision (1) of this subsection, the Agency of Human Services shall present a report on the benefit package proposal to the House Committee on Health Care and the Senate Committee on Health and Welfare. The report shall describe the covered services to be included in the Green Mountain Care benefit package and any cost-sharing requirements. If the General Assembly is not in session at the time that the Agency makes its recommendations, the Agency shall send its report electronically or by first-class mail to each member of the House Committee on Health Care and the Senate Committee on Health and Welfare. (3) Prior to implementing Green Mountain Care and annually after implementation, recommend to the Governor a three-year Green Mountain Care budget pursuant to 32 V.S.A. chapter 5, to be adjusted annually in response to realized revenues and expenditures, that reflects any modifications to the benefit package and includes recommended appropriations, revenue estimates, and necessary modifications to tax rates and other assessments. (d) Annually on or before January 15, the Board shall submit a report of its activities for the preceding calendar year to the House Committee on Health Care and the Senate Committee on Health and Welfare. (1) The report shall include: (A) any changes to the payment rates for health care professionals pursuant to section 9376 of this title; (B) any new developments with respect to health information technology; (C) the evaluation criteria adopted pursuant to subdivision (b)(8) of this section and any related modifications; (D) the results of the systemwide performance and quality evaluations required by subdivision (b)(8) of this section and any resulting recommendations; (E) the process and outcome measures used in the evaluation; (F) the impact of the Medicaid and Medicare cost shifts and uncompensated care on health insurance premium rates and any recommendations on mechanisms to ensure that appropriations intended to address the Medicaid cost shift will have the intended result of reducing the premiums imposed on commercial insurance premium payers below the amount they otherwise would have been charged; (G) the status of its efforts to establish methodologies for and begin implementation of reference-based pricing and development of global hospital budgets, and the effects of these efforts and activities on increasing access to care, improving the quality of care, and reducing the cost of care in Vermont; (H) any recommendations for modifications to Vermont statutes; and (I) any actual or anticipated impacts on the work of the Board as a result of modifications to federal laws, regulations, or programs. (2) The report shall identify how the work of the Board comports with the principles expressed in section 9371 of this title. (e)(1) The Board shall summarize and synthesize the key findings and recommendations from reports prepared by and for the Board, including its expenditure analyses and focused studies. The Board shall develop, in consultation with the Office of the Health Care Advocate, a standard for creating plain language summaries that the public can easily use and understand. (2) All reports and summaries prepared by the Board shall be available to the public and shall be posted on the Board’s website. Added 2011, No. 48, § 3, eff. May 26, 2011; amended 2011, No. 171 (Adj. Sess.), § 12, eff. May 16, 2012; 2013, No. 79, § 5 l, eff. Jan. 1, 2014; 2013, No. 79, § 41; 2015, No. 54, § 7, eff. June 5, 2015; 2015, No. 113 (Adj. Sess.), § 4, eff. Jan. 1, 2018; 2017, No. 88 (Adj. Sess.), § 1, eff. Feb. 20, 2018; 2017, No. 113 (Adj. Sess.), § 105; 2017, No. 154 (Adj. Sess.), § 3, eff. May 21, 2018; 2017, No. 167 (Adj. Sess.), §§ 1, 8, eff. May 22, 2018; 2017, No. 187 (Adj. Sess.), § 4, eff. May 28, 2018; 2019, No. 19, § 3, eff. Jan. 1, 2020; 2019, No. 53, § 2; 2019, No. 55, § 4, eff. June 10, 2019; 2019, No. 63, § 10 eff. June 17, 2019; 2019, No. 140 (Adj. Sess.), § 1, eff. July 6, 2020; 2021, No. 167 (Adj. Sess.), § 9, eff. June 1, 2022; 2025, No. 11, § 19, eff. Sept. 1, 2025; 2025, No. 62, § 4, eff. July 1, 2025; 2025, No. 68, § 2, eff. June 12, 2025; 2025, No. 68, § 16, eff. July 1, 2026.

18 V.S.A. § 9375a Repealed. 2017, No. 167 (Adj. Sess.), § 12, effective May 22, 2018.

18 V.S.A. § 9376 Payment amounts; methods

9376. Payment amounts; methods (a) Intent. It is the intent of the General Assembly to ensure payments to health care professionals that are consistent with efficiency, economy, and quality of care and will permit them to provide, on a solvent basis, effective and efficient health services that are in the public interest. It is also the intent of the General Assembly to eliminate the shift of costs between the payers of health services to ensure that the amount paid to health care professionals is sufficient to enlist enough providers to ensure that health services are available to all Vermonters and are distributed equitably. (b) Rate-setting. (1) The Board shall set reasonable rates for health care professionals, health care provider bargaining groups created pursuant to section 9409 of this title, manufacturers of prescribed products, medical supply companies, and other companies providing health services or health supplies based on methodologies pursuant to section 9375 of this title, in order to have a consistent reimbursement amount accepted by these persons. In its discretion, the Board may implement rate-setting for different groups of health care professionals over time and need not set rates for all types of health care professionals. In establishing rates, the Board may consider legitimate differences in costs among health care professionals, such as the cost of providing a specific necessary service or services that may not be available elsewhere in the State, and the need for health care professionals in particular areas of the State, particularly in underserved geographic or practice shortage areas. (2) Nothing in this subsection shall be construed to: (A) limit the ability of a health care professional to accept less than the rate established in subdivision (1) of this subsection (b) from a patient without health insurance or other coverage for the service or services received; or (B) reduce or limit the covered services offered by Medicare or Medicaid. (c) Methodologies. The Board shall approve payment methodologies that encourage cost-containment; provision of high-quality, evidence-based health services in an integrated setting; patient self-management; access to primary care health services; and healthy lifestyles. Such methodologies shall be consistent with payment reform and with evidence-based practices, and may include fee-for-service payments if the Board determines such payments to be appropriate. (d) Supervision. To the extent required to avoid federal antitrust violations and in furtherance of the policy identified in subsection (a) of this section, the Board shall facilitate and supervise the participation of health care professionals and health care provider bargaining groups in the process described in subsection (b) of this section. (e) Reference-based pricing. (1)(A) The Board shall establish reference-based prices that represent the maximum amounts that hospitals shall accept as payment in full for items provided and services delivered in Vermont. The Board may also implement reference-based pricing for services delivered outside a hospital by setting the minimum amounts that shall be paid for items provided and services delivered by nonhospital-based health care professionals. The Board shall consult with health insurers, hospitals, other health care professionals as applicable, the Office of the Health Care Advocate, and the Agency of Human Services in developing reference-based prices pursuant to this subsection (e), including on ways to achieve all-payer alignment on the design and implementation of reference-based pricing. (B) The Board shall implement reference-based pricing in a manner that does not allow health care professionals to charge or collect from patients or health insurers any amount in excess of the reference-based amount established by the Board. (2)(A) Reference-based prices established pursuant to this subsection (e) shall be based on a percentage of the Medicare reimbursement for the same or a similar item or service or on another benchmark, as appropriate, provided that if the Board establishes prices that are referenced to Medicare, the Board may opt to update the prices in the future based on a reasonable rate of growth that is separate from Medicare rates, such as the Medicare Economic Index measure of inflation, in order to provide predictability and consistency for health care professionals and payers and to protect against federal funding pressures that may impact Medicare rates in an unpredictable manner. The Board may also reference to, and update based on, other payment or pricing systems where appropriate. (B) In establishing reference-based prices for a hospital pursuant to this subsection (e), the Board shall consider the composition of the communities served by the hospital, including the health of the population, demographic characteristics, acuity, payer mix, labor costs, social risk factors, and other factors that may affect the costs of providing care in the hospital service area, as well as the hospital’s role in Vermont’s health care system. (3)(A) The Board shall begin implementing reference-based pricing as soon as practicable but not later than hospital fiscal year 2027 by establishing the maximum amounts that Vermont hospitals shall accept as payment in full for items provided and services delivered. After initial implementation, the Board shall review the reference-based prices for each hospital annually as part of the hospital budget review process set forth in chapter 221, subchapter 7 of this title. (B) The Board, in collaboration with the Department of Financial Regulation, shall monitor the implementation of reference-based pricing to ensure that any decreases in amounts paid to hospitals also result in decreases in health insurance premiums. The Board shall post its findings regarding the alignment between price decreases and premium decreases annually on its website. (4) The Board shall identify factors that would necessitate terminating or modifying the use of reference-based pricing in one or more hospitals, such as a measurable reduction in access to or quality of care. (5) The Green Mountain Care Board, in consultation with the Agency of Human Services and the Vermont Steering Committee for Comprehensive Primary Health Care established pursuant to section 9403b of this title, may implement reference-based pricing for services delivered outside a hospital, such as primary care services, and may increase or decrease the percentage of Medicare or another benchmark as appropriate, first to enhance access to primary care and later for alignment with the Statewide Health Care Delivery Strategic Plan established pursuant to section 9403 of this title, once established. The Board may consider establishing reference-based pricing for services delivered outside a hospital by setting minimum amounts that shall be paid for the purpose of prioritizing access to high-quality health care services in settings that are appropriate to patients’ needs in order to contain costs and improve patient outcomes. (6) The Board’s authority to establish reference-based prices pursuant to this subsection shall not include the authority to set amounts applicable to items provided or services delivered to patients who are enrolled in Medicare or Medicaid. Added 2011, No. 48, § 3, eff. May 26, 2011; amended 2015, No. 54, § 8, eff. June 5, 2015; 2025, No. 68, § 3, eff. June 12, 2025.

18 V.S.A. § 9377 Payment reform; pilots

9377. Payment reform; pilots (a) It is the intent of the General Assembly to achieve the principles stated in section 9371 of this title. In order to achieve this goal and to ensure the success of health care reform, it is the intent of the General Assembly that payment reform be implemented and that payment reform be carried out as described in this section. It is also the intent of the General Assembly to ensure sufficient State involvement and action in the design and implementation of the payment reform pilot projects described in this section to comply with federal and State antitrust provisions by replacing competition between payers and others with State-supervised cooperation and regulation. (b)(1) The Board shall be responsible for payment and delivery system reform, including the pilot projects established in this section. (2) Payment reform pilot projects shall be developed and implemented to manage the costs of the health care delivery system, improve health outcomes for Vermonters, provide a positive health care experience for patients and health care professionals, and further the following objectives: (A) payment reform pilot projects should align with the Blueprint for Health strategic plan and the Statewide Health Information Technology Plan; (B) health care professionals should coordinate patient care through a local entity or organization facilitating this coordination or another structure that results in the coordination of patient care and a sustained focus on disease prevention and promotion of wellness that includes individuals, employers, and communities; (C) health insurers, Medicaid, Medicare, and all other payers should reimburse health care professionals for coordinating patient care through consistent payment methodologies, which may include a global budget; a system of cost containment limits, health outcome measures, and patient consumer satisfaction targets, which may include risk-sharing or other incentives designed to reduce costs while maintaining or improving health outcomes and patient consumer satisfaction; or another payment method providing an incentive to coordinate care and control cost growth; (D) the scope of services in any capitated payment should be broad and comprehensive, including prescription drugs, diagnostic services, acute and sub-acute home health services, services received in a hospital, mental health and substance abuse services, and services from a licensed health care practitioner; and (E) health insurers, Medicaid, Medicare, and all other payers should reimburse health care professionals for providing the full spectrum of evidence-based health services. (3) In addition to the objectives identified in subdivision (a)(2) of this section, the design and implementation of payment reform pilot projects may consider: (A) alignment with the requirements of federal law to ensure the full participation of Medicare in multipayer payment reform; and (B) with input from long-term care providers, the inclusion of home health services and long-term care services as part of capitated payments. (c) To the extent required to avoid federal antitrust violations, the Board shall facilitate and supervise the participation of health care professionals, health care facilities, and insurers in the planning and implementation of the payment reform pilot projects, including by creating a shared incentive pool if appropriate. The Board shall ensure that the process and implementation include sufficient State supervision over these entities to comply with federal antitrust provisions and shall refer to the Attorney General for appropriate action the activities of any individual or entity that the Board determines, after notice and an opportunity to be heard, violate State or federal antitrust laws without a countervailing benefit of improving patient care, improving access to health care, increasing efficiency, or reducing costs by modifying payment methods. (d) The Board or designee shall apply for grant funding, if available, for the evaluation of the pilot projects described in this section. (e) The Board or designee shall convene a broad-based group of stakeholders, including health care professionals who provide health services, health insurers, professional organizations, community and nonprofit groups, consumers, businesses, school districts, the Office of the Health Care Advocate, and State and local governments, to advise the Board in developing and implementing the pilot projects and to advise the Green Mountain Care Board in setting overall policy goals. (f) The first pilot project shall become operational not later than July 1, 2012, and two or more additional pilot projects shall become operational not later than October 1, 2012. (g)(1) Health insurers shall participate in the development of the payment reform strategic plan for the pilot projects and in the implementation of the pilot projects, including providing incentives, fees, or payment methods, as required in this section. This requirement may be enforced by the Department of Financial Regulation to the same extent as the requirement to participate in the Blueprint for Health pursuant to 8 V.S.A. § 4025. (2) The Board may establish procedures to exempt or limit the participation of health insurers offering a stand-alone dental plan or specific disease or other limited-benefit coverage or participation by insurers with a minimal number of covered lives as defined by the Board, in consultation with the Commissioner of Financial Regulation. Health insurers shall be exempt from participation if the insurer offers only benefit plans that are paid directly to the individual insured or the insured’s assigned beneficiaries and for which the amount of the benefit is not based upon potential medical costs or actual costs incurred. (3) In the event that the Secretary of Human Services is denied permission from the Centers for Medicare and Medicaid Services to include financial participation by Medicare in the pilot projects, health insurers shall not be required to cover the costs associated with individuals covered by Medicare. (4) After implementation of the pilot projects described in this subchapter, health insurers shall have appeal rights pursuant to section 9381 of this title. Added 2011, No. 48, § 3, eff. May 26, 2011; amended 2011, No. 171 (Adj. Sess.), § 27, eff. May 16, 2012; 2013, No. 79, § 35c, eff. Jan. 1, 2014; 2023, No. 6, § 224, eff. July 1, 2023; 2025, No. 11, § 20, eff. Sept. 1, 2025.

18 V.S.A. § 9377a Prior authorization pilot program

9377a. Prior authorization pilot program (a) The Green Mountain Care Board shall develop and implement a pilot program or programs for the purpose of measuring the change in system costs within primary care associated with eliminating prior authorization requirements for imaging, medical procedures, prescription drugs, and home care. The program shall be designed to measure the effects of eliminating prior authorizations on provider satisfaction and on the number of requests for and expenditures on imaging, medical procedures, prescription drugs, and home care. In developing the pilot program proposal, the Board shall collaborate with health care professionals and health insurers throughout the State or regionally. (b) The Board shall submit an update regarding implementation of prior authorization pilot programs as part of its annual report under subsection 9375(d) of this title. Added 2013, No. 79, § 40a.

18 V.S.A. § 9378 Public process

9378. Public process The Green Mountain Care Board shall provide a process for soliciting public input. The process may include receiving written comments on proposed new or amended rules or holding public hearings, or both. Added 2011, No. 48, § 3, eff. May 26, 2011.

18 V.S.A. § 9379 Agency cooperation

9379. Agency cooperation The Secretary of Administration shall ensure that, in accordance with State and federal privacy laws, the Green Mountain Care Board has access to data and analysis held by any Executive Branch agency that is necessary to carry out the Board’s duties as described in this chapter. Added 2011, No. 48, § 3, eff. May 26, 2011.

18 V.S.A. § 9380 Rules

9380. Rules The Board may adopt rules pursuant to 3 V.S.A. chapter 25 as needed to carry out the provisions of this chapter. Added 2011, No. 48, § 3, eff. May 26, 2011.

18 V.S.A. § 9381 Appeals

9381. Appeals (a) The Green Mountain Care Board shall adopt procedures for administrative appeals of its actions, orders, or other determinations. Such procedures shall provide for the issuance of a final order and the creation of a record sufficient to serve as the basis for judicial review pursuant to subsection (b) of this section. (b) Any person aggrieved by a final action, order, or other determination of the Green Mountain Care Board may, upon exhaustion of all administrative appeals available pursuant to subsection (a) of this section, appeal to the Supreme Court pursuant to the Vermont Rules of Appellate Procedure. (c) If an appeal or other petition for judicial review of a final order is not filed in connection with an order of the Green Mountain Care Board pursuant to subsection (b) of this section, the Chair may file a certified copy of the final order with the clerk of a court of competent jurisdiction. The order so filed has the same effect as a judgment of the court and may be recorded, enforced, or satisfied in the same manner as a judgment of the court. (d) A decision of the Board’s approving, modifying, or disapproving a health insurer’s proposed rate pursuant to 8 V.S.A. § 4026 shall be considered a final action of the Board and may be appealed to the Supreme Court pursuant to subsection (b) of this section. Added 2011, No. 48, § 3, eff. May 26, 2011; amended 2011, No. 171 (Adj. Sess.), eff. May 16, 2012; 2013, No. 79, § 5m, eff. Jan. 1, 2014; 2025, No. 11, § 21, eff. Sept. 1, 2025.

18 V.S.A. § 9382 Oversight of accountable care organizations

9382. Oversight of accountable care organizations (a)(1) In order to be eligible to operate in Vermont, each accountable care organization shall obtain and maintain certification from the Green Mountain Care Board. The Board shall adopt rules pursuant to 3 V.S.A. chapter 25 to establish standards and processes for certifying accountable care organizations. To the extent permitted under federal law, the Board shall ensure these rules anticipate and accommodate a range of ACO models and sizes, balancing oversight with support for innovation. In order to certify an ACO to operate in this State, the Board shall ensure that the following criteria are met: (A) The ACO’s mechanisms and care models, taken as a whole, support and do not hinder the State’s principles for health care reform as set forth in section 9371 of this title. (B) The ACO’s financial incentives for providers and patients are reasonably calculated to improve, or at a minimum, maintain, the quality of, access to, and affordability of care. (C) The ACO has established appropriate mechanisms to receive and distribute payments to its participating health care providers in a fair and equitable manner. (D) The ACO has established appropriate mechanisms and criteria for accepting health care providers to participate in the ACO that prevent unreasonable discrimination. (E) The ACO has performance standards and measures to evaluate the quality and utilization of care delivered by its participating health care providers. (F) The ACO does not place any restrictions on the information its participating health care providers may provide to patients about their health or decisions regarding their health. (G) The ACO offers assistance to health care consumers, including: (i) maintaining a consumer telephone line for questions, complaints, and grievances from attributed patients; (ii) responding and making best efforts to resolve complaints and grievances from attributed patients, including providing assistance in identifying appropriate rights under a patient’s health plan; (iii) providing an accessible mechanism for explaining how ACOs work; (iv) providing contact information for the Office of the Health Care Advocate; and (v) sharing deidentified complaint and grievance information with the Office of the Health Care Advocate at least twice annually. (H) The ACO has in place a financial guarantee sufficient to cover its potential losses. (2) Notwithstanding subdivision (1) of this subsection, the Green Mountain Care Board may adopt rules in accordance with 3 V.S.A. chapter 25 to establish a streamlined process for certification as a Medicare-only ACO for an entity authorized by the Centers for Medicare and Medicaid Services to act as an accountable care organization under the Medicare program. The streamlined process may require a Medicare-only ACO to meet one or more of the criteria set forth in subdivision (1) of this subsection. Certification obtained pursuant to the streamlined process shall apply to the Medicare-only ACO’s actions only as they relate to Medicare beneficiaries and only to the extent that the federal authorization allows. (b) The Green Mountain Care Board shall adopt rules in accordance with 3 V.S.A. chapter 25 to establish standards and processes for reviewing, modifying, and approving the budgets of ACOs that receive payments from Medicaid or commercial insurers, or both, on behalf of attributed lives in Vermont. To the extent permitted under federal law, the Board shall ensure the rules anticipate and accommodate a range of ACO models and sizes, balancing oversight with support for innovation. In its review, the Board shall review and consider: (1) information gathered from meetings with the ACO to review and discuss its proposed budget for the forthcoming fiscal year; (2) the efficacy with which the ACO uses funds from Medicaid and commercial insurers, as applicable, to enhance and expedite the State’s health care system transformation efforts; (3) the ACO’s reasonable use of State and commercial insurance funds for its own administrative costs, as defined by the Board; (4) the ACO’s collaboration with a range of provider types, such as home- and community-based providers, dental health providers, and mental health and substance use disorder treatment providers; (5) the ACO’s use of a consumer advisory board and other mechanisms for inviting and considering consumer input; and (6) public comment on all aspects of the ACO’s costs, operations, and proposed budget. (c)(1) The Office of the Health Care Advocate shall have the right to receive copies of all materials related to any ACO certification or budget review and may: (A) ask questions of employees of the Green Mountain Care Board related to the Board’s ACO budget review; (B) submit written questions to the Board that the Board will ask of the ACO in advance of any hearing held in conjunction with the Board’s ACO review; (C) submit written comments for the Board’s consideration; and (D) ask questions and provide testimony in any hearing held in conjunction with the Board’s ACO budget review. (2) The Office of the Health Care Advocate shall not disclose further any confidential or proprietary information provided to the Office pursuant to this subsection. (d) The Board’s rules shall include requirements for submission of information and data by ACOs and their participating providers as needed to evaluate an ACO’s success. The rules may also establish standards as appropriate to promote an ACO’s ability to participate in applicable federal programs for ACOs. (e) All information required to be filed by an ACO pursuant to this section or to rules adopted pursuant to this section shall be made available to the public in accordance with 1 V.S.A. chapter 5, subchapter 3 (Public Records Act), provided that individual patients or health care providers shall not be directly or indirectly identifiable. (f) To the extent required to avoid federal antitrust violations, the Board shall supervise the participation of health care professionals, health care facilities, and other persons operating or participating in an accountable care organization. The Board shall ensure that its certification and oversight processes constitute sufficient State supervision over these entities to comply with federal antitrust provisions and shall refer to the Attorney General for appropriate action the activities of any individual or entity that the Board determines, after notice and an opportunity to be heard, may be in violation of State or federal antitrust laws without a countervailing benefit of improving patient care, improving access to health care, increasing efficiency, or reducing costs by modifying payment methods. (g) The Board shall collect the following amounts from an accountable care organization: (1) $10,000.00 for initial certification in accordance with subsection (a) of this section; (2) $2,000.00 annually following initial certification to maintain certification; and (3) $125,000.00 for each review of the accountable care organization’s budget in accordance with subsection (b) of this section. Added 2015, No. 113 (Adj. Sess.), § 5, eff. Jan. 1, 2018; amended 2017, No. 59, § 1; 2017, No. 167 (Adj. Sess.), §§ 2, 13a, eff. May 22, 2018; 2017, No. 200 (Adj. Sess.), § 15; 2017, No. 204 (Adj. Sess.), § 7; 2019, No. 14, § 54, eff. April 30, 2019; 2019, No. 52, § 2a; 2025, No. 62, § 5.

18 V.S.A. § 9383 Expenditure analysis; health care spending estimate

9383. Expenditure analysis; health care spending estimate (a) The Board shall develop annually an expenditure analysis and an estimate of future health care spending covering a period of at least two years. These analyses shall contain data and information as set forth in this section that the Board shall consider and incorporate into its work in furtherance of its statutory duties, including using them as tools in the Board’s review of health insurance rates and the budgets of hospitals and accountable care organizations. The analyses shall: (1) inform the Board’s regulatory processes in order to promote improved health outcomes, health care cost containment, quality of care, access to care, and appropriate resource allocation; and (2) quantify the total amount of money that has been and is estimated to be expended for all health care services provided by health care facilities and providers in Vermont and for health care services provided to residents of this State regardless of the site of service, to the extent data are available. (b) The expenditure analysis and the estimate of future health care spending shall include breakdowns for broad sectors such as hospital, physician, mental health, home health, and pharmacy and may include estimates for disease prevention and health promotion activities and other social determinants of health. The analyses shall include: (1) expenditures by commercial health plans, hospital and medical service corporations, and health maintenance organizations regulated by this State; and (2) expenditures for Medicare, Medicaid, self-insured employers, and other forms of health coverage, to the extent data are available. (c) Annually on or before January 15, the Board shall submit the expenditure analysis and the estimate of future health care spending to the House Committees on Appropriations, on Health Care, and on Human Services and the Senate Committees on Appropriations, on Health and Welfare, and on Finance. Added 2017, No. 167 (Adj. Sess.), § 9, eff. May 22, 2018.

18 V.S.A. § 9384 Reduction or reallocation of reimbursement rates; risks to health insurer solvency

9384. Reduction or reallocation of reimbursement rates; risks to health insurer solvency (a) As used in this section: (1) “Hospital” has the same meaning as in section 9451 of this title. (2) “Hospital network” means a system comprising two or more affiliated hospitals, and may include other health care professionals and facilities, that derives 50 percent or more of its operating revenue, at the consolidated network level, from Vermont hospitals and in which the affiliated hospitals deliver health care services in a coordinated manner using an integrated financial and governance structure. (b) If the Green Mountain Care Board determines, after consultation with the Commissioner of Financial Regulation, that a domestic health insurer faces an acute and immediate threat to its solvency because its risk-based capital level has triggered a regulatory action level event pursuant to 8 V.S.A. § 8304, the Board may order a reduction of the insurer’s reimbursement rates to one or more Vermont hospitals as set forth in subsection (c) of this section until such time as the amount of the insurer’s risk-based capital exceeds the company action level risk-based capital threshold defined in 8 V.S.A. § 8301. Notwithstanding any provision of 3 V.S.A. chapter 25 to the contrary, the Board’s activities under this section shall not be construed to be a contested case. Any person aggrieved by a final Board action, order, or determination under this section may appeal as set forth in section 9381 of this title. (c)(1) The Board shall only order a reduction in the reimbursement rates to a hospital that meets one or both of the following criteria: (A) the hospital has more than 135 days’ cash on hand and had a positive operating margin in the previous fiscal year; or (B) the hospital is a member of a hospital network that, at the consolidated network level, has more than 135 days’ cash on hand or had a positive operating margin in the previous fiscal year, or both. (2) The Board shall order a reduction in reimbursement rates to a hospital pursuant to this section only to the extent necessary to remediate the threat to the domestic health insurer’s solvency. In determining whether and to what extent to reduce a hospital’s reimbursement rates pursuant to this section, the Board shall consider the competing financial obligations of the hospital and of the domestic health insurer. (3) The Board shall provide a hospital with the opportunity to request relief from a rate reduction ordered pursuant to this section. (4) In no event shall a reduction ordered by the Board pursuant to this section result in a decrease to a hospital’s or hospital network’s projected days’ cash on hand to below 125 days. Added 2025, No. 49, § 1, eff. June 5, 2025.

Source: Vermont General Assembly (legislature.vermont.gov)URL: https://legislature.vermont.gov/statutes/chapter/18/220Fetched: 10/21/2026