Vermont § 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. September 1, 2025.)