Vermont § 9382 - Oversight of accountable care organizations [Subsection

§ 9382. Oversight of accountable care organizations [Subsection

• (a) effective until January 1, 2027; see also subsection (a) effective
  January 1, 2027, set out below] (a) In order to be eligible to receive payments from Medicaid or commercial insurance
  through any payment reform program or initiative, including an all-payer model, 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: (1) The ACO’s governance, leadership, and management structure is transparent, reasonably
  and equitably represents the ACO’s participating providers and its patients, and includes
  a consumer advisory board and other processes for inviting and considering consumer
  input. (2) The ACO has established appropriate mechanisms and care models to provide, manage,
  and coordinate high-quality health care services for its patients, including incorporating
  the Blueprint for Health, coordinating services for complex high-need patients, and
  providing access to health care providers who are not participants in the ACO. The
  ACO ensures 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. (3) The ACO has established appropriate mechanisms to receive and distribute payments
  to its participating health care providers in a fair and equitable manner. To the
  extent that the ACO has the authority and ability to establish provider reimbursement
  rates, the ACO shall minimize differentials in payment methodology and amounts among
  comparable participating providers across all practice settings, as long as doing
  so is not inconsistent with the ACO’s overall payment reform objectives. (4) The ACO has established appropriate mechanisms and criteria for accepting health care
  providers to participate in the ACO that prevent unreasonable discrimination and are
  related to the needs of the ACO and the patient population served. (5) The ACO has established mechanisms and care models to promote evidence-based health
  care, patient engagement, coordination of care, use of electronic health records,
  and other enabling technologies to promote integrated, efficient, seamless, and effective
  health care services across the continuum of care, where feasible. (6) The ACO’s participating providers have the capacity for meaningful participation in
  health information exchanges. (7) The ACO has performance standards and measures to evaluate the quality and utilization
  of care delivered by its participating health care providers. (8) 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. (9) The ACO’s participating health care providers engage their patients in shared decision
  making to inform them of their treatment options and the related risks and benefits
  of each. (10) The ACO offers assistance to health care consumers, including: (A) maintaining a consumer telephone line for complaints and grievances from attributed
  patients; (B) 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; (C) providing an accessible mechanism for explaining how ACOs work; (D) providing contact information for the Office of the Health Care Advocate; and (E) sharing deidentified complaint and grievance information with the Office of the Health
  Care Advocate at least twice annually. (11) The ACO collaborates with providers not included in its financial model, including
  home- and community-based providers and dental health providers. (12) The ACO does not interfere with patients’ choice of their own health care providers
  under their health plan, regardless of whether a provider is participating in the
  ACO; does not reduce covered services; and does not increase patient cost sharing. (13) The meetings of the ACO’s governing body comply with the provisions of section 9572 of this title. (14) The impact of the ACO’s establishment and operation does not diminish access to any
  health care or community-based service or increase delays in access to care for the
  population and area it serves. (15) The ACO has in place appropriate mechanisms to conduct ongoing assessments of its
  legal and financial vulnerabilities. (16) The ACO has in place a financial guarantee sufficient to cover its potential losses. (17) The ACO provides connections and incentives to existing community services for preventing
  and addressing the impact of childhood adversity. The ACO collaborates on the development
  of quality-outcome measurements for use by primary care providers who work with children
  and families and fosters collaboration among care coordinators, community service
  providers, and families. [Subsection (a) effective January 1, 2027; see also subsection (a) effective until
  January 1, 2027, set out above.] (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. [Subsections (b)–(e) effective until January 1, 2026; see also subsections (b)–(g)
  effective January 1, 2026, set out below.] (b)(1) The Green Mountain Care Board shall adopt rules pursuant to 3 V.S.A. chapter 25 to establish standards and processes for reviewing, modifying, and approving the
  budgets of ACOs with 10,000 or more 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: (A) information regarding utilization of the health care services delivered by health
  care providers participating in the ACO and the effects of care models on appropriate
  utilization, including the provision of innovative services; (B) the Health Resource Allocation Plan identifying Vermont’s critical health needs, goods,
  services, and resources as identified pursuant to section 9405 of this title; (C) the expenditure analysis for the previous year and the proposed expenditure analysis
  for the year under review by payer; (D) the character, competence, fiscal responsibility, and soundness of the ACO and its
  principals; (E) any reports from professional review organizations; (F) the ACO’s efforts to prevent duplication of high-quality services being provided efficiently
  and effectively by existing community-based providers in the same geographic area,
  as well as its integration of efforts with the Blueprint for Health and its regional
  care collaboratives; (G) the extent to which the ACO provides incentives for systemic health care investments
  to strengthen primary care, including strategies for recruiting additional primary
  care providers, providing resources to expand capacity in existing primary care practices,
  and reducing the administrative burden of reporting requirements for providers while
  balancing the need to have sufficient measures to evaluate adequately the quality
  of and access to care; (H) the extent to which the ACO provides incentives for systemic integration of community-based
  providers in its care model or investments to expand capacity in existing community-based
  providers, in order to promote seamless coordination of care across the care continuum; (I) the extent to which the ACO provides incentives for systemic health care investments
  in social determinants of health, such as developing support capacities that prevent
  hospital admissions and readmissions, reduce length of hospital stays, improve population
  health outcomes, reward healthy lifestyle choices, and improve the solvency of and
  address the financial risk to community-based providers that are participating providers
  of an accountable care organization; (J) the extent to which the ACO provides incentives for preventing and addressing the
  impacts of adverse childhood experiences (ACEs) and other traumas, such as developing
  quality outcome measures for use by primary care providers working with children and
  families, developing partnerships between nurses and families, providing opportunities
  for home visits, and including parent-child centers and designated agencies as participating
  providers in the ACO; (K) public comment on all aspects of the ACO’s costs and use and on the ACO’s proposed
  budget; (L) information gathered from meetings with the ACO to review and discuss its proposed
  budget for the forthcoming fiscal year; (M) information on the ACO’s administrative costs, as defined by the Board; (N) the effect, if any, of Medicaid reimbursement rates on the rates for other payers; (O) the extent to which the ACO makes its costs transparent and easy to understand so
  that patients are aware of the costs of the health care services they receive; and (P) the extent to which the ACO provides resources to primary care practices to ensure
  that care coordination and community services, such as mental health and substance
  use disorder counseling that are provided by community health teams, are available
  to patients without imposing unreasonable burdens on primary care providers or on
  ACO member organizations. (2) The Green Mountain Care Board shall adopt rules pursuant to 3 V.S.A. chapter 25 to establish standards and processes for reviewing, modifying, and approving the
  budgets of ACOs with fewer than 10,000 attributed lives in Vermont. In its review,
  the Board may consider as many of the factors described in subdivision (1) of this
  subsection as the Board deems appropriate to a specific ACO’s size and scope. (3)(A) The Office of the Health Care Advocate shall have the right to receive copies of all
  materials related to any ACO budget review and may: (i) ask questions of employees of the Green Mountain Care Board related to the Board’s
  ACO budget review; (ii) 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; (iii) submit written comments for the Board’s consideration; and (iv) ask questions and provide testimony in any hearing held in conjunction with the Board’s
  ACO budget review. (B) The Office of the Health Care Advocate shall not disclose further any confidential
  or proprietary information provided to the Office pursuant to this subdivision (3). (c) 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.
  They may also establish standards as appropriate to promote an ACO’s ability to participate
  in applicable federal programs for ACOs. (d) 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 upon request,
  provided that individual patients or health care providers shall not be directly or
  indirectly identifiable. (e) 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. [Subsections (b)–(g) effective January 1, 2026; see also subsections (b)–(e) effective
  until January 1, 2026, set out above.] (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.)