Source: http://www.leg.state.vt.us/docs/legdoc.cfm?URL=/docs/2008/acts/ACT203.htm
Timestamp: 2017-10-16 22:10:52
Document Index: 45136885

Matched Legal Cases: ['§ 4080', '§ 4080', '§ 1983', '§ 4080', '§ 1973', '§ 4080', '§ 1974', '§ 4080', '§ 1982', '§ 4080', '§ 4080', '§ 104', '§ 104', '§ 11', '§ 11', '§ 133', '§ 903', '§ 9418', '§ 9418', '§ 9418', '§ 9418', '§ 9418', '§ 9418', '§ 9408']

NO. 203. AN ACT RELATING TO HEALTH CARE REFORM.
* * * Findings and Intent * * *
(a) The general assembly hereby finds that:
(1) Health care costs continue to rise at two to three times the rate of inflation, from approximately $3,000.00 per person per year in Vermont in 1997 to $3,800.00 in 2000 and $6,300.00 in 2006. These increases cause hardships to individuals, families, businesses, taxpayers, and public institutions and make the need for comprehensive health care reform urgent.
(2) The Health Care Affordability for Vermonters Act of 2006 has started significant new initiatives to transform the health care system by improving access, controlling costs, and changing the way we pay for and deliver health care. These system changes will take many years and are dependent upon continued funding and implementation. To date, these efforts have provided coverage to thousands of Vermonters, instituting changes in the care of chronic conditions, and enabling greater use of health information technology.
(3) There continues to be a large number of Vermonters who have no health insurance or are underinsured. For this population, health care is unaffordable and, as a result, often not received in the most timely and effective manner.
(4) The rising prevalence of chronic illnesses and the new medical approaches to treat them account for nearly two-thirds of the increase in health care spending. Health care reform must address the cost drivers that underlie this rise in spending. First, more effective use of preventive care and chronic care management is needed to prevent or slow the progression of chronic diseases and reduce disease complications, which is the focus of the Blueprint for Health. Second, reform needs to include a sustained public health approach to decrease the likelihood of individuals developing a chronic illness in the first place. Reducing major health risks such as poor diet, lack of physical activity, tobacco use, and alcohol and drug abuse will stem the rising incidence of chronic diseases linked to these factors over the long term. In addition, Vermonters with a chronic mental illness are at a substantially greater risk for other illnesses and conditions than those without a chronic mental illness. Identifying the mental health needs of Vermonters and integrating health care are an important response to a high risk factor for other illnesses and conditions and will pay dividends in the form of healthier citizens and reductions in costs to the health care system.
(5) Although the quality of health care services in Vermont is generally very good, there is a need to improve quality, efficiency, and safety. Improvements in health care quality will result in improved health and reduced costs. A new payment system that relates reimbursement to improved health would encourage better care and greater efficiency than the existing fee-for-service system. And the implementation and effective use of health information technology will significantly improve patient safety by reducing medical errors and improving the reliability of patient care processes.
(6) Federal laws and programs, such as Medicaid, Medicare, and the Employee Retirement Income Security Act of 1974 (ERISA), constrain Vermont’s ability to establish immediately an integrated health care system. In addition, the current federal administration’s unwillingness to allow states to implement innovative approaches to health care reform has hampered Vermont’s ability to make extensive improvements to its own system.
(b) It is the intent of the general assembly that all Vermonters receive affordable and appropriate health care at the appropriate time, and that health care costs be contained over time. Building on the reforms enacted in the Health Care Affordability for Vermonters Act of 2006, the general assembly finds that effective next steps to achieving these goals include expanding affordable coverage, reducing the rate of the increase of medical costs, reforming the financing of health care, and supporting health information technology.
* * * Building Blocks for Health Care Reform * * *
Sec. 2. OVERVIEW
(a) The commission on health care reform is charged with making recommendations to meet the goal of section 902 of Title 2 that “by 2009, Vermont has an integrated system of care that provides all Vermonters access to affordable, high quality health care that is financed in a fair and equitable manner.” Achieving this will require a series of fundamental changes which cumulatively will build a more integrated system with aligned financial incentives. The commission on health care reform should conduct studies to develop key building blocks for moving toward such a system in Vermont, to the extent that funds and staffing resources are available, including:
(1) The feasibility of community-based payment reform and integration of care. This study should assess the feasibility of alternative designs for a pilot project to test using a system-wide budgeting initiative at the regional level within the state, including a design based on the accountable care organization model;
(2) The possible merger of fragmented risk pools. The continued fragmentation of risk pools and structural issues with the individual and small group markets present major obstacles to achieving universal coverage and stable premium rates. This study should propose a preliminary design for the merger by calendar year 2011 of the nongroup (including Catamount Health), small group, and association markets; and
(3) Various health care financing options. This study will expand upon the completed financing analysis called for in Sec. 277d of No. 215 of the Acts of the 2005 Adj. Sess. (2006) to create a common analytic basis for policy decisions on the public financing of health care, explore broad-based revenue sources, identify and assess major federal issues with public financing, and analyze the impact of different financing options on the underlying cost drivers in health care.
(b) One of the objectives of these studies is to position Vermont as first in line for federal health care reform. Health care reform will be a major priority of the next federal administration, and the federal government is likely to be much more supportive of health care reform efforts at the state level. Vermont is uniquely situated to be a statewide laboratory for health care reform and needs to be positioned to receive early approval for increased flexibility in areas traditionally constraining reform, such as Medicare demonstrations and waivers and electronic health record demonstrations. The commission on health care reform’s evaluation should explicitly identify federal and other barriers to the critical steps in health care reform and determine how best to position Vermont at the forefront of progress in health care reform.
* * * Expanding Affordable Coverage * * *
Sec. 3. 8 V.S.A. § 4080a(h)(2)(B) is amended to read:
(B) The commissioner’s rules shall permit a carrier, including a hospital or medical service corporation and a health maintenance organization, to establish rewards, premium discounts, split benefit designs, rebates, or otherwise waive or modify applicable co-payments, deductibles, or other cost‑sharing amounts in return for adherence by a member or subscriber to programs of health promotion and disease prevention. The commissioner shall consult with the commissioner of health, the director of the Blueprint for Health, and the director of the office of Vermont health access in the development of health promotion and disease prevention rules that are consistent with the Blueprint for Health. Such rules shall:
(iii) provide that the reward under the program is available to all similarly situated individuals and shall comply with the nondiscrimination provisions of the federal Health Insurance Portability and Accountability Act of 1996; and
Sec. 4. EXPEDITED RULEMAKING
(a) No later than January 1, 2009 and notwithstanding the provisions of chapter 25 of Title 3, the department of banking, insurance, securities, and health care administration shall adopt rules to implement the healthy lifestyle insurance discount and split benefit design established in subsection 4080a(h) of Title 8.
(b) “Split benefit design” shall mean a health insurance plan with two or more benefit levels in which the premium for all levels is the same but the benefits differ in the amount of the co-payments, coinsurance, deductibles, out‑of‑pocket maximums, or a combination of these options. The rules for the split benefit design shall include provisions that promote good health; identify, manage, and prevent disease; and encourage healthier lifestyles without penalizing individuals due to disability, poor health, or socioeconomic status. Premium rates shall target a 10 percent reduction in rates below the premium of a comparable product in the relevant market. The difference between the actuarial value of the benefits in the benefit levels shall not exceed 20 percent, and insurers shall not be permitted to impose additional rate deviations.
(c) The department shall adopt the rules pursuant to the following expedited rulemaking process:
(2) The legislative committee on administrative rules shall review and may approve or may object to the final proposed rules under section 842 of Title 3, except that its action shall be completed by the committee no later than 14 days after the final proposed rules are filed with the committee.
(C) if the department has received a notice of objection from the legislative committee on administrative rules, after having responded to the objection from the committee pursuant to section 842 of Title 3.
(4) Rules adopted under this section shall be effective upon being filed with the secretary of state and shall have the full force and effect of rules adopted pursuant to chapter 25 of Title 3. Rules filed by the department with the secretary of state pursuant to this section shall be deemed to be in full compliance with section 843 of Title 3 and shall be accepted by the secretary of state if filed with a certification by the commissioner of banking, insurance, securities, and health care administration that the rule is required to meet the purposes of this section.
Sec. 5. EXPANDING ACCESS TO CATAMOUNT HEALTH
(a) No later than February 1, 2009, the secretary of human services shall apply to the federal Centers for Medicare and Medicaid Services for a waiver amendment to allow Vermont to shorten the waiting period for coverage under Catamount Health and the Vermont health access plan to six months from the current 12 months. Within 60 days following approval of the waiver, the secretary of administration shall submit to the commission on health care reform created pursuant to section 901 of Title 2 a recommendation on whether to proceed with reducing the waiting period. Upon receipt of the secretary’s recommendation, the commission on health care reform shall consider:
(1) the availability of resources;
(2) issues surrounding implementation; and
(3) potential benefits to the health care system.
(b) The commission on health care reform shall make a recommendation to the senate committees on health and welfare and on appropriations and the house committees on health care and on appropriations on whether to proceed with or delay implementation of the reduction in the waiting period. The committees shall present their recommendations to the general assembly, which shall make a determination whether to proceed with implementation of the reduced waiting period.
Sec. 6. 8 V.S.A. § 4080f(a)(9) is amended to read:
(9) “Uninsured” means an individual who does not qualify for Medicare, Medicaid, the Vermont health access plan, or Dr. Dynasaur, and: who had no private insurance or employer-sponsored coverage that includes both hospital and physician services within 12 months prior to the month of application,; who has had a nongroup health insurance plan with an annual deductible of no less than $10,000.00 for an individual or an annual deductible of no less than $20,000.00 for two‑person or family coverage for at least six months; or who lost private insurance or employer-sponsored coverage during the prior 12 months for the following reasons:
(i) loss of employment, including a reduction in hours that results in ineligibility for employer-sponsored coverage, unless the employer has terminated its employees or reduced their hours for the primary purpose of discontinuing employer-sponsored coverage and establishing their eligibility for Catamount Health;
(iv) no longer qualifying receiving coverage as a dependent under the plan of a parent or caretaker relative; or
(v) no longer receiving COBRA, VIPER, or other state continuation coverage; or
(B) college- or university-sponsored health insurance became unavailable to the individual because the individual graduated, took a leave of absence, decreased enrollment below a threshold set for continued coverage, or otherwise terminated studies.
Sec. 7. 33 V.S.A. § 1983 is amended to read:
(a)(1) Except as provided in subdivisions (3), and (4), and (5) of this subsection, an individual shall be eligible for Catamount Health assistance if the individual is an uninsured Vermont resident without access to an approved employer-sponsored insurance plan under section 1974 of this title.
(5) Notwithstanding any other provision of law, when an individual is enrolled in Catamount Health solely under the high deductible standard outlined in 8 V.S.A. § 4080f(a)(9), the individual shall not be eligible for premium assistance for the 12-month period following the date of enrollment in Catamount Health.
Sec. 8. 33 V.S.A. § 1973(e) is amended to read:
(1) an individual with household income, after allowable deductions, at or below 75 percent of the federal poverty guideline for households of the same size;
(2) an individual who had no private insurance or employer-sponsored coverage that includes both hospital and physician services within 12 months prior to the month of application; or
(3) an individual who lost private insurance or employer-sponsored coverage during the prior 12 months for the following reasons:
(A) the individual’s coverage ended because of:
(i) loss of employment, including a reduction in hours that results in ineligibility for employer-sponsored coverage, unless the employer has terminated its employees or reduced their coverage for the primary purpose of discontinuing employer-sponsored coverage and establishing their eligibility for Catamount Health;
(4) Notwithstanding any other provision of law, when an individual is enrolled in Catamount Health solely under the high deductible standard outlined in 8 V.S.A. § 4080f(a)(9), the individual shall not be eligible for the Vermont health access plan for the 12-month period following the date of enrollment in Catamount Health.
Sec. 9. 33 V.S.A. § 1974 is amended to read:
(6) Notwithstanding any other provision of law, when an individual is enrolled in Catamount Health solely under the high deductible standard outlined in 8 V.S.A. § 4080f(a)(9), the individual shall not be eligible for premium assistance for the 12-month period following the date of enrollment in Catamount Health.
(B) “Uninsured” means an individual who does not qualify for Medicare, Medicaid, the Vermont health access plan, or Dr. Dynasaur, and had no private insurance or employer-sponsored coverage that includes both hospital and physician services within 12 months prior to the month of application, or lost private insurance or employer-sponsored coverage during the prior 12 months for the following reasons:
(i) the individual’s private insurance or employer-sponsored coverage ended because of:
(ii) college- or university-sponsored health insurance became unavailable to the individual because the individual graduated, took a leave of absence, decreased enrollment below a threshold set for continued coverage, or otherwise terminated studies.
(3) The premium assistance program under this subsection shall provide a subsidy of premiums or cost-sharing amounts based on the household income of the eligible individual, with greater amounts of financial assistance provided to eligible individuals with lower household income and lesser amounts of assistance provided to eligible individuals with higher household income. Until an approved employer-sponsored plan is required to meet the standard in subdivision (4)(B)(ii) of this subsection, the subsidy shall include premium assistance and assistance to cover cost-sharing amounts for chronic care health services covered by the Vermont health access plan that are related to evidence-based guidelines for ongoing prevention and clinical management of the chronic condition specified in the blueprint for health in section 702 of Title 18. Notwithstanding any other provision of law, when an individual is enrolled in Catamount Health solely under the high deductible standard outlined in section 4080f(a)(9) of Title 8, the individual shall not be eligible for premium assistance for the 12-month period following the date of enrollment in Catamount Health.
Sec. 10. 33 V.S.A. § 1982(2) is amended to read:
(2) “Uninsured” means an individual who does not qualify for Medicare, Medicaid, the Vermont health access plan, or Dr. Dynasaur, and had no private insurance or employer‑sponsored coverage that includes both hospital and physician services within 12 months prior to the month of application or lost private insurance or employer‑sponsored coverage during the prior 12 months for the following reasons:
(i) loss of employment, including a reduction in hours that results in ineligibility for employer-sponsored coverage, unless the employer has terminated its employees or reduced their hours for the primary purpose of discontinuing employer‑sponsored coverage and establishing their eligibility for Catamount Health;
* * * Preexisting Conditions under Catamount Health * * *
Sec. 11. 8 V.S.A. § 4080f(e) is amended to read:
(e)(1) For a 12‑month period from the effective date of coverage earliest date of application, a carrier offering Catamount Health may limit coverage of preexisting conditions which existed during the 12‑month period before the effective date of coverage earliest date of application, except that such exclusion or limitation shall not apply to chronic care if the individual is participating in a chronic care management program, nor apply to pregnancy. A carrier shall waive any preexisting condition provisions for all individuals and their dependents who produce evidence of continuous creditable coverage during the previous nine months. If an individual has a preexisting condition excluded under a subsequent policy, such exclusion shall not continue longer than the period required under the original contract or 12 months, whichever is less. The carrier shall credit prior coverage that occurred without a break in coverage of 63 days or more. A break in coverage shall be tolled after the earliest date of application, subject to reasonable time limits, as defined by the commissioner, for the individual to complete the application process. For an eligible individual, as such term is defined in Section 2741 of Title XXVII of the Public Health Service Act the Health Insurance Portability and Accountability Act of 1996, a carrier offering Catamount Health shall not limit coverage of preexisting conditions.
(2) Notwithstanding subdivision (1) of this subsection, a carrier offering Catamount Health shall not limit coverage of preexisting conditions for subscribers who apply before November 1, 2008. This subdivision (2) shall not apply to claims incurred prior to the effective date of this section.
* * * 75 Percent Rule * * *
Sec. 12. 8 V.S.A. § 4080a(l) is amended to read:
(l)(1) A registered small group carrier which is not a nonprofit health maintenance organization shall may require that at least 75 percent or less of the employees or members of a small group with more than 10 employees participate in the carrier’s plan, provided that if a nonprofit health maintenance organization provides a small group plan to more than 25 percent of the employees or members of the small group, a registered small group carrier may offer or continue to provide its small group plan to the remaining employees or members. A registered small group carrier may require that 50 percent or less of the employees or members of a small group with 10 or fewer employees or members participate in the carrier’s plan. A small group carrier’s rules established pursuant to this subsection shall be applied to all small groups participating in the carrier’s plans in a consistent and nondiscriminatory manner.
(2) For purposes of this requirement the requirements set forth in subdivision (1) of this subsection (l), the a registered small group carrier shall not include in its calculation an employee or member who is already covered by another group health benefit plan as a spouse or dependent or who is enrolled in Catamount Health, Medicaid, the Vermont health access plan, or Medicare. Employees or members of a small group who are enrolled in the employer’s plan and receiving premium assistance under chapter 19 of Title 33 shall be considered to be participating in the plan for purposes of this section. If the small group is an association, trust, or other substantially similar group, this the participation requirement requirements shall be calculated on an employer-by-employer basis.
(3) A small group carrier may not require recertification of compliance with the participation requirements set forth in this section more often than annually at the time of renewal. If, during the recertification process, a small group is found not to be in compliance with the participation requirements, the small group shall have 120 days to become compliant prior to termination of the plan.
* * * Preventing Chronic Conditions Through Healthy Lifestyles * * *
Sec. 13. COMMUNITY PLANS
The commissioner of health, through the 12 district health offices, shall work with communities in each region to develop comprehensive plans that identify and prioritize community needs relating to wellness and healthy living. The 12 district health offices shall involve schools, worksites, and other stakeholders interested in improving community health and shall consult existing sources of community‑level population health data. In drafting the plans, the commissioner shall work with community stakeholders to develop an inventory of policy and environmental supports related to wellness and healthy living. Such plans shall be made available to the public.
Sec. 14. 18 V.S.A. § 104b is amended to read:
§ 104b. COMMUNITY HEALTH AND WELLNESS GRANTS
(a) The commissioner shall establish a program for awarding competitive, substantial, multi-year grants to comprehensive community health and wellness projects. Successful projects must:
(4) use strategies that have been demonstrated to be effective in reaching the desired outcome; and
(5) provide data for evaluating and monitoring progress;
(6) include a plan for ensuring that all food vending machines located in public buildings within the control of the grant recipient contain foods and portion sizes consistent with the Vermont nutrition and fitness policy guidelines or other relevant science-based resources; and
(7) address socioeconomic or other barriers that stand in the way of fit and healthy lifestyles in their communities.
(b) The commissioner, through the 12 district health offices, shall assist communities by:
(1) providing technical assistance to support communities in following a consistent and coordinated approach to planning and implementation, including practices such as needs assessment, defined priorities, action plans, and evaluation;
(2) providing access to best and promising practices and approved public policies;
(3) providing assistance to help communities develop public awareness materials and communication tools with well-researched and well-coordinated messaging;
(3)(4) helping projects communities obtain and maximize funding from all applicable sources; and
(4)(5) providing other assistance as appropriate.
(e) By January 15 1 of each year, the commissioner shall report on the status of the program to the general assembly, the senate committee on health and welfare, and the house committees on human services and on health care by including a section on prevention grants in the annual report of the Blueprint for Health.
Sec. 15. INVENTORY OF COORDINATED SCHOOL HEALTH
The commissioner of health, in collaboration with the commissioner of education and the secretaries of agriculture, food and markets and of transportation, shall compile an inventory of all programs both inside and outside the agencies and departments that award grants or similar funding and that provide technical assistance to supervisory unions and school districts to address issues such as nutrition and physical activity (both indoor and outdoor) for students and staff, obesity, tobacco use, and substance abuse. The inventory shall include for each program a description of the program purposes, priorities, and any restrictions on the use of funds or technical assistance. The inventory shall be accompanied by recommendations on how state agencies and other state funding sources may improve coordination of grant awards and technical assistance for school health initiatives and how to work with school districts with a more comprehensive and coordinated approach to planning and implementation, including practices such as needs assessment, defined priorities, action plans, and evaluations and the involvement of school health teams and school health coordinators in community planning efforts. The recommendations shall also propose a coordinated process for awarding grants to support school health, such as coordination or integration with the community grants process in section 104b of Title 18. The inventory and recommendations must be submitted to the senate committees on health and welfare and on education, the house committees on health care, on human services, and on education, and made available on the Internet for review by town offices and school districts, no later than January 15, 2009.
Sec. 16. NUTRITION GUIDELINES FOR COMPETITIVE FOOD AND
BEVERAGE SALES IN SCHOOLS
(a) The commissioner of education shall collaborate with the commissioner of health and the secretary of agriculture, food and markets to update the current Vermont nutrition policy guidelines applicable to competitive foods and beverages sold outside the federally reimbursable school nutrition programs. The revised guidelines shall rely on science-based nutrition standards recommended by the alliance for a healthier generation, the institute of medicine, and other relevant science-based resources and shall be available to school districts before the 2008–2009 school year.
(b) By January 15, 2009, the commissioners of education and of health shall report to the house committees on agriculture, on education, on health care, and on human services, and the senate committees on health and welfare and on education regarding the number of school districts that have and have not adopted a nutrition policy that is substantially the same as the Vermont nutrition policy guidelines applicable to competitive foods and beverages as revised in accordance with subsection (a) of this section. The report shall include specific information about how policies adopted by the school boards may differ from the Vermont nutrition policy guidelines and include recommendations on how to ensure that all Vermont school districts will meet the state school nutrition guidelines by July 1, 2011.
Sec. 17. HEALTHY COMMUNITY DESIGN AND ACCESS TO
(a) The commissioner of health, in consultation with the secretaries of agriculture, foods and markets and of transportation, the commissioners of the departments of education, of housing and community affairs, and of forests, parks and recreation, and the regional planning association, shall make recommendations on how to strengthen strategies for environmental and policy change to increase healthy choices in Vermont communities and how to enhance coordination among existing programs and funding. In addition, the commissioner, through the 12 district health offices, shall work with communities to support efforts in planning, implementation, and obtaining funding from applicable sources. Recommended environmental and policy change strategies shall include ways to:
(1) Promote and support opportunities for physical activity at the community level through increasing access to walking and bicycle paths, bicycle lanes, safe routes to schools, indoor and outdoor recreational facilities, and parks and other recreational areas;
(2) Increase access to healthy foods in Vermont communities, including local foods, through strategies such as food pricing and economic approaches, food and beverage marketing and promotion, improving access to affordable healthy foods in low income communities, and other promising food‑related policy and environmental strategies; and
(3) Promote the goals of physical activity, nutrition, and healthy living in planning processes that involve zoning and land use, growth centers, and downtown revitalization.
(b) The commissioner shall make recommendations in a consolidated report on healthy living initiatives to the senate committee on health and welfare and the house committees on health care and on human services on priorities and recommendations no later than January 15, 2009.
Sec. 18. HEALTHY WORKSITES
(a)(1) The commissioner of health shall convene a work group to identify priorities and develop recommendations to enhance collaborative learning and interactive sharing of best practices in worksite wellness and employee health management, through approaches such as statewide or regional worksite wellness conferences, web‑enhanced resources and seminars, and the worksite recognition awards of the governor’s council on physical fitness and sports.
(2) The work group should examine best practices in Vermont and other states that include:
(A) Use of premium discounts, reduced cost sharing, or other financial incentives to encourage employee participation in wellness and health promotion activities;
(B) Strategies to spread the adoption of workplace policies and practices that support breastfeeding for mothers;
(C) Strategies to reach out to small employers and their employees who lack access to worksite wellness programs, such as the use of the VT 2‑1‑1 information and referral service as an information resource for healthy diet and physical activity, and the use of hospital‑based programs offering classes and one-to-one counseling similar to hospital-based tobacco use prevention programs; and
(D) Use of financial incentives (such as small grants or tax credits) for small employers to establish worksite wellness programs, and the feasibility of group‑purchasing arrangements to help small employers gain access to worksite wellness products at a lower cost.
Sec. 19. PROMOTING HEALTHY WEIGHT THROUGH PRIMARY CARE
(a) The commissioner of health shall coordinate with the Blueprint for Health director on practice‑based pilot projects to promote effectiveness in implementing evidence-based recommendations for the promotion of healthy weight and for the assessment, prevention, and treatment of obesity in primary care settings, in consultation with the Vermont child health improvement program and the area health education centers program. The pilot projects shall focus on best practices in implementation by working with members of the medical practice to design, test, and evaluate strategies for changing office systems to better support efforts to promote healthy weight and prevent obesity in children and adults.
(b)(1) The commissioner shall convene a work group comprising the three major insurance carriers in Vermont, the office of Vermont health access, self‑insured employers, school health personnel and students, and health care providers to review recommended best practices in primary care settings for the promotion of healthy weight and for the assessment, prevention, and treatment of child and adolescent eating disorders, overweight, and obesity and to recommend changes in coverage and payment policies as needed to support best practices that have a high health impact and cost-effectiveness. As part of its review, the work group should:
(A) Review models of successful obesity prevention and care strategies developed by insurance carriers and primary care practices in Vermont and other states;
(B) Identify the respective roles of health practitioners shown to be most effective and cost-effective in the promotion of healthy weight and the assessment, prevention, and treatment of obesity, including physicians, dieticians, nonmedical counselors, self‑management groups, weight management programs, physical activity counselors, and others;
(C) Review models for standard third party payment of breastfeeding education and support services;
(D) Develop a plan for promoting measurement and tracking of the body mass index (BMI) percentile for children and adolescents, such as through the collection of data relating to BMI, lack of physical exercise, and inappropriate diet and eating habits using the ICD‑9‑DM V‑codes in the ninth edition of International Classification of Disease Codes;
(E) Include in the tracking plan guidelines for how such information will be coordinated and shared in order to maintain reasonable expectations of privacy; and
(F) Identify ways that payment policies might encourage stronger relationships among primary care practices, public health supports (such as WIC clinics for children under the age of six years), and school health personnel.
(2) The commissioner shall make recommendations in a consolidated report on healthy living initiatives to the senate committee on health and welfare and the house committees on health care and on human services on priorities and recommendations no later than January 15, 2009.
Sec. 20. 18 V.S.A. § 11 is amended to read:
§ 11. CARDIOVASCULAR HEALTH: COALITION FOR HEALTHY
ACTIVITY, MOTIVATION, AND PREVENTION PROGRAMS
(CHAMPPS)/FIT AND HEALTHY Advisory Council
(6) Convene a CHAMPPS/fit and healthy advisory council chaired by the commissioner of health or designee and composed of state agencies and private sector partners which shall advise the commissioner on developing, implementing, and coordinating initiatives to increase physical activity and improve nutrition and reduce overweight and obesity.
(A) The functions and duties of the council shall include:
(i) Recommending ways that the department of health and other state agencies can reach out to communities, schools, worksites, and municipal and regional planners to assist them in creating environments and policies conducive to healthy living for all Vermonters; and
(ii) Assessing available resources and funding streams, recommending how best to coordinate those initiatives and resources across state agencies and private sector organizations for the greatest impact, and recommending new initiatives and priorities utilizing data and best-practice guidelines.
(B) The department of health shall review the fit and healthy Vermonters prevention plan and the status of its major initiatives with the advisory council at least every three years. The advisory council shall advise and make recommendations to the department of health as the department develops an annual work plan setting forth prioritized strategies to implement a three-year prevention plan.
Sec. 21. FOODS CONTAINING ARTIFICIAL TRANS FAT AND MENU
The Vermont department of health, in collaboration with the Vermont hospitality council, the American Heart Association, and representatives of the food service industry in Vermont, shall develop proposed labeling that will inform consumers of healthy nutrition choices in food service facilities, including the presence of trans fats. The department of health shall also recommend methods for making Vermont free of artificial trans fats in prepared foods by 2011. The department of health shall make recommendations in a consolidated report on healthy living initiatives to the senate committee on health and welfare and the house committees on health care and on human services no later than January 15, 2009.
Sec. 22. 16 V.S.A. § 133(c) is added to read:
(c) Vermont school districts may include a module within the secondary school health class curricula relating to cervical cancer and the human papillomavirus. The department of education shall work with relevant medical authorities to update the current model module to reflect up-to-date information and practices for health education in this area.
Sec. 23. Vermont Academic Detailing Program
(a) The University of Vermont (UVM) College of Medicine office of primary care and the Vermont area health education centers (AHEC) shall operate the Vermont academic detailing program, a university-based educational outreach for health care professionals. The goal of the Vermont academic detailing program is to promote high-quality, evidence-based, patient-centered, cost-effective medication treatment decisions. This program shall present an objective overview of what evidence from studies shows about various drugs used to treat a medical condition.
(b) The UVM office of primary care and AHEC may collaborate with other states that are working on similar programs.
(c) The UVM office of primary care may request information and collaboration from prescribers, pharmacists, private insurers, hospitals, pharmacy benefit managers, drug utilization review boards, state agencies, and other programs in order to best utilize resources, prevent redundancies of effort, and facilitate appropriate linkages to complementary programs, such as the Vermont Blueprint for Health.
(d) The Vermont Department of Health and the office of Vermont health access shall collaborate with the UVM office of primary care and AHEC Vermont academic detailing program to notify prescribers about commonly used brand‑name drugs for which the patent has expired within the past 12 months or will expire in the coming 12 months and, to the extent permitted by funding, the program may include the distribution of vouchers for samples of generic medicines.
(e) The sum of $100,000.00 is appropriated from the general fund to the UVM College of Medicine in fiscal year 2009 to support the Vermont academic detailing program, provided that such appropriation shall expire upon collection of the first dollar of the manufacturer fee established in section 2004 of Title 33 and all funds remaining from this appropriation shall be redeposited in the general fund.
* * * Supporting Health Information Technology * * *
Sec. 24. 22 V.S.A. § 903 is amended to read:
(c)(1) The commissioner shall contract enter into a grant agreement with the Vermont information technology leaders (VITL), a broad‑based health information technology advisory group that includes providers, payers, employers, patients, health care purchasers, information technology vendors, and other business leaders, to develop the health information technology plan, including applicable standards, protocols, and pilot programs. In carrying out their responsibilities under this section, members of VITL shall be subject to conflict of interest policies established by the commissioner to ensure that deliberations and decisions are fair and equitable.
(g) On or before January 1, 2007, VITL shall submit to the commission on health care reform, the secretary of administration, the commissioner of information and innovation, the commissioner of banking, insurance, securities, and health care administration, the director of the office of Vermont health access, the senate committee on health and welfare, and the house committee on health care a preliminary health information technology plan for establishing a statewide, integrated electronic health information infrastructure in Vermont, including specific steps for achieving the goals and objectives of this section. A final plan shall be submitted July 1, 2007. The plan shall include also recommendations for self-sustainable funding for the ongoing development, maintenance, and replacement of the health information technology system. Upon recommendation by the commissioner of information and innovation and approval by the general assembly, the plan shall serve as the framework within which certificate of need applications for information technology are reviewed under section 9440b of Title 18 by the commissioner. VITL shall update the plan annually to reflect emerging technologies, the state’s changing needs, and such other areas as VITL deems appropriate and shall submit the updated plan to the commissioner. Upon approval by the commissioner, VITL shall distribute the updated plan to the commission on health care reform; the secretary of administration; the commissioner of banking, insurance, securities, and health care administration; the director of the office of Vermont health access; the senate committee on health and welfare; the house committee on health care; affected parties; and interested stakeholders.
Sec. 25. E‑PRESCRIBING STUDY
(a) The director of the commission on health care reform and the VITL project review committee shall conduct a planning and feasibility study to determine the impact of implementing a statewide e‑prescriber program.
(b) The study shall address:
(1) a consideration of the best methods of access to e‑prescribing, including the use of freestanding handheld devices, web-based options, and e‑prescribing modules integrated with electronic medical records;
(2) identification of an appropriate business model, including incentives to encourage provider participation;
(3) an inventory of current e-prescribing activities and existing capacity for e-prescribing in this state;
(4) a cost-benefit analysis of creating a statewide e-prescriber program;
(5) the ability of an e-prescriber program to ensure the privacy and security of prescription data, including controls over data-mining;
(6) state and national studies and reports on data-mining in e-prescribing and the appropriate use of e-prescription information;
(7) the use of practice management systems and electronic claims data sources through the Vermont health information exchange;
(8) existing state and national initiatives such as the National
e-Prescribing Patient Safety Initiative and Massachusetts’s Partners Health Care; and
(9) an assessment of the readiness of pharmacies to participate in e‑prescribing and the impact on independent pharmacies.
(c) No later than January 15, 2009, the director of the commission on health care reform shall report on the findings of the study to the commission on health care reform, the house committee on health care, and the senate committee on health and welfare.
* * * Investing in Vermont’s Health Care System and Workforce * * *
Sec. 26. HEALTH IMPROVEMENT APPROPRIATIONS
(a) The amount of $100,000.00 is appropriated from the general fund to the Vermont department of health for the child psychiatry division in the Vermont Center for Children, Youth, and Families (VCCYF) to support child
tele-psychiatry pilots in community health centers that will:
(1) Pair Vermont health centers’ medical, nursing, social work, and psychology staff with the UVM VCCYF child psychiatric consultative team;
(2) Provide monthly training and education resources for health center staff by UVM faculty;
(3) Help strengthen and expand the newly established UVM child psychiatry fellowship program; and
(4) Provide critical child psychiatry assessment and consulting services across the state that will establish relationships to help recruit and retain new child psychiatrists for Vermont.
(b) In addition to other monies appropriated elsewhere for this program, the sum of $40,000.00 is appropriated from the general fund to the department of health in fiscal year 2009 to be deposited into the Vermont educational loan repayment fund and used for the purposes of loan repayment for nurse educators pursuant to section 10a of Title 18.
* * * Fair Standards for Provider Contracts with Insurers * * *
Sec. 27. 18 V.S.A. § 9418 is amended to read:
§ 9418. payment for health care services
(i) If In addition to any other remedy provided by law, if the commissioner finds that a health plan has engaged in a pattern and practice of violating this section, the commissioner may impose an administrative penalty against the health plan of no more than $500.00 for each violation, and may order the health plan to cease and desist from further violations and order the health plan to remediate the violation. In determining the amount of penalty to be assessed, the commissioner shall consider the following factors:
(1) The appropriateness of the penalty with respect to the financial resources and good faith of the health plan.
(2) The gravity of the violation or practice.
(3) The history of previous violations or practices of a similar nature.
(4) The economic benefit derived by the health plan and the economic impact on the health care facility or health care provider resulting from the violation.
(j) A health plan in this state shall not impose on any provider any retrospective denial of a previously paid claim or any part of that previously paid claim, unless:
(1) The health plan has provided at least 30 days’ notice of any retrospective denial or overpayment recovery or both in writing to the provider. The notice must include:
(A) the patient’s name;
(B) the service date;
(C) the payment amount;
(D) the proposed adjustment; and
(E) a reasonably specific explanation of the proposed adjustment.
(2) The time that has elapsed since the date of payment of the previously paid claim does not exceed 12 months.
(k) The retrospective denial of a previously paid claim shall be permitted beyond 12 months from the date of payment for any of the following reasons:
(1) The plan has a reasonable belief that fraud or other intentional misconduct has occurred;
(2) The claim payment was incorrect because the provider of the insured was already paid for the health services identified in the claim;
(4) The claim payment is the subject of adjustment with another health insurer; or
(5) The claim payment is the subject of legal action.
(l) Notwithstanding this section, a health plan may not retroactively deny or recoup a pharmacy point-of-sale payment except in the circumstances of fraud, intentional misconduct, a member not receiving the prescription, or error in the processing of the claim.
(m) Nothing in this section shall be construed to prohibit a health plan from applying payment policies that are consistent with applicable federal or state laws and regulations, or to relieve a health plan from complying with payment standards established by federal or state laws and regulations, including rules adopted by the commissioner pursuant to section 9408 of this title relating to claims administration and adjudication standards, and rules adopted by the commissioner pursuant to section 9414 of this title and section 4088f of Title 8 relating to pay for performance or other payment methodology standards.
(n) The provisions of this section shall not apply to stand-alone dental plans or to a workers’ compensation policy of a casualty insurer licensed to do business in Vermont.
Sec. 28. 18 V.S.A. § 9418a is added to read:
§ 9418a. PROCESSING CLAIMS, DOWNCODING, AND ADHERENCE
TO CODING RULES
(1) “Claim” means any claim, bill, or request for payment for all or any portion of provided health care services that is submitted by:
(A) A health care provider or a health care facility pursuant to a contract or agreement with the health plan; or
(B) A health care provider, a health care facility, or a patient covered by the health plan.
(2) “Contest” means the circumstance in which the health plan was not provided with:
(A) Sufficient information needed to determine payer liability; or
(B) Reasonable access to information needed to determine the liability or basis for payment of the claim.
(3) “Health plan” means a health insurer, disability insurer, health maintenance organization, or medical or hospital service corporation, but does not include a stand-alone dental plan or a workers’ compensation policy of a casualty insurer licensed to do business in Vermont. “Health plan” also includes a health plan that requires its medical groups, independent practice associations, or other independent contractors to pay claims for the provision of health care services.
(b) Health plans shall accept and initiate the processing of all health care claims submitted by a health care provider pursuant to and consistent with the current version of the American Medical Association’s current procedural terminology (CPT) codes, reporting guidelines and conventions; the Centers for Medicare and Medicaid Services health care common procedure coding system (HCPCS); the National Correct Coding Initiative; the National Council for Prescription Drug Programs coding; or other appropriate standards, guidelines, or conventions approved by the commissioner.
(c) Nothing in this section shall preclude a health plan from determining that any such claim is not eligible for payment in full or in part, based on a determination that:
(1) The claim is contested as defined in subdivision 9418(a)(3) of this title;
(2) The service provided is not a covered benefit under the contract, including a determination that such service is not medically necessary or is experimental or investigational;
(3) The insured did not obtain a referral, prior authorization, or precertification, or satisfy any other condition precedent to receiving covered benefits from the health care provider;
(4) The covered benefit exceeds the benefit limits of the contract;
(5) The person is not eligible for coverage or is otherwise not compliant with the terms and conditions of his or her coverage agreement;
(6) The health plan has a reasonable belief that fraud or other intentional misconduct has occurred; or
(7) The health plan determines through coordination of benefits that another health insurer is liable for the claim.
(d) Nothing in this section shall be deemed to require a health plan to pay or reimburse a claim, in full or in part, or to dictate the amount of a claim to be paid by a health plan to a health care provider.
(e) No health plan shall automatically reassign or reduce the code level of evaluation and management codes billed for covered services (downcoding), except that a health plan may reassign a new patient visit code to an established patient visit code based solely on CPT codes, CPT guidelines, and CPT conventions.
(f) Notwithstanding the provisions of subsection (c) of this section, and other than the edits contained in the conventions in subsection (b) of this section, health plans shall continue to have the right to deny, pend, or adjust claims for covered services on other bases and shall have the right to reassign or reduce the code level for selected claims for covered services based on a review of the clinical information provided at the time the service was rendered for the particular claim or a review of the information derived from a health plan’s fraud or abuse billing detection programs that create a reasonable belief of fraudulent or abusive billing practices, provided that the decision to reassign or reduce is based primarily on a review of clinical information.
(g) Every health plan shall publish on its provider website and in its provider newsletter the name of the commercially available claims editing software product that the health plan utilizes and any significant edits, as determined by the health plan, added to the claims software product after the effective date of this section, which are made at the request of the health plan. The health plan shall also provide such information upon written request of a health care provider who is a participating member in the health plan’s provider network.
(h) In addition to any other remedy provided by law, if the commissioner finds that a health plan has engaged in a pattern and practice of violating this section, the commissioner may impose an administrative penalty against the health plan of no more than $500.00 for each violation, and may order the health plan to cease and desist from further violations and order the health plan to remediate the violation. In determining the amount of penalty to be assessed, the commissioner shall consider the following factors:
(i) Nothing in this section shall be construed to prohibit a health plan from applying payment policies that are consistent with applicable federal or state laws and regulations, or to relieve a health plan from complying with payment standards established by federal or state laws and regulations, including rules adopted by the commissioner pursuant to section 9408 of this title relating to claims administration and adjudication standards, and rules adopted by the commissioner pursuant to section 9414 of this title and section 4088f of Title 8 relating to pay for performance or other payment methodology standards.
Sec. 29. 18 V.S.A. § 9418b is added to read:
§ 9418b. PRIOR AUTHORIZATION
(2) “Health plan” means a health insurer, disability insurer, health maintenance organization, or medical or hospital service corporation but does not include a stand-alone dental plan or a workers’ compensation policy of a casualty insurer licensed to do business in Vermont. “Health plan” also includes a health plan that requires its medical groups, independent practice associations, or other independent contractors to pay claims for the provision of health care services.
(b) Health plans shall pay claims for health care services for which prior authorization was required by and received from the health plan, unless:
(1) The insured was not a covered individual at the time the service was rendered;
(2) The insured’s benefit limitations were exhausted;
(3) The prior authorization was based on materially inaccurate information from the health care provider;
(4) The health plan has a reasonable belief that fraud or other intentional misconduct has occurred; or
(5) The health plan determines through coordination of benefits that another health insurer is liable for the claim.
(c) Notwithstanding the provisions of subsection (b) of this section, nothing in this section shall be construed to prohibit a health plan from denying continued or extended coverage as part of concurrent review, denying a claim if the health plan is not primarily obligated to pay the claim, or applying payment policies that are consistent with an applicable law, rule, or regulation.
(d) A health plan shall furnish, upon request from a health care provider, a current list of services and supplies requiring prior authorization.
(e) A health plan shall post a current list of services and supplies requiring prior authorization to the insurer’s website.
(f) In addition to any other remedy provided by law, if the commissioner finds that a health plan has engaged in a pattern and practice of violating this section, the commissioner may impose an administrative penalty against the health plan of no more than $500.00 for each violation, and may order the health plan to cease and desist from further violations and order the health plan to remediate the violation. In determining the amount of penalty to be assessed, the commissioner shall consider the following factors:
(g) Nothing in this section shall be construed to prohibit a health plan from applying payment policies that are consistent with applicable federal or state laws and regulations, or to relieve a health plan from complying with payment standards established by federal or state laws and regulations, including rules adopted by the commissioner pursuant to section 9408 of this title, relating to claims administration and adjudication standards, and rules adopted by the commissioner pursuant to section 9414 of this title and section 4088f of Title 8, relating to pay for performance or other payment methodology standards.
Sec. 30. 18 V.S.A. § 9408a is amended to read:
(d) An insurer or a A hospital shall notify a provider concerning the status of the provider’s completed credentialing application not later than:
(1) Sixty days after the insurer or hospital receives the completed credentialing application form; and
(2) Every 30 days after the notice is provided under subdivision (1) of this subsection, until the hospital makes a final credentialing determination concerning the provider.
(f) An insurer shall act upon and finish the credentialing process of a completed application submitted by a provider within 60 calendar days of receipt of the application. An application shall be considered complete once the insurer has received all information and documentation necessary to make its credentialing determination as provided in subsections (b) and (c) of this section.
Sec. 31. FAIR CONTRACTING STANDARDS STUDY
The Vermont medical society, in collaboration with the department of banking, insurance, securities, and health care administration; the Vermont association of hospital and health systems; insurers; practice managers; and other interested parties, shall work to address the following issues and report to the house committee on health care and the senate committee on health and welfare on or before January 15, 2009:
(1) Fair and transparent contracting standards for providers participating in health insurance plans;
(2) Categories of coverage;
(3) Rental networks; and
(4) Most favored nation clauses.
Sec. 32. RESTRICTIVE COVENANTS STUDY
The Vermont medical society, in collaboration with the department of health, the area health education centers program, and the Vermont association of hospitals and health systems, shall work to address the issue of the use of restrictive covenants in employment contracts of health care professionals and the impact of restrictive covenants on recruitment and retention of health care professionals in Vermont and shall report to the senate committee on health and welfare and the house committee on health care on or before January 15, 2009.
Sec. 33. WORKERS’ COMPENSATION STUDY
The Vermont medical society, in collaboration with the Vermont association of hospitals and health systems; the department of banking, insurance, securities, and health care administration; the department of labor; workers’ compensation carriers; practice managers; and other interested parties, shall work to address the following issues and shall report to the senate committees on health and welfare and on economic development, housing and general affairs and the house committees on health care and on commerce on or before January 15, 2009:
(1) Timely payment of workers’ compensation claims;
(2) Notification and resolution process for contested claims;
(3) Enforcement of timely payment, including assessment of interest and penalties;
(4) Charges for examinations, reviews, and investigations in connection with workers’ compensation claims;
(5) Filing of carriers’ written claims processing practices with the department of labor;
(6) Development of online claim processing and claim tracking systems accessible to health care providers; and
(7) Uniform claims processing standards for workers’ compensation insurers.