Code of Vermont Rules › Agency 21 - DEPARTMENT OF FINANCIAL REGULATION › Sub-Agency 040 - DIVISION OF HEALTH CARE ADMINISTRATION › Chapter 020 - REGULATION NO. H-2007-05 - HEALTH CARE PRICE AND QUALITY TRANSPARENCY RULE › Section 21 040 020 - REGULATION NO. H-2007-05 - HEALTH CARE PRICE AND QUALITY TRANSPARENCY RULE

Current through
				June, 2024
Section 1
				Purpose
The purpose of this Rule is to provide consumers with access
				  to information concerning health care prices, health care quality, and other
				  information necessary to empower consumers, including uninsured consumers, to
				  make economically sound and medically appropriate decisions.
Section 2 Authority
This Rule is issued pursuant to the authority vested in the
				  Commissioner by law, including but not limited to
				  18 V.S.A. §
											9410(a)(2),
				  8 V.S.A.
				  § 15(a), and 18 V.S.A. § 9404(d).
Section 3 Definitions
As used in this Rule:
(1) "Brand Name Drug" means a drug marketed
				under a proprietary, trademark-protected name.
(2) "Charge" means the amount sought as
				payment by a Health Care Facility, Health Care Provider, or seller of
				prescription drugs, durable medical equipment, or medical supplies for a health
				care service or product before the application of any discount, write-off,
				contract or plan adjustment or allowance, or other reduction to such
				amount.
(3) "Commissioner" means
				the Commissioner of the Department.
(4) "Consumer Information Plan" means the
				Consumer Information Plan filed by a Health Insurer for the benefit of the
				Health Insurer's Members, and approved by the Commissioner under Section
				4
				of this Rule.
(5) "Department"
				means the Vermont Department of Banking, Insurance, Securities and Health Care
				Administration.
(6) "Diagnostic
				Related Group" or "DRG" means any of the diagnostic categories which Medicare
				accepts that can be used to classify a patient's inpatient service for
				reimbursement purposes.
(7)
				"Generic Drug" means a drug which has been approved by the Food and Drug
				Administration as a generic drug to be equivalent to a Brand Name Drug in
				dosage, safety, strength, how it is taken, quality, performance, and intended
				use.
(8) "Health Care Facility"
				means all institutions, whether public or private, proprietary or nonprofit,
				which offer diagnosis, treatment, inpatient or ambulatory care to two or more
				unrelated persons, and the buildings in which those services are offered. The
				term shall not apply to any facility operated by religious groups relying
				solely on spiritual means through prayer or healing, but includes all
				institutions included in subdivision
				9432(7)
				of Title 18, except health maintenance organizations.
(9) "Health Care Provider" means a person,
				partnership or corporation, other than a facility or institution, licensed or
				certified or authorized by law to provide professional health care service in
				this state to an individual during that individual's medical care, treatment or
				confinement, and, except in connection with the requirements of Section
				6 of this
				Rule, practicing under a participating provider agreement with a Health
				Insurer.
(10) " Health Care
				Provider Practice" means an organization of Health Care Providers whose
				financial information is reported annually by a Hospital pursuant to 18 V.S.A.
				Chapter 221, subchapter 7
(11)
				"Health Insurer" means:
(A) any health
				insurance company, nonprofit hospital and medical services corporation, or
				health maintenance organization with at least five percent of the lives covered
				in the insured market in Vermont, as reported by the Department for the prior
				calendar year. The requirements of this Rule apply to:
(i) a Health Insurer in connection with its
				insured plans;
(ii) a Health
				Insurer, or the controlled affiliate of a Health Insurer, acting as a
				third-party administrator for a health benefit plan, and
(iii) the agents or affiliates of the Health
				Insurer who contract to administer the benefits covered or administered by the
				Health Insurer, such as pharmacy benefit managers and mental health services
				review agents licensed under
				8 V.S.A. §
													4089a; and
(B) the employee health benefit plan offered
				by the State of Vermont, or any agency or instrumentality of the state;
				and
(C) Medicaid, VHAP, SCHIP and
				any other health benefit plan offered or administered by the Vermont Office of
				Health Access, to the extent permitted by federal law or authority.
(12) "Hospital" means an acute
				care hospital licensed under chapter 43 of Title 18, Vermont Statutes
				Annotated, and except for purposes of Section
				6 of this
				Rule, any out of state hospital with more than 1,000 annual inpatient
				discharges of Vermont residents. The Department shall publish annually a list
				of hospitals that satisfy the criteria of this subdivision.
(13) "Member" means an individual or
				dependent covered by the health benefit plan of a Health Insurer.
(14) "Physician" means a physician practicing
				under a participating provider agreement with a Health Insurer, except in
				connection with the requirements of Section
				6 of this
				Rule.
(15) "Price" means the amount
				due to a Health Care Facility, Health Care Provider, or seller of durable
				medical equipment, or medical supplies for a health care service or product
				after the application of any discount, write-off, contract or plan adjustment
				or allowance, or other reduction to the Charge amount, and before the
				application of any individual Member cost-sharing, including deductibles,
				co-payments, co-insurance, and out-of-pocket maximums. The "Price" of
				prescription drugs means the amount due to the pharmacy or other entity for the
				delivery of prescription drugs to the Health Insurer's Members, or the
				pharmacy's or other entity's usual and customary charge, whichever is lower;
				provided that the Health Insurer may, but is not required to disclose the lower
				usual and customary charge.
(16)
				"Primary Care Physician" means a Physician who provides primary care services,
				and who is designated as a primary care physician by the Health
				Insurer.
(17) "Rule" means the
				administrative rule adopted herein.
(18) "Therapeutic Equivalent Drug" means drug
				products classified as therapeutically equivalent by the Food and Drug
				Administration that can be substituted with the full expectation that the
				substituted product will produce the same clinical effect and safety profile as
				the prescribed product.
(19)
				"Uninsured Consumer Information Plan" means the Uninsured Consumer Information
				Plan filed by a Hospital or by a Health Care Provider Practice and approved by
				the Commissioner under Section
				6 of this
				Rule.