Code of Vermont Rules › Agency 80 - ADMINISTRATIVE AND ADVISORY AGENCIES › Sub-Agency 280 - GREEN MOUNTAIN CARE BOARD › Chapter 005 - RULE 5.000: OVERSIGHT OF ACCOUNTABLE CARE ORGANIZATIONS › Section 80 280 005 - RULE 5.000: OVERSIGHT OF ACCOUNTABLE CARE ORGANIZATIONS

Current through June, 2024
Section 5.100 GENERAL PROVISIONS
Section 5.101 Authority
The Board adopts this Rule pursuant to
				18 V.S.A. §§
											9375(b),
				9380, and
				9382,
				and Act 113 (2015 adj. sess.), §§ 6 and 8(b).
Section 5.102 Purpose
This Rule establishes standards and processes the Green
				Mountain Care Board (Board) will use to certify Accountable Care Organizations
				(ACOs) and review, modify, and approve the budgets of ACOs. This Rule also
				establishes mechanisms by which the Board will monitor and oversee the
				activities and performance of ACOs, including enforcement mechanisms by which
				the Board may limit, suspend, or revoke the certification of an ACO or require
				an ACO to take remedial action. The Board adopts this Rule to comply with its
				duties under
				18 V.S.A. §§
											9375 and
				9382;
				to provide sufficient oversight of ACOs operating in Vermont to comply with
				antitrust laws; and to ensure any all-payer, ACO-based payment reform model in
				Vermont is implemented in a manner that is consistent with the requirements of
				18 V.S.A. §
											9551 and the health care reform principles of
				18 V.S.A. §
											9371.
Section 5.103 Definitions
For purposes of this Rule:
1. "Accountable Care Organization" and "ACO"
			 mean an organization of ACO Participants that has a formal legal structure, is
			 identified by a federal Taxpayer Identification Number, and agrees to be
			 accountable for the quality, cost, and overall care of the patients assigned to
			 it.
2. "ACO Participant" and
			 "Participant" mean a Health Care Provider that has, through a formal, written
			 document, agreed to participate in a Payer program with the ACO and collaborate
			 on one or more ACO programs designed to improve Quality of Care and patient
			 experience, and manage costs.
3.
			 "ACO Provider" means an individual or entity that bills for services under the
			 billing number of an ACO Participant.
4. "Actuary" means an individual who meets
			 the qualification standards established by the American Academy of Actuaries
			 for an actuary and follows the practice standards established by the Actuarial
			 Standards Board.
5. "Alternative
			 Payment Methodologies" means methods of paying for Health Care Services that
			 are alternatives to traditional fee for service reimbursement, such as Shared
			 Savings and Shared Savings/Shared Loss arrangements, bundled payments, and
			 global or partial Capitation Payment Arrangements.
6. "Applicant" means an ACO that has
			 submitted an application to the Board for certification pursuant to section
			 5.301 of this Rule.
7. "At-Risk
			 Enrollee" means an Enrollee identified (e.g., through a validated risk
			 adjustment methodology or an analysis of utilization data) as having a
			 significant burden of illness and being someone for whom considerable future
			 health care expenditures are highly likely.
8. "Benchmark" means a Payer-specific
			 financial target against which expenditures for Enrollees will be assessed.
			 Payer-specific Shared Savings and Shared Losses for an ACO will be determined
			 based on this assessment.
9.
			 "Blueprint for Health" means the State program established in Title 18, chapter
			 13 of the Vermont Statutes Annotated.
10. "Board" means the Green Mountain Care
			 Board established in Title 18, chapter 220 of the Vermont Statutes Annotated,
			 and any designee of the Board.
11.
			 "Budget Year" means the twelve-month period beginning on January 1 and ending
			 on December 31.
12. "Capitation
			 Payment" and "Capitation Payment Arrangement" mean a contractually based
			 payment or prepayment made to an ACO, or an arrangement for such a payment or
			 prepayment to be made, on a per-member per-month or percentage-of-premium
			 basis, in exchange for one or more Contracted Services to be rendered,
			 referred, or otherwise arranged by the ACO.
13. "CMS" means the Centers for Medicare and
			 Medicaid Services, an agency within the United States Department of Health and
			 Human Services.
14. "Contracted
			 Services" means the services for which an ACO is financially responsible, as
			 defined by the terms of its contract with a Payer.
15. "DVHA" means the Department of Vermont
			 Health Access, a department within the Vermont Agency of Human Services.
16. "Enrollee" means an individual
			 covered by a Payer holding a contract with an ACO for whom the ACO has, based
			 on a contractually-defined attribution methodology, assumed responsibility for
			 managing cost and Quality of Care.
17. "Health Care Provider" and "Provider"
			 mean a person, partnership, corporation, unincorporated association, or other
			 legal entity, including a health care facility, that is licensed, certified, or
			 otherwise authorized by law to provide Health Care Services in Vermont to an
			 individual during that individual's medical care, treatment, or
			 confinement.
18. "Health Care
			 Services" has the same meaning as "health service" in 1 8 V.S.A. §
			 9373.
19. "HIPAA" means the Health
			 Insurance Portability and Accountability Act of 1996 and its associated rules
			 and regulations, including the Standards for the Privacy of Individually
			 Identifiable Health Information ("Privacy Rule") and the Security Standards
			 ("Security Rule") at 42 C.F.R. Parts 160 and 164.
20. "NCQA" means the National Committee for
			 Quality Assurance.
21. "Office of
			 the Health Care Advocate" means the Office established by Title 18, chapter 229
			 of the Vermont Statutes Annotated.
22. "Payer" means a third-party health care
			 payer, including, to the extent permitted under federal law, any (a) publicly
			 funded health care benefit plan; (b) health insurance company, health
			 maintenance organization, or nonprofit hospital or medical service corporation;
			 (c) employer or employee organization that offers a "group health plan" as
			 defined by the federal Employee Retirement and Income Security Act; or (d)
			 administrator for one of the above.
23. "Primary Care Provider" means a Provider
			 who, within that Provider's scope of practice, principally provides Primary
			 Care Services.
24. "Primary Care
			 Services" are Health Care Services furnished by Providers specifically trained
			 for and skilled in first-contact and continuing care for persons with signs,
			 symptoms, or health concerns, not limited by problem origin (biological,
			 behavioral or social), organ system, or diagnosis. Primary Care Services
			 include health promotion, disease prevention, health maintenance, counseling,
			 patient education, self-management support, care planning, and the diagnosis
			 and treatment of acute and chronic illnesses in a variety of health care
			 settings.
25. "Quality Evaluation
			 and Improvement Program" means a set of policies, procedures, and activities
			 designed to improve the Quality of Care and the quality of the ACO's services
			 to Enrollees and Participants by assessing the Quality of Care or service
			 against a set of establish standards and taking action to improve it.
26. "Quality of Care" means the degree to
			 which services for individuals and populations increase the likelihood of
			 desired health outcomes, decrease the probability of undesired health outcomes,
			 and are consistent with current professional knowledge or, where available,
			 clinical best practices.
27. "Risk
			 Cap" means the maximum amount of risk an ACO may assume during a given Budget
			 Year.
28. "Risk Contract" means a
			 contract between a Payer and an ACO under which the ACO is responsible for the
			 full or partial expense, as defined by the contract, of treating or arranging
			 for the treatment of a group of patients, if that expense exceeds an
			 agreed-upon amount.
29. "Shared
			 Loss" means the monetary amount owed to a Payer by an ACO as determined by
			 comparing the ACO's expenditures for Enrollees against the Benchmark for that
			 Payer and accounting for the ACO's performance against any quality
			 measures.
30. "Shared Savings"
			 means the monetary amount owed to an ACO by a Payer as determined by comparing
			 the ACO's expenditures for Enrollees against the Benchmark for that Payer and
			 accounting for the ACO's performance against any quality measures.