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1 S.151
2 Introduced by Senator Lyons
3 Referred to Committee on
4 Date:
5 Subject: Health; Green Mountain Care Board; health insurers; health care
6 providers; pay parity; transparency; contracts; primary care;
7 Medicaid; Blueprint for Health; provider rates; workers’
8 compensation; prior authorization; pharmacy benefit managers;
9 hospital budgets; Department of Financial Regulation
10 Statement of purpose of bill as introduced: This bill proposes to require the
11 Green Mountain Care Board to review health care contracts and fee schedules
12 between health plans and health care providers to increase transparency in
13 health care. This bill would also increase primary care payments and spending
14 and provide an exemption from prior authorization requirements. This bill
15 proposes to allow a minor 12 years of age or older to consent to medical care
16 for the prevention of a sexually transmitted infection and would also adjust the
17 age at which an individual’s colorectal cancer screenings are covered by health
18 insurance. This bill also proposes to make certain temporary prohibitions on
19 pharmacy benefit managers permanent. This bill proposes to modify the
20 nomination and appointment process for members of the Green Mountain Care
21 Board. This bill would also add new filing and reporting requirements for VT LEG #366330 v.3
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1 health insurers and would require the Department of Financial Regulation to
2 submit an analysis to the Green Mountain Care Board regarding hospital
3 budget proposals.
4 An act relating to pay parity and transparency in health care
5 It is hereby enacted by the General Assembly of the State of Vermont:
6 * * * Contracts; Health Plans; Health Care Providers * * *
7 Sec. 1. GREEN MOUNTAIN CARE BOARD; HEALTH CARE
8 CONTRACTS; FEE SCHEDULES; REPORT
9 (a) The Green Mountain Care Board shall collect and review a
10 representative sample of health care contracts and fee schedules from health
11 insurers, including contracts and fee schedules with hospital-affiliated, non-
12 hospital-affiliated, and independent health care providers to inform the Board’s
13 development of a methodology for increasing the transparency around health
14 care contracts.
15 (b) On or before January 15, 2024, the Board shall provide information to
16 the House Committee on Health Care and the Senate Committees on Health
17 and Welfare and on Finance regarding the Board’s proposed methodology for
18 increasing the transparency around health care contracts, including the
19 standards and criteria that the Board intends to use for its reviews of health VT LEG #366330 v.3
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1 care contracts and fee schedules, and any recommendations for legislative
2 action.
3 (c) Confidential business information and trade secrets received from an
4 insurer pursuant to subsection (a) of this section shall be exempt from public
5 inspection and copying under 1 V.S.A. § 317(c)(9) and shall be kept
6 confidential, except that the Board may disclose or release information
7 publicly in summary or aggregate form if doing so would not disclose
8 confidential business information or trade secrets.
9 * * * Blueprint for Health * * *
10 Sec. 2. BLUEPRINT FOR HEALTH; PATIENT-CENTERED MEDICAL
11 HOMES; REPORT
12 On or before January 15, 2024, the Director of Health Care Reform in the
13 Agency of Human Services shall recommend to the House Committees on
14 Health Care and on Appropriations and the Senate Committees on Health and
15 Welfare, on Appropriations, and on Finance the amounts by which health
16 insurers and Vermont Medicaid should increase the amount of the per-person,
17 per-month payments they make to patient centered medical homes
18 participating in Blueprint for Health, in furtherance of the goal of providing
19 additional resources necessary for delivery of comprehensive primary care
20 services to Vermonters and to sustain access to primary care services in
21 Vermont. The Agency shall also provide an estimate of the State funding that VT LEG #366330 v.3
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1 would be needed to support the increase for Medicaid, both with and without
2 federal financial participation.
3 * * * Primary Care Providers; Medicaid Reimbursement Rates * * *
4 Sec. 3. 33 V.S.A. § 1901a is amended to read:
5 § 1901a. MEDICAID BUDGET
6 (a) Financial plan. The General Assembly shall approve each year a
7 Medicaid budget. The annual Medicaid budget shall include an annual
8 financial plan, and a five-year financial plan accounting for expenditures and
9 revenues relating to Medicaid and any other health care assistance program
10 administered by the Agency of Human Services.
11 (b) Quarterly information and analysis. The Secretary of Human Services
12 or his or her the Secretary’s designee and the Commissioner of Finance and
13 Management shall provide quarterly to the Joint Fiscal Committee such
14 information and analysis as the Committee reasonably determines is necessary
15 to assist the General Assembly in the preparation of the Medicaid budget.
16 (c) Medicaid provider rates; primary care. It is the intent of the General
17 Assembly that Vermont’s health care system should reimburse all Medicaid
18 participating providers at rates that are equal to 100 percent of the Medicare
19 rates for the services provided, with first priority for primary care providers. In
20 support of this goal, in its annual budget proposal, the Department of Vermont
21 Health Access shall either provide reimbursement rates for Medicaid VT LEG #366330 v.3
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1 participating providers for primary care services at rates that are equal to 100
2 percent of the Medicare rates for the services in effect in calendar year 2022,
3 with positive Consumer Price Index inflation adjustment rates in subsequent
4 years, or, in accordance with 32 V.S.A. § 307(d)(6), provide information on
5 the additional amounts that would be necessary to achieve full reimbursement
6 parity for primary care services with the Medicare rates.
7 Sec. 4. 18 V.S.A. § 9414b is added to read:
8 § 9414b. INCREASING PRIMARY CARE SPENDING ALLOCATIONS
9 (a)(1) Each of the following entities shall increase the percentage of total
10 health care spending it allocates to primary care, using the baseline percentages
11 determined by the Green Mountain Care Board in accordance with 2020 Acts
12 and Resolves No. 17, by at least one percentage point per year until primary
13 care comprises at least 12 percent of the plan’s or payer’s overall annual health
14 care spending:
15 (A) each health insurer with 500 or more covered lives for
16 comprehensive, major medical health insurance in this State;
17 (B) the State Employees’ Health Benefit Plan; and
18 (C) health benefit plans offered pursuant to 24 V.S.A. § 4947 to
19 entities providing educational services.
20 (2) Upon achieving the 12 percent primary care spending allocation
21 required by subdivision (1) of this subsection, each plan or payer shall VT LEG #366330 v.3
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1 maintain or increase the percentage of total health care spending it allocates to
2 primary care at or above 12 percent.
3 (3) A plan’s or payer’s increased proportional spending on primary care
4 shall not:
5 (A) result in higher health insurance premiums;
6 (B) be achieved through increased fee-for-service payments to
7 providers; or
8 (C) increase the plan’s or payer’s overall health care expenditures.
9 (b)(1) On or before June 1 of each year, each entity listed in subdivisions
10 (a)(1)(A)–(C) of this section shall report to the Green Mountain Care Board the
11 percentage of its total health care spending that was allocated to primary care
12 during the previous plan year.
13 (2) On or before December 1 of each year from 2024 to 2029, the Green
14 Mountain Care Board shall report to the House Committee on Health Care and
15 the Senate Committees on Health and Welfare and on Finance on progress
16 toward increasing the percentage of health care spending systemwide that is
17 allocated to primary care.
18 Sec. 5. 21 V.S.A. § 640 is amended to read:
19 § 640. MEDICAL BENEFITS; ASSISTIVE DEVICES; HOME AND
20 AUTOMOBILE MODIFICATIONS
21 ***
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1 (d) The liability of the employer to pay for medical, surgical, hospital, and
2 nursing services and supplies, prescription drugs, and durable medical
3 equipment provided to the injured employee under this section shall not exceed
4 the maximum fee for a particular service, prescription drug, or durable medical
5 equipment as provided by a schedule of fees and rates prepared by the
6 Commissioner. The Commissioner shall update the schedule of fees and rates
7 on a consistent basis and not less than biennially. The reimbursement rate for
8 services and supplies in the fee schedule shall include consideration of medical
9 necessity, clinical efficacy, cost-effectiveness, and safety, and those services
10 and supplies shall be provided on a nondiscriminatory basis consistent with
11 workers’ compensation and health care law. The Commissioner shall
12 authorize reimbursement at a rate higher than the scheduled rate if the
13 employee demonstrates to the Commissioner’s satisfaction that reasonable and
14 necessary treatment, prescription drugs, or durable medical equipment is not
15 available at the scheduled rate. An employer shall establish direct billing and
16 payment procedures and notification procedures as necessary for coverage of
17 medically-necessary medically necessary prescription medications for chronic
18 conditions of injured employees, in accordance with rules adopted by the
19 Commissioner.
20 ***
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1 Sec. 6. 8 V.S.A. § 4062g is added to read:
2 § 4062g. EXEMPTION FROM PRIOR AUTHORIZATION
3 REQUIREMENTS
4 (a) Definitions. As used in this section:
5 (1) “Health care services” has the same meaning as in section 5101 of
6 this title.
7 (2) “Health insurance plan” means Medicaid and a group health
8 insurance policy or health benefit plan offered by a health insurance company,
9 nonprofit hospital or medical service corporation, or health maintenance
10 organization but does not include policies or plans providing coverage for a
11 specified disease or other limited benefit coverage.
12 (3) “Health insurer” and “health care provider” have the same meanings
13 as in 18 V.S.A. § 9402.
14 (4) “Prior authorization” means a determination by a health insurer that
15 health care services proposed to be provided to a patient are medically
16 necessary and appropriate.
17 (b) Exemption from prior authorization requirements for health care
18 providers providing certain health care services.
19 (1) A health insurer that uses a prior authorization process for health
20 care services may not require a health care provider to obtain prior
21 authorization for any health care service if, in the most recent six-month VT LEG #366330 v.3
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1 evaluation period, as described in subdivision (2) of this subsection, the health
2 insurer has approved or would have approved not less than 90 percent of the
3 prior authorization requests submitted by the health care provider for the
4 particular health care service.
5 (2) Except as provided in subdivision (3) of this subsection, a health
6 insurer shall evaluate whether a health care provider qualifies for an exemption
7 from prior authorization requirements under subdivision (1) of this subsection
8 once every six months.
9 (3) A health insurer may continue an exemption under subdivision (1) of
10 this subsection without evaluating whether the health care provider qualifies
11 for the exemption for a particular evaluation period.
12 (4) A health care provider is not required to request an exemption under
13 subdivision (1) of this subsection to qualify for the exemption.
14 (c) Duration of prior authorization exemption.
15 (1) A health care provider’s exemption from prior authorization
16 requirements under this section remains in effect until:
17 (A) the 30th day after the date the health insurer notifies the health
18 care provider of the health insurer’s determination to rescind the exemption
19 under this section if the health care provider does not appeal the health
20 insurer’s determination; or VT LEG #366330 v.3
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1 (B) if the health care provider appeals the determination, the fifth day
2 after the date the independent review organization affirms the health insurer’s
3 determination to rescind the exemption.
4 (2) If a health insurer does not finalize a rescission determination as
5 specified in subdivision (1) of this subsection, then the health care provider is
6 considered to have met the criteria under this section to continue to qualify for
7 the exemption.
8 (d) Denial or rescission of prior authorization exemption.
9 (1) A health insurer may rescind an exemption from prior authorization
10 requirements under this section only:
11 (A) During January or June of each year.
12 (B) If the health insurer makes a determination, on the basis of
13 retrospective review of a random sample of not fewer than five and not more
14 than 20 claims submitted by the health care provider during the most recent
15 evaluation period prescribed in this section, that less than 90 percent of the
16 claims for the particular health care service met the medical necessity criteria
17 that would have been used by the health insurer when conducting prior
18 authorization review for the particular health care service during the relevant
19 evaluation period.
20 (C) If the health insurer complies with other applicable requirements
21 specified in this section, including notifying the health care provider not less VT LEG #366330 v.3
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1 than 25 days before the proposed rescission is to take effect. The notice shall
2 include the sample information used to make the determination under
3 subdivision (1)(B) of this subsection (d) and a plain language explanation of
4 how the health care provider may appeal and seek an independent review of
5 the determination.
6 (2) A determination made under subdivision (1)(B) of this subsection
7 shall be made by an individual licensed to practice medicine in this State. For
8 a determination made under subdivision (1)(B) of this subsection with respect
9 to a physician, the determination shall be made by an individual licensed to
10 practice medicine in this State who has the same or similar specialty as that
11 physician.
12 (3) A health insurer may deny an exemption from prior authorization
13 requirements under this section only if:
14 (A) the health care provider does not have the exemption at the time
15 of the relevant evaluation period: and
16 (B) the health insurer provides the health care provider with actual
17 statistics and data for the relevant prior authorization request evaluation period
18 and detailed information sufficient to demonstrate that the health care provider
19 does not meet the criteria for an exemption from prior authorization
20 requirements for the particular health care service under this section.
21 (e) Independent review of exemption determination.
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1 (1) A health care provider has a right to a review of an adverse
2 determination r