ACT NO. 191

(H.861)

Medicaid; chronic care; insurance

This act has several health care reform initiatives (see also summaries on the legislative health care page).

· Reform Coordination and Future Steps

o Charges the secretary of administration with coordinating the health care reform initiatives, including Blueprint for Health; information technology - VITL, multi-payer database, common claims and credentialing forms; public health initiatives, Medicaid, VHAP, Dr. Dynasaur, and Catamount Health

o Charges the commission on health care to report on a plan to increase incrementally health care coverage to ensure universal access no later than 2011

· Chronic Care Initiatives

o Defines and codifies the Blueprint for Health - an initiative to create a chronic care infrastructure and uniform model of providing chronic care in Vermont

o Establishes criteria for a Medicaid request for proposals which would create a chronic care management program for individuals enrolled in Medicaid, Dr. Dynasaur, and VHAP

o Requires coordination between the Blueprint and other initiatives around chronic care in state government, including any initiatives in the agency of human services

o Provides that the commissioner of human resources and VSEA will look at the chronic care program offered to state employees to determine if it meets the Blueprint model and, if not, how to coordinate

· Catamount Health

o Carriers: Insurers currently in the small group market may offer Catamount Health, which is a comprehensive insurance plan covering primary care, chronic care, and hospital services

o Purchasers: uninsured Vermont residents

o Benefits

_ a $250.00 deductible for an individual and a $500.00 deductible for a family for health services received in network;

_ a $500.00 deductible for an individual and a $1,000.00 deductible for a family for health services received out of network;

_ 20 percent co-insurance, in and out of network;

_ a $10.00 office co-payment;

_ prescription drug coverage without a deductible, $10.00 co-payments for generic drugs, $30.00 co-payments for drugs on the preferred drug list, and $50.00 co-payments for nonpreferred drugs;

_ out-of-pocket maximums of $800.00 for an individual and $1,600.00 for a family for in-network services and $1,500.00 for an individual and $3,000.00 for a family for out-of-network services; and

_ a waiver of the deductible and other cost-sharing payments for chronic care for individuals participating in chronic care management and for preventive care

o Reimbursements

_ Health care professionals: Medicare +10% in 2006 increasing as per Medicare reimbursement methodology

_ Hospitals: Cost +10% increasing as per Medicare economic index

o Chronic Care

_ Plan offers a chronic care management program which complies with the criteria in 18 V.S.A. § 703 and reports under the Blueprint for Health criteria

_ The carrier agrees to participate in a pay for performance demonstration project

_ Premium rates

_ Actuarially determined

_ Narrower standard to ensure affordability, while also ensuring insurers financial stability

o Assistance

_ Uninsured Vermont residents under 300% of FPL without access to employer-sponsored insurance as good as Catamount Health

_ Carrier bills individual and state; one bill to the state

_ Individuals over 300% can purchase at full cost

_ Hard enrollment cap - emergency board makes determination

o Oversight

_ Market created upon passage; expedited rulemaking

_ Carriers have 30 days from the rules to offer letters of intent

_ Plans go through BISHCA process

_ BISHCA can require Blue Cross Blue Shield or nonprofit hospital and medical organizations to offer Catamount Health, if necessary

_ Commission on Health Care Reform to review October 1, 2009 for cost-effectiveness and may trigger a self-insured plan if market is not cost-effective

· Medicaid Initiatives

o Establishes criteria for a Medicaid request for proposals which would create a chronic care management program for individuals enrolled in Medicaid, Dr. Dynasaur, and VHAP and requires Medicaid to determine how to restructure payment for chronic care

o Reduces VHAP premiums by 35% starting July 1, 2007

o Reduces Dr. Dynasaur premiums by 50% starting July 1, 2007

o Increases reimbursements for doctors and hospitals starting January 1, 2007

· Employer-Sponsored Insurance

o VHAP

_ Requires individuals enrolled in or eligible for VHAP to move to an employer-sponsored insurance plan, if available, as long as certain criteria are met

_ Individuals contribute an amount substantially similar to the VHAP premiums and cost-sharing; state to provide a benefit wrap to VHAP benefit level

_ Employer plans must meet a standard: typical plan of 4 largest insurers in the small group and association market

_ Provides that state will review move from VHAP to ESI to ensure cost-effectiveness to the state

o Over VHAP to 300%

_ Provides premium assistance to uninsured individuals between 150-300% of FPL who are otherwise eligible for Catamount Health

_ Catamount Health is the standard for approving employer plans; but ESI has more flexibility on what chronic care is covered until Jan. 1, 2009; specific assistance amounts to be set

_ Provides that state will review to ensure cost-effectiveness to the state

o Hard enrollment cap - emergency board makes determination

o Health Access Oversight Committee and the Joint Fiscal Committee to review the details of the plan in order to approve appropriation amount over $250,000.00 for implementation costs

· Financing

o Employers' Health Care Premium Contribution

_ Establishes a quarterly assessment of $1 per day per full-time equivalent employees of employers who do not offer health insurance, employees who are not eligible for an employer's insurance, and uninsured employees

_ Exempts 8 employees per employer in 2007 and 2008; 6 in 2009; 4 in 2010

_ Starts April 1, 2007 to be paid at the end of that quarter (June 2007)

_ Establishes a study on the best method of accounting for seasonal employees

o Cigarette and Tobacco Taxes

_ Increases the cigarette tax by 60 cents in 2006 and an additional 20 cents in 2008

_ Taxes little cigars and roll-your-own tobacco as cigarettes

_ Changes method of taxing moist snuff to a per-ounce basis and increases tax in 2008 by $0.17 cents

o Global Commitment - Requires the agency of human services to seek a Global Commitment waiver to include Catamount Health assistance and the employer-sponsored insurance premium assistance program in the Medicaid waiver

· Commission on Health Care Reform

o Charge revised and codified

· Insurance Mandate -review to see if Vermont has a 96% insured rate in 2010 - Commission looks into details on how to do a mandate

· Immunizations - starting October 1, 2007, clinically recommended immunizations are provided to all Vermonters; study to determine appropriate administration

· Individual Health Insurance Market Reform

o Provides assistance to carriers in the individual market of 5% in order to reduce premiums by that amount

o Study to determine feasibility of merging the individual and small group markets

· Cost Shift Review

o Expands hospital reporting on cost shift

o Creates a cost-shift task force to determine methods of accounting for the cost shift and ensuring that reductions in the cost shift are passed on to private insurance consumers

o Establishes a process to create a uniform, statewide uncompensated care policy or set of policies for all hospitals

· Common Sense Initiatives (from S.310)

o Healthy Lifestyles Insurance Discounts - allows discounts of up to 15% of premium for compliance with health promotion program and limits total deviation from community rate to 30% (including these discounts)

o Common claims and procedures - work group to make recommendations

o Common Credentialing for Providers - BISHCA will require use of single, standard form for multiple credentialing applications

o Multi-payer Database and Consumer Price and Quality Information - requires insurers and third party administrators to report data in order for BISHCA to provide price and quality information to consumers

o Master Provider Index - AHEC work group to recommend whether and how to create a master provider index for information technology referencing purposes

Effective Date: This act shall take effect upon passage, except as follows:

(1) Secs. 9 (Medicaid reimbursement), 10 (Blueprint for Health reimbursements), 25 (hospital cost shift analysis), 33 (community health care planning grant) and 41 (state health care resources fund) shall take effect July 1, 2006.

(2) Secs. 11 (VHAP premiums), 12 (Dr. Dynasaur premiums), 17-19 (technical insurance changes), 27, and 28 (Nongroup market security trust and insurance rates) shall take effect July 1, 2007.

(3) Secs. 13 (Employer-sponsored insurance premium assistance) and 16 (Catamount Health assistance) shall take effect June 30, 2006, for the purposes of establishing and administering the Catamount fund under section 1986 of Title 33, and preparing for administration and enrollment of the programs; implementation of the programs, however, shall not commence until October 1, 2007.

(4) Sec. 23 (immunizations) shall take effect July 1, 2007 for the purposes of establishing the program, but the program shall not be implemented until October 1, 2007.