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H.861

Introduced by   Committee on Health Care

Date:

Subject:   Health; preventive and chronic care; management; uninsured; benefit plan; catamount health; Medicaid reimbursements; global commitment

Statement of purpose:  This bill proposes to:

(1)  enhance and improve the delivery of chronic care to Vermonters by codifying the Vermont blueprint for health chronic care prevention and management plan, unifying the chronic care efforts within the state, and initiating chronic care prevention and management in Medicaid and catamount health;

(2)  establish catamount health, a comprehensive health benefits plan for uninsured Vermonters, and to direct the legislative health access oversight committee to monitor implementation;

(3)  increase Medicaid reimbursements for primary care services; and

(4)  strengthen the authority of the department of banking, insurance, securities, and health care administration to reduce health insurance premium growth rates as a result of reductions in the uninsured population and increases in Medicaid rates.

AN ACT RELATING TO HEALTH CARE AFFORDABILITY FOR VERMONTERS

It is hereby enacted by the General Assembly of the State of Vermont:

Sec. 1.  HEALTH CARE REFORM PRINCIPLES

The general assembly adopts the following guidelines, modeled after the Coalition 21 principles, as a framework for reforming health care in Vermont:

(1)  It is the policy of the state of Vermont to ensure universal access to and coverage for essential health care services for all Vermonters. 

(2)  Health care coverage needs to be comprehensive and continuous. 

(3)  Vermont’s health delivery system must model continuous improvement of health care quality and safety. 

(4)  The financing of health care in Vermont must be sufficient, equitable, fair, and sustainable. 

(5)  Built-in accountability for quality, cost, access, and participation must be the hallmark of Vermont’s health care system.

(6)  Vermonters must be engaged, to the best of their ability, to pursue healthy lifestyles, to focus on preventive care and wellness efforts, and to make informed use of all health care services throughout their lives.

Sec. 2.  LEGISLATIVE PURPOSE AND INTENT

(a)  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.  The general assembly finds that effective first steps to achieving this purpose are the prevention and management of chronic disease and coverage of the uninsured through catamount health, a self-insured, comprehensive benefit plan with sliding-scale premiums.  The general assembly finds that chronic care management is one tool to contain health care costs and ensure that Vermont’s health care system becomes sustainable.

(b)  It is also the intent of the general assembly to ensure that any reduction in the “cost shift” is returned to consumers by slowing the rate of growth in insurance premiums.  The cost shift results when the costs of health services are inadequately paid for by public health care programs and when individuals are unable to pay for services.  Raising Medicaid payment rates and reducing the number of uninsured will reduce the cost shift.  

Sec. 3.  3 V.S.A. § 2222a is added to read:

§ 2222a.  HEALTH CARE SYSTEM REFORM; QUALITY AND

               AFFORDABILITY

(a)  The secretary of administration, working in collaboration with the general assembly, shall be responsible for the coordination of health care system reform among executive branch agencies, departments, and offices.

(b)  The secretary shall ensure that those executive branch agencies, departments, and offices responsible for the development, improvement, and implementation of Vermont’s health care system reform do so in a timely manner.

(c)  Vermont’s health care system reform initiatives include:

(1)  The state’s chronic care infrastructure, disease prevention, and management program contained in the “blueprint for health” established by chapter 13 of Title 18, the goal of which is to achieve a unified, comprehensive, statewide system of care that improves the lives of Vermonters with or at risk for chronic disease.

(2)  The Vermont health information technology project.

(3)  The multi-payer data collection project.

(4)  The common claims administration project.

(5)  The consumer price and quality information system.

(6)  The public health promotion programs of the department of health and the department of disabilities, aging, and independent living.

(7)  Medicaid, the Vermont health access plan, Dr. Dynasaur, VPharm, and Vermont Rx, established in chapter 19 of Title 33, which contain programs to provide health care coverage to elderly, disabled, and low to middle income Vermonters.

(8)  Catamount health, established in subchapter 6 of chapter 19 of Title 33, which provides a comprehensive benefit plan with a sliding-scale premium to uninsured Vermonters.

(d)  The secretary shall report to the commission on health care reform, the health access oversight committee, the house committee on health care,  the senate committee on health and welfare, and the governor on or before December 1, 2006 with a five-year strategic plan for implementing Vermont’s health care system reform initiatives, together with any administrative or legislative recommendations.  Annually, beginning January 15, 2007, the secretary shall report to the general assembly on the progress of the reform initiatives.

(e)  The secretary of administration or designee shall provide information and testimony on the activities included in this section to any legislative committee upon request and during adjournment to the health access oversight committee and the commission on health care reform.

* * * Chronic Care Infrastructure and Prevention * * *

Sec. 4.  BLUEPRINT FOR HEALTH

(a)  The general assembly endorses the “blueprint for health” prevention and chronic care management initiative as a foundation which it intends to strengthen by broadening its scope and coordinating the initiative with other public and private chronic care coordination and management programs.

(b)  The charge and strategic plan for the blueprint for health are codified as chapter 13 of Title 18. 

(c)  The department of health shall revise the current strategic plan for the blueprint for health and provide the revised plan to the commission on health care reform, the health access oversight committee, the house committee on health care, and the senate committee on health and welfare no later than October 1, 2006.  The revised strategic plan shall provide that a model for the patient registry under the blueprint for health is fully designed no later than January 1, 2007.

Sec. 5.  18 V.S.A. chapter 13 is added to read:

Chapter 13.  CHRONIC CARE INFRASTRUCTURE

AND PREVENTION

§ 701.  DEFINITIONS

For the purposes of this chapter:

(1)  “Blueprint for health” means the state’s chronic care infrastructure, disease prevention, and case management program.

(2)  “Chronic care” means health services provided by a health care professional for an established disease that is expected to last a year or more and that requires ongoing clinical management attempting to restore the individual to highest function, minimize the negative effects of the disease, and prevent disease-related complications.  Examples of chronic disease include diabetes, hypertension, cardiovascular disease, cancer, asthma, pulmonary disease, substance abuse, mental illness, and hyperlipidemia.

(3)  “Chronic care management” means a system of coordinated health care interventions and communications for individuals with chronic disease, including significant patient self-care efforts, systemic supports for the physician and patient relationship, and a plan of care emphasizing prevention of complications utilizing evidence-based practice guidelines, patient empowerment strategies, and evaluation of clinical, humanistic, and economic outcomes on an ongoing basis with the goal of improving overall health.

(4)  “Health care professional” means an individual, partnership, corporation, facility, or institution licensed or certified or authorized by law to provide professional health care services.

(5)  “Health risk assessment” means screening by a health care professional for the purpose of assessing an individual’s health, including tests or physical exams and a survey or other tool used to gather information about an individual’s health, medical history, and health risk factors during a health screening.

(6)  “Patient registry” means the electronic database developed under the blueprint for health.

§ 702.  BLUEPRINT FOR HEALTH; STRATEGIC PLAN

(a)  In coordination with the secretary of administration under section 2222a of Title 3, the commissioner of health shall be responsible for the development and implementation of the blueprint for health, including the five-year strategic plan.

(b)  The commissioner shall establish an executive committee to advise the commissioner on creating and implementing a strategic plan for the development of the statewide system of chronic care as described under this section.  The executive committee shall engage a broad range of health care professionals who provide services under section 2024 of Title 33, health insurance plans, professional organizations, community and nonprofit groups, consumers, businesses, school districts, and state and local government in developing and implementing a five-year strategic plan. 

(c)(1)  The strategic plan shall include:

(A)  a description of the Vermont blueprint for health chronic care model, which includes general, standard elements established in section 703 of this title to be used uniformly statewide by private insurers, third party administrators, and public programs;

(B)  a description of prevention programs and how these programs are integrated into communities and with chronic care management;

(C)  a plan to develop and implement reimbursement systems aligned with the goal of managing the care for individuals with or at risk for chronic disease in order to improve outcomes and the quality of care;

(D)  the involvement of public and private groups, health care professionals, insurers, third party administrators, associations, and firms to facilitate and assure the sustainability of a new system of care;

(E)  alignment of any information technology needs with other health care information technology initiatives;

(F)  the use and development of outcome measures and reporting requirements, aligned with existing outcome measures within the agency of human services, to assess and evaluate the system of care;

(G)  target timelines for inclusion of specific chronic diseases to be included in the chronic care infrastructure and for statewide implementation of the blueprint for health; and

(H)  a strategy for ensuring statewide participation no later than January 1, 2009, in the chronic care management plan, including common outcome measures, best practices and protocols, data reporting requirements, payment methodologies, and other standards.

(2)  The strategic plan shall be reviewed biennially and amended as necessary to reflect changes in priorities.  Amendments to the plan shall be reported to the general assembly in the report established under subsection (d) of this section.

(d)(1)  The commissioner of health shall report quarterly on the status of implementation of the Vermont blueprint for health to the house committee on health care, the senate committee on health and welfare, and the health access oversight committee.  The quarterly report shall include the number of participating insurers, health care professionals, and patients, the progress for achieving statewide participation in the chronic care management plan, including the measures established under subsection (c) of this section, the expenditures and savings for the period, and other information as requested by the committees.  At least annually, the commissioner shall report the results of health care professional and patient satisfaction surveys. The surveys shall be developed in collaboration with the executive committee established under subdivision (b) of this section.

(2)  If statewide participation is not achieved by January 1, 2009, the commissioner shall recommend to the general assembly statutory changes to create alternative measures to ensure statewide participation by health insurers, third party administrators, and health care professionals.

§ 703.  CHRONIC DISEASE PREVENTION AND CARE

             MANAGEMENT; CATAMOUNT HEALTH; REQUEST FOR

            PROPOSALS

(a)(1)  The secretary of administration or designee shall issue a request for proposals no later than January 1, 2007 for health services for individuals with chronic disease who are enrolled in Medicaid, the Vermont health access plan, or Dr. Dynasaur and for health services for individuals enrolled in catamount health.  

(2)  With the goal of including all individuals, the secretary may initially target the chronic care management program to certain groups of individuals to ensure successful implementation and quality of services and to maximize cost savings.  Individuals with chronic disease who are enrolled in catamount health shall be included in the chronic care management program upon enrollment.  In the request for proposals, the secretary may provide a time period for implementing chronic care management to individuals currently enrolled in Medicaid, the Vermont health access plan, or Dr. Dynasaur in order to allow sufficient time for health care professionals and the entity administering the proposal to identify and enroll these individuals.

(3)  The secretary or designee shall apply for a waiver or other approval from the Centers for Medicare and Medicaid Services to include individuals who are dually eligible for Medicare and Medicaid.   

(b)  The secretary shall include in the request for proposal a broad range of chronic diseases for chronic care management.

(c)  The request for proposals shall stipulate that responses include:

(1)  a method involving the health care professional in identifying eligible patients, including the use of the patient registry, an enrollment process which provides incentives and strategies for maximum patient participation, and a standard statewide health risk assessment for each individual;

(2)  the process for coordinating care among health care professionals;

(3)  the methods of increasing communication among health care professionals and patients, including patient education, self-management, and follow‑up plans;

(4)  the educational, wellness, and clinical management protocols and tools used by the care management organization, including management guideline materials for health care professionals to assist in patient-specific recommendations;

(5)  process and outcome measures to provide performance feedback for health care professionals and information on the quality of care, including patient satisfaction and health status outcomes;

(6)  payment methodologies which create financial incentives and rewards for health care professionals to improve disease management and the quality of care, including case management fees or pay for performance; and

(7)  payment to the care management organization which would guarantee net savings to the state or put the care management organization’s fee at risk if the management is not successful in reducing costs to the state.

(d)  The secretary shall review the request for proposals with the commission on health care reform prior to issuance.  The issuance of the requests for proposals is conditioned on the approval of the commission in order to ensure that the request meets the intent of this section and section 702 of this title.

(e)  The secretary shall ensure that the responses to the requests for proposals, including future requests, shall comply with the Vermont blueprint for health.

Sec. 6.  CHRONIC DISEASE PREVENTION AND CARE

             MANAGEMENT; AGENCY OF HUMAN SERVICES;

             IMPLEMENTATION PLAN

(a)  No later than January 1, 2007, the agency of human services shall develop an implementation plan for chronic disease prevention and care management which at minimum meets the criteria and requirements of chapter 13 of Title 18.  The agency’s implementation plan shall be revised periodically to reflect changes to the chronic care infrastructure, disease prevention, and management strategic plan.  In addition to the chronic care management provided under section 703 of Title 18, the agency may provide additional care coordination services to appropriate individuals as specified in its strategic plan.  The agency shall ensure that Medicaid, Medicaid waiver programs, and Dr. Dynasaur change the payment methodologies in order to comply with the recommendation of the strategic plan and the request for proposals developed under chapter 13 of Title 18.  The agency shall analyze and include a recommendation as to any waivers or waiver modifications needed to implement a chronic care management program.

(b)  The agency shall require recertification or reapplication for Medicaid, the Vermont health access plan, and Dr. Dynasaur only once a year.

Sec. 7.  CHRONIC DISEASE PREVENTION AND CARE MANAGEMENT;

             STATE EMPLOYEES

The commissioner of human resources shall include in any request for proposals for the administration of the state employees health benefit plans a request for a description of any chronic care management program provided by the entity and how the program aligns with the Vermont blueprint for health developed under section 702 of Title 18.  The commissioner shall also work with the secretary of administration or designee, and the Vermont state employees’ association on how and when to align the state employees’ health benefit plan with the goals and statewide standards developed by the Vermont blueprint for health in section 702 of Title 18.

* * * Medicaid Reimbursement * * *

Sec. 8.  MEDICAID REIMBURSEMENT

(a)  For fiscal year 2007, the office of Vermont health access shall increase Medicaid reimbursement for evaluation and management procedure codes to enhance payment for primary care services under Medicaid and the Vermont health access plan to a level equivalent to rates in the Medicare program.  Starting in fiscal year 2008, the office shall also align Medicaid rates to reflect the changes in reimbursement for the chronic disease prevention and care management program provided for in chapter 13 of Title 18.

(b)  In fiscal years subsequent to 2007, Medicaid reimbursement increases to health care professionals and hospitals under Medicaid, the Vermont health access plan, and Dr. Dynasaur should be tied to the standards developed under the chronic disease prevention and care management program established in section 702 of Title 18, quality or performance measures.  Prior to implementation, these standards shall be approved by the general assembly through the appropriations process.

Sec. 9.  HOSPITAL SERVICE AREA PILOT PROJECTS

(a)  The office of Vermont health access, in consultation with the department of health, shall issue requests for proposals for community pilot projects in two separate hospital service areas.  The goal of the project shall be to increase integration and collaboration among health care professionals and community partners to coordinate the delivery of quality health care services in an efficient manner for implementation of the blueprint for health and catamount health.

(b)  The responses shall include:

(1)  a comprehensive evaluation process that would establish test measures to monitor improvements and changes in access, clinical outcomes, quality, and cost‑containment;

(2)  parameters for evaluating sharing the financial risk and any savings; and

(3)  developing payment methodologies which include cost containment and realignment of incentives.

(c)  The office shall negotiate with the applicants to determine the scope and duration of the project.  The office shall provide incentive grants of $100,000.00 to successful applicants to be used to coordinate and enhance the effectiveness of the pilot. 

Sec. 10.  VHAP PREMIUM ADJUSTMENTS

Sec. 147(d) of No. 66 of the Acts of 2003, as amended by Sec. 129 of No. 122 of the Acts of the 2003 Adj. Sess. (2004) and Sec. 279 of No. 71 of the Acts of 2005, is further amended to read:

(d)  VHAP, premium-based.

* * *

(2)  The agency shall establish per individual premiums for the VHAP Uninsured program for the following brackets of income for the VHAP group as a percentage of federal poverty level (FPL):

(A)  Income greater than 50 percent and less than or equal to 75 percent of FPL:  $11.00 $7.00 per month.

(B)  Income greater than 75 percent and less than or equal to 100 percent of FPL:  $39.00 $25.00 per month.

(C)  Income greater than 100 percent and less than or equal to 150 percent of FPL:  $50.00 $33.00 per month.

(D)  Income greater than 150 percent and less than or equal to 185 percent of FPL:  $75.00 $49.00 per month.

Sec. 11.  DR. DYNASAUR AND SCHIP PREMIUM ADJUSTMENTS 

Sec. 147(f) of No. 66 of the Acts of 2003, as amended by Sec. 280 of No. 71 of the Acts of 2005, is amended to read:

(f)  Dr. Dynasaur and SCHIP premium changes.

(1)  The agency is authorized to amend the rules for individuals eligible for Dr. Dynasaur under the federal Medicaid and SCHIP programs to require beneficiary households to pay a monthly premium based on the following:

(A)  for individuals living in households whose incomes are greater than 225 percent of FPL and less than or equal to 300 percent of FPL, and who have no other insurance coverage:  $80.00 $40.00 per household per month.

(B)  for individuals living in households whose incomes are greater than 225 percent of FPL and less than or equal to 300 percent of FPL, and who have other insurance coverage:  $40.00 $20.00 per household per month.

(C)  for individuals living in households whose incomes are greater than 185 percent of FPL and less than or equal to 225 percent of FPL:  $30.00 $15.00 per household per month.

* * *

* * * Private Insurance Cost Shift Reviews* * *

Sec. 12.  8 V.S.A. § 4062d is added to read:

§ 4062d.  COST SHIFT REVIEW OF HEALTH INSURANCE PREMIUMS

In connection with insurers’ rate filings made pursuant to sections 4062, 4062b, 4515a, 4587, and 5104 of this title and any other applicable provisions of law, the commissioner shall ensure that health insurers appropriately account for reductions in hospital and provider charges attributable to any increase in Medicaid or other public insurance program reimbursements for health care providers or facilities and to a reduction in bad debt or charity care.

Sec. 13.  COST SHIFT TASK FORCE

The department of banking, insurance, securities, and health care administration shall convene a task force of health care professionals, insurers, hospitals, and other interested parties to determine how to ensure that reductions in hospital and provider charges are reflected in a slower rate of growth in health insurance premiums.  The task force shall make written recommendations on statutory or administrative changes needed to ensure that a reduction in the cost shift is reflected in health insurance premiums to the commission on health care reform no later than December 1, 2006.

* * * Catamount Health * * *

Sec. 14.  33 V.S.A. chapter 19, subchapter 6 is added to read:

Subchapter 6.  Catamount Health

§ 2021.  POLICY AND PURPOSE

Catamount health is established to provide uninsured Vermont residents a defined benefit package of primary, preventive, hospital, acute episodic care, and chronic care, including assistance in preventing and managing chronic disease.  

§ 2022.  DEFINITIONS

As used in this subchapter:

(1)  “Agency” means the agency of administration or the secretary’s designee.

(2)  “Benefits” means health services and amounts of coverage provided by catamount health, including allocation of cost-sharing amounts, deductibles, and benefit limits.

(3)  “Catamount health” means the health benefit plan offered under this subchapter.

(4)  “Chronic care” means health services provided by a health care professional for an established disease that is expected to last a year or more and that requires ongoing clinical management attempting to restore the individual to highest function, minimize the negative effects of disease, and prevent disease-related complications.  Examples of chronic disease include diabetes, hypertension, cardiovascular disease, cancer, asthma, pulmonary disease, substance abuse, mental illness, and hyperlipidemia.

(5)  “Chronic care management” means a system of coordinated health care interventions and communications for individuals with chronic disease, including significant patient self-care efforts, systemic supports for the physician and patient relationship, and a plan of care emphasizing prevention of complications utilizing evidence-based practice guidelines, patient empowerment strategies, and evaluation of clinical, humanistic, and economic outcomes on an ongoing basis with the goal of improving overall health.

(6)  “Health care professional” means an individual, partnership, corporation, facility, or institution licensed or certified or authorized by law to provide professional health care services.

(7)  “Health risk assessment” means screening by a health care professional for the purpose of assessing an individual’s health, including tests or physical examinations and a survey or other tool used to gather information about an individual’s health, medical history, and health risk factors during a health screening.

(8)  “Health service” means any medically necessary treatment or procedure to maintain, diagnose, or treat an individual’s physical or mental condition, including services ordered by a health care professional and services to assist in activities of daily living.

(9)  “Preventive care” means health services provided by health care professionals to identify and treat asymptomatic individuals who have developed risk factors or preclinical disease, but in whom the disease is not clinically apparent, including immunizations and screening, counseling, treatment, and medication determined by scientific evidence to be effective in preventing or detecting disease.

(10)  “Primary care” means health services provided by health care professionals specifically trained for and skilled in first-contact and continuing care for individuals with signs, symptoms, or health concerns, not limited by problem origin, organ system, or diagnosis, and shall include prenatal care and the treatment of mental illness.

(11)  “Uninsured” means an individual who does not qualify for Medicare, Medicaid, the Vermont health access plan, or Dr. Dynasaur, 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:

(A)  the individual’s employer-sponsored coverage ended because of:

(i)  loss of employment;

(ii)  death of the principal insurance policyholder;

(iii)  divorce or dissolution of a civil union;

(iv)  no longer qualifying as a dependent under the plan of a parent or caretaker relative;

(v)  no longer qualifying for 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, or otherwise terminated studies.

(12)  “Vermont resident” means an individual domiciled in Vermont as evidenced by an intent to maintain a principal dwelling place in Vermont indefinitely and to return to Vermont if temporarily absent, coupled with an act or acts consistent with that intent.

§ 2023.  ELIGIBILITY

(a)  An individual shall be eligible for catamount health if the individual is an uninsured Vermont resident.  An individual receiving Medicaid, the Vermont health access plan, or Dr. Dynasaur within 12 months of applying for catamount health shall not be required to wait 12 months to be eligible for catamount health.  An individual who has coverage under catamount health may purchase an insurance policy designed to provide health services not covered by catamount health and remain eligible.

(b)  The agency shall establish rules pursuant to chapter 25 of Title 3 on the specific criteria to demonstrate eligibility, including criteria for and proof of residency, income, and insurance status.

(c)  Nothing in this subchapter shall require an individual already covered by health insurance to terminate that insurance or enroll in catamount health.

§ 2024.  BENEFITS

(a)  The agency shall develop by rule pursuant to chapter 25 of Title 3 a comprehensive benefit package of health services and chronic care management to be provided uninsured Vermont residents under catamount health, beginning July 2, 2007.  The benefits shall include primary care, preventive and chronic care, acute episodic care, and hospital services.  The benefits shall be actuarially equivalent to the Selectcare point of service plan administered by Cigna and offered to state employees in 2006, except that the premium and cost-sharing amounts shall be as provided for in this subchapter.

(b)  To the extent catamount health provides coverage for any particular type of health service or for any particular medical condition, it shall cover those health services and conditions when provided by any type of health care professional acting within the scope of practice authorized by law. Catamount health may establish a term or condition that places a greater financial burden on an individual for access to treatment by the type of health care professional only if it is related to the efficacy or cost-effectiveness of the type of service.

(c)  The agency shall ensure that catamount health will provide a choice of services and health care professionals, contain costs over time, include chronic care management, and improve quality of care and health outcomes.  In determining the amount, duration, and scope of benefits to be provided under this subchapter, the agency shall consider:

(1)  credible, evidence-based, scientific research and comment by health care professionals both nationally and internationally concerning clinical efficacy and risk;

(2)  the cost-effectiveness of health services and technology; and

(3)  revenues anticipated to be available to finance catamount health.

§ 2025.  ADMINISTRATION

(a)  The agency shall contract with a third party administrator to administer catamount health as provided for in section 703 of Title 18.  For catamount health, the agency shall include criteria for an aggressive enrollment strategy by the administrator.  The agency shall ensure that each individual receives a health risk assessment upon enrollment in catamount health.  The agency shall weigh the costs and benefits of purchasing a reinsurance policy for catamount health as a method of managing risk and reducing the cost of the premium amounts.  The agency may purchase reinsurance if it determines that it is

cost-effective and prudent to do so.

(b)  In addition to the chronic disease prevention and care management payment provisions in the request for proposals under section 703 of Title 18, the agency shall pay for other covered health services at a level at least ten percent greater than for levels paid under the Medicare program.  If Medicare does not pay for a service covered under the plan, the commissioner shall establish some other payment amount for such services determined after consultation with affected providers.  Members of catamount health shall not be billed any additional amount for health services, except as provided for as cost sharing in section 2026 of this title.

(c)  The agency or administrator of catamount health shall make available the necessary information, forms, and billing procedures to health care professionals to ensure payment for health services covered under catamount health.  The agency or administrator shall use a single, uniform, simplified form to determine eligibility for Medicaid, any Medicaid waiver program, Dr. Dynasaur, any state‑funded pharmacy program, and catamount health to ensure that any individual eligible for these programs has the opportunity to enroll.  The agency shall collect data necessary to evaluate catamount health, including the individual’s reason for not having insurance, whether the individual’s employer offers insurance, and how the individual got information about catamount health.  Receipt of this information shall not be an eligibility requirement.  The agency shall require individuals to reapply or recertify only annually.  

(d)  The agency shall structure the administration of catamount health to ensure that individuals may transition smoothly between Medicaid, the Vermont health access plan, Dr. Dynasaur, and catamount health.  The agency may also modify the administrative systems for Medicaid, the Vermont health access plan, or Dr. Dynasaur to achieve this purpose.

(e)  An individual aggrieved by an adverse decision of the agency or the administrator may grieve or appeal the decision under rules and procedures consistent with 42 C.F.R. § 438.402.

§ 2026.  COST-SHARING; WELLNESS DISCOUNT

(a)  The agency shall propose to the general assembly reasonable sliding‑scale premiums for individuals up to 350 percent of the federal poverty level, deductibles, co-payments, or other cost‑sharing amounts applicable to catamount health.  Individuals with incomes above 350 percent of federal poverty level shall be charged a premium reflecting the actual cost of catamount health.  Cost-sharing amounts shall not apply to chronic care for individuals in chronic care management or to preventive care.

(b)  For an individual who enrolls 13 months or more after the initial month of eligibility for catamount health, premiums shall increase one percent per month for each month thereafter when the individual was eligible for but did not enroll in catamount health.

(c)  The agency may include financial or other incentives to encourage healthy lifestyles and patient self‑management.  These incentives shall comply with the rules developed by the department of banking, insurance, securities, and health care administration for health promotion and disease prevention programs offered by health insurers.

Sec. 15.  CATAMOUNT HEALTH; PREMIUMS

Subject to amendment in the fiscal year 2008 budget, the agency of administration shall establish individual and family premium amounts for catamount health established in subchapter 6 of chapter 19 of Title 33.  The agency shall establish family premium amounts by income bracket based on the individual premium amounts and the average family size.  The individual premiums shall be by income bracket as a percentage of federal poverty level (FPL):

(1)  Income less than or equal to 200 percent of FPL:  $60.00 per month.

(2)  Income greater than 200 percent and less than or equal to 225 percent of FPL:  $90.00 per month.

(3)  Income greater than 225 percent and less than or equal to 250 percent of FPL:  $110.00 per month.

(4)  Income greater than 250 percent and less than or equal to 275 percent of FPL:  $125.00 per month.

(5)  Income greater than 275 percent and less than or equal to 300 percent of FPL:  $135.00 per month.

(6)  Income greater than 300 percent and less than or equal to 325 percent of FPL:  $150.00 per month.

(7)  Income greater than 325 percent and less than or equal to 350 percent of FPL:  $170.00 per month.

(8)  Income greater than 350 percent:  $310.00 per month.

Sec. 16.  RULES PROCESS AND OVERSIGHT

(a)  The secretary of administration or designee shall submit any final proposed rules required to implement this act to the commission on health care reform established by Sec. 277c of No. 71 of the Acts of 2005 and the health access oversight committee for consideration.  The commission and committee may submit separate recommendations, limit comment to certain provisions in the rules, or to the extent feasible, make joint recommendations to the legislative committee on rules.

(b)  The health access oversight committee shall monitor the development, implementation, and ongoing operation of catamount health established by subchapter 6 of chapter 19 of Title 33.  The agency of administration shall submit to the committee quarterly progress reports that shall include revenue and expenditures for catamount health for the prior months, enrollment and projected enrollment, projected expenditures related to enrollment for the fiscal year, and other information as requested by the committee.  At least annually, the secretary shall report the results of health care professional and patient satisfaction surveys regarding the administration of catamount health.

Sec. 17.  GLOBAL COMMITMENT FINANCING

To the extent feasible and allowable under federal law, the agency of administration and human services shall finance catamount health through the Global Commitment for Health Medicaid Section 1115 waiver.  No later than July 1, 2006, the agency shall seek a waiver amendment from the Centers for Medicare and Medicaid Services to include catamount health in the premium amount paid to the office of Vermont health access under Global Commitment.  The agency may require the office of Vermont health access to use revenue from the capitation payments related to beneficiaries covered under Global Commitment as described in Term and Condition 40 to finance some or all of catamount health.  The agency may administer catamount health in the manner required by the Global Commitment waiver.

Sec. 18.  REPORTS

(a)  The department of banking, insurance, securities, and health care administration shall complete the survey of insurance status no later than June 30, 2009.  The agency of administration shall make recommendations to the general assembly no later than January 15, 2010 on any changes to catamount health needed to increase enrollment to achieve a 98 percent rate of insured Vermonters.  In making its recommendations, the agency shall consider whether mandating participation in public health care programs and health insurance coverage is necessary to increase enrollment.  The agency shall include supporting information and data for the recommendation.

(b)  No later than January 15, 2009, the agency of administration shall report to the general assembly on:

(1)  the feasibility of catamount health by allowing individuals who have been insured during the previous 12 months, individuals who are underinsured, and employers to buy into the program at full premium cost;

(2)  the number of individuals enrolled in catamount health who have employer-sponsored insurance and the per‑member per‑month costs of these individuals;

(3)  the number of individuals enrolled in any chronic care management program which complies with the requirements in chapter 13 of Title 18, including those covered by private insurance; and

(4)  removing or capping the premium increases for enrollment outside the initial enrollment period.


Sec. 19.  ENROLLMENT INITIATIVES

The secretary of administration or designee and the director of the office of Vermont health access shall engage interested groups and parties in assisting with outreach and informational initiatives to ensure Vermonters have information about health care coverage options provided by Medicaid, the Vermont health access plan, Dr. Dynasaur, and catamount health.  

Sec. 20.  COMMISSION ON HEALTH CARE REFORM

Any reports required by this act shall be provided to the commission on health care reform established by Sec. 277c of No. 71 of the Acts of 2005 until the time that the commission dissolves.

Sec. 21.  APPROPRIATIONS

(a)  For fiscal year 2007, the sum of $2,900,000.00 is appropriated from the Global Commitment fund for the increase in Medicaid rates under Sec. 8 of this act.

(b)  For fiscal year 2007, the sum of $200,000.00 is appropriated from the general fund for the incentive grants for the hospital service area payment pilot projects under Sec. 9 of this act.

Sec. 22.  EFFECTIVE AND IMPLEMENTATION DATES

(a)  This act shall take effect upon passage, except that Secs. 8 (Medicaid reimbursement) and 12 (cost shift review) shall take effect July 1, 2006, and Secs. 10 (VhHAP premiums) and 11 (Dr. Dynasaur premiums) shall take effect July 1, 2007.

(b)  Catamount health shall be implemented on July 2, 2007.  The agency of administration shall make application forms available and allow individuals to apply for the program at least 90 days prior to implementation.



Published by:

The Vermont General Assembly
115 State Street
Montpelier, Vermont


www.leg.state.vt.us