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H.861

AN ACT RELATING TO HEALTH CARE AFFORDABILITY FOR VERMONTERS

The Senate proposes to the House to amend the bill by striking out all after the enacting clause and inserting in lieu thereof the following:

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 conditions; coverage of the uninsured through Catamount Health, a comprehensive and affordable benefit plan with sliding-scale premiums; and providing minimum preventive services starting with immunizations for all Vermonters.  The general assembly finds that chronic care management is one tool to contain health care costs and ensure that the costs of Vermont’s health care system become sustainable.

(b)  It is also the intent of the general assembly to ensure that any reduction in the “cost shift” to private insurance is returned to consumers by slowing the rate of growth in insurance premiums.  This 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 this cost shift.  In addition, standardizing the minimum criteria and reporting requirements for uncompensated care and bad debt write-offs by hospitals will more clearly identify and account for this 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 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 manner that is timely, patient-centered, and seeks to improve the quality and affordability of patient care.

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

(1)  the state’s chronic care infrastructure, 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 a chronic condition or disability.

(2)  the Vermont health information technology project pursuant to section 9417 of Title 18.

(3)  the multi-payer data collection project pursuant to section 9410 of Title 18.

(4)  the common claims administration project pursuant to section 9408 of Title 18.

(5)  the consumer price and quality information system pursuant to section 9410 of Title 18.

(6)  any information technology work done by the quality assurance system pursuant to section 9416 of Title 18.

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

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

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

(10)  the uniform hospital uncompensated care policies.

(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 recommendations for administration or legislation.  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 of the general assembly 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” chronic condition 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 the strategic plan for the blueprint for health are codified in Sec. 5 of this act as chapter 13 of Title 18. 

(c)(1)  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

(2)  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.

(3)  Due to the increase in funding and expected expanded capacity of the blueprint for health, the commissioner of health, in collaboration with the executive committee established under section 702 of Title 18, shall consider and include recommendations in the revised strategic plan for an implementation structure and time line.  The considerations and recommendations shall include at minimum an assessment of the options for an organizational structure, and a recommendation as to which structure is most likely to achieve the statewide goals of the blueprint for health, to maintain an effective partnership between the public and private sectors, and to broaden the participation of stakeholders statewide.  The commissioner of health shall submit a preliminary report on the implementation structure no later than June 15, 2006 to the commission on health care reform.

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

Chapter 13.  CHRONIC CARE INFRASTRUCTURE

AND PREVENTION MEASURES

§ 701.  DEFINITIONS

For the purposes of this chapter:

(1)  “Blueprint for health” means the state’s plan for chronic care infrastructure, prevention of chronic conditions, and chronic care management program, and includes an integrated approach to patient self-management, community development, health care system and professional practice change, and information technology initiatives.

(2)  “Chronic care” means health services provided by a health care professional for an established disease, condition, or disability 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 condition or disability, and prevent complications related to chronic conditions or disabilities.  Examples of chronic conditions 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 conditions or disabilities, 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 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.

(6)  “Patient registry” means the electronic database developed under the blueprint for health that will include information on all cases of a particular disease or health condition in a defined population of individuals.

§ 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)(1)  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 and prevention as described under this section.  The executive committee shall consist of no fewer than 10 individuals, including a representative from the department of banking, insurance, securities, and health care administration; the office of Vermont health access; the Vermont medical society; the Vermont program for quality in health care; the Vermont association of hospitals and health systems; two representatives of private health insurers; a consumer; a representative of the complementary and alternative medicine profession; and a primary care professional serving low-income or uninsured Vermonters. 

(2)  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 model, which includes general, standard elements established in section 703 of this title, patient self-management, community initiatives, and health system and information technology reform, 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, with chronic care management, and the blueprint for health model;

(C)  a plan to develop and implement reimbursement systems aligned with the goal of managing the care for individuals with or at risk for conditions 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)  the involvement of community and consumer groups to facilitate and assure the sustainability of health services supporting healthy behaviors and good patient self-management for the prevention and management of chronic conditions;

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

(G)  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 chronic care;

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

(I)  identification of resource needs for implementation and sustaining the blueprint for health and strategies to meet the needs; and

(J)  a strategy for ensuring statewide participation no later than January 1, 2009, by insurers, third-party administrators, health care professionals, hospitals and other providers, and consumers 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 annually 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 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; the results of health care professional and patient satisfaction surveys; the progress toward creation and implementation of privacy and security protocols; and other information as requested by the committees.  The surveys shall be developed in collaboration with the executive committee established under subsection (b) of this section.

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

§ 703.  CHRONIC CARE MANAGEMENT PROGRAM

(a)  The secretary of administration or designee shall create a chronic care management program administered or provided by a private entity for individuals with chronic conditions who are enrolled in Medicaid, the Vermont health access plan (VHAP), Dr. Dynasaur, or Catamount Health.

(b)  The secretary shall include a broad range of chronic conditions in the chronic care management program.

(c)  The chronic care management program shall be designed to 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 communications 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 to align reimbursements and create financial incentives and rewards for health care professionals to establish management systems for chronic conditions, to improve health outcomes, and to improve the quality of care, including case management fees, pay for performance, payment for technical support and data entry associated with patient registries, the cost of staff coordination within a medical practice, and any reduction in a health care professional’s productivity;

(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;

(8)  a requirement that the data on enrollees be shared, to the extent allowable under federal law, with the secretary in order to inform the health care reform initiatives under section 2222a of Title 3;

(9)  a method for the care management organization to participate closely in the blueprint for health and other health care reform initiatives; and

(10)  participation in the pharmacy best practices and cost-control program under subchapter 5 of chapter 19 of Title 33, including the multi-state purchasing pool and the statewide preferred drug list.

(d)  The secretary shall ensure that the chronic care management program is modified over time to comply with the Vermont blueprint for health strategic plan and to the extent feasible, collaborate in its initiatives.

Sec. 6.  PREVENTION AND CHRONIC 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 prevention of chronic conditions and for chronic 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 Vermont blueprint for health 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)  Where permitted under federal law, the agency shall require recertification or reapplication for Medicaid, the Vermont health access plan (VHAP), and Dr. Dynasaur no more often than once a year.

Sec. 7.  PREVENTION AND CHRONIC CARE MANAGEMENT; STATE

             EMPLOYEES

The commissioner of human resources shall include in any request for proposals for the administration of the health benefit plans for state employees 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 strategic plan 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.

* * * Administration of Medicaid and Catamount Health * * *

Sec. 7a.  REQUEST FOR PROPOSALS; MEDICAID; CATAMOUNT

              HEALTH

(a)(1)  The agency of administration shall issue a request for proposals no later than January 1, 2007 for a single private entity to provide coverage for health services for individuals enrolled in Medicaid, the Vermont health access plan (VHAP), Dr. Dynasaur, or Catamount Health as provided for in section 703 of Title 18 and in chapter 19 of Title 33.  The secretary shall not include individuals enrolled in Medicaid or Dr. Dynasaur who are also eligible for Medicare, who are enrolled in the Choices for Care Medicaid Section 1115 waiver, or who are in an institute for mental disease as defined in 42 C.F.R § 435.1009.

(2)  The request for proposals shall provide that responses may allow an entity to accept the financial risk and administration of the programs, to administer the programs without accepting financial risk, or to provide for a combination of risk sharing.

(b)  The secretary shall review the request for proposals with the commission on health care reform prior to issuance.  The issuance of the request for proposals is conditioned on the approval of the commission in order to ensure that the request meets the intent of this section, section 702 of Title 18, and chapter 19 of Title 33.

(c)  Within 10 days of the receipt of the proposals, the secretary shall provide copies of the proposals to an independent actuary or other appropriate consultant retained by the joint fiscal committee to review the proposals and provide the commission on health care reform and the joint fiscal committee with an analysis and recommendation.

(d)  The implementation of the programs is conditional upon approval by act of the general assembly, or, if the general assembly is not in session and the speaker and the president pro tempore determine that it will not reconvene within the next 30‑day period, by a majority vote of the combined membership of the joint fiscal committee and the commission on health care reform at a joint meeting.  Prior to consideration by the general assembly, the commission on health care reform and the joint fiscal committee shall provide the general assembly with recommendations on the proposals.   

* * * Medicaid Initiatives * * *

Sec. 8.  MEDICAID REIMBURSEMENT

(a)(1)  The office of Vermont health access shall adjust Medicaid and the Vermont health access plan reimbursement to reflect the following priorities in the following order:

(A)  an increase in base rates for evaluation and management procedure codes to enhance payment to primary care specialties for primary care services to a level equivalent to the 2006 rates in the Medicare program;

(B)  an increase in the PCPlus case management rates by $5.00 per member per month for patients whose primary care provider participates in the Vermont blueprint for health established in section 702 of Title 18;

(C)  the provision of incentives and payment restructuring for health care professionals participating in the care coordination program;

(D)  an increase in base rates for frequently used current procedural terminology (CPT) codes which are significantly lower than the 2006 Medicare reimbursement levels; and

(E)  an increase in dental reimbursement by increasing the dental cap for adults and by rate increases.   

(2)  The Medicaid reimbursement rate increases in subdivision (1) of this section shall be effective on January 1, 2007 for fiscal year 2007, and July 1 for fiscal years 2008 through 2010.

(b)  For fiscal year 2007, the office of Vermont health access shall increase Medicaid reimbursement rates to hospitals by five percent effective January 1, 2007.  In fiscal year 2008 and thereafter, the office shall increase Medicaid reimbursement rates for inpatient services to hospitals by five percent annually on July 1. 

(c)  In fiscal years subsequent to 2007, it is the intent of the general assembly that 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 and quality or performance measures developed under the Vermont blueprint for health strategic plan established in section 702 of Title 18.  Prior to implementation, these standards shall be approved by the general assembly through the appropriations process.

(d)  No later than October 31, 2006, the office shall report to the health access oversight committee with a plan for allocation of the appropriated amounts for fiscal year 2007 among the priorities established in subsection (a) of this section and among inpatient services for hospitals as provided for in subsection (b) of this section.  Prior to the implementation of the reimbursement adjustments in this section, the health access oversight committee shall review and determine if the allocation among the priorities is equitable and reflects legislative intent.

Sec. 9.  VHAP PREMIUM REDUCTIONS 

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. 10.  DR. DYNASAUR AND SCHIP PREMIUM REDUCTIONS

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.

* * *

Sec. 11.  PREMIUM ASSISTANCE PROGRAM;

               EMPLOYER‑SPONSORED INSURANCE

(a)  No later than October 1, 2007, the agency of human services shall establish a premium assistance program to assist individuals eligible for or enrolled in the Vermont health access plan and Catamount Health and their dependents to purchase an approved employer-sponsored insurance plan if offered to those individuals by an employer.  Children who are eligible for Medicaid or Dr. Dynasaur may be enrolled in either the premium assistance program or the Medicaid or Dr. Dynasaur programs.  

(b)  VHAP-eligible premium assistance.  For individuals enrolled in the Vermont health access plan on October 1, 2007 or for those who apply for enrollment in the Vermont health access plan on or after October 1, 2007 who have access to an approved employer‑sponsored insurance plan, the employer premium assistance program shall provide:

(1)  A subsidy of premiums or cost‑sharing amounts based on the household income of the eligible individual to ensure that the individual is obligated to make out‑of‑pocket expenditures for premiums and cost‑sharing amounts which are substantially equivalent to or less than the premium and cost‑sharing obligations on an annual basis under the Vermont health access plan.

(2)  A requirement that eligible individuals enroll in an approved employer‑sponsored insurance plan as a condition of continued assistance under this section or coverage under the Vermont health access plan, except that dependents who are children of eligible individuals shall not be required to enroll in the premium assistance program.

(3)  Supplemental benefit coverage to some or all individuals eligible for premium assistance under this subsection if offered by the office of Vermont health access.

(c)  Catamount Health-eligible premium assistance.  For individuals who are eligible for Catamount Health and who have access to an approved employer-sponsored insurance plan, the employer premium assistance program shall provide:

(1)  A subsidy of premiums or cost‑sharing amounts which are substantially equivalent to or less than the premium and cost‑sharing obligations on an annual basis under Catamount Health. 

(2)  A requirement that eligible individuals enroll in an approved employer‑sponsored insurance plan as a condition of continued assistance under this section or coverage under Catamount Health, except that dependents who are children of eligible individuals shall not be required to enroll in the premium assistance program.

(d)  In consultation with the department of banking, insurance, securities, and health care administration, the agency shall develop criteria for approving employer‑sponsored health insurance plans to ensure the plans provide comprehensive and affordable health insurance when combined with the assistance under this section.  At minimum, an approved employer-sponsored insurance plan shall include covered benefits and chronic care management to be substantially similar, as determined by the agency, to the benefits covered under Catamount Health.

(e)  In the event that the agency determines that appropriations for the premium assistance program are insufficient to meet the projected costs of enrolling new program participants, the agency may suspend or terminate new enrollment for participants in the program or restrict enrollment to eligible lower-income individuals.

(f)  The agency of human services shall request federal approval for an amendment to the Global Commitment for Health Medicaid Section 1115 waiver for the premium assistance program authorized by this section.

(g)  Of the amount appropriated in Sec. 271 of H.881 of the 2005 adjourned session for the employer-sponsored insurance premium assistance program established by this section, no more than $250,000.00 may be expended until additional information and analysis is provided to determine the specific parameters involved in an employer-sponsored premium assistance program, the costs of the program, and savings that may be attributable to the transition of individuals from the Vermont health access plan (VHAP) to an available employer‑sponsored plan.  Expenditures of any additional amounts appropriated by this section may be made after November 15, 2006, only upon approval by a majority of the combined membership of the joint fiscal committee and the health access oversight committee at a joint meeting upon receipt of a report from the agency, including the following:

(1)  a plan for additional expenditures;

(2)  a survey to determine whether individuals currently enrolled in VHAP, including those eligible as caretakers, are potentially eligible for employer-sponsored premium assistance under this section; and

(3)  the anticipated budgetary impact of an employer-sponsored insurance premium assistance program for fiscal year 2008, including savings attributable to enrolling current VHAP enrollees in the premium assistance program established under this section and the cost of providing the subsidy to these enrollees.

Sec. 12.  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.  

* * * Private Insurance Cost Shift Reviews * * *

Sec. 13.  18 V.S.A. § 9456(b)(9) is amended to read:

(9)  require each hospital to file an analysis that reflects a reduction in net revenue needs from non-Medicaid payers equal to any anticipated increase in Medicaid, Medicare, or another public health care program reimbursements resulting from appropriations designed to reduce the Medicaid cost shift, and to any reduction in bad debt or charity care due to an increase in the number of insured individuals.

Sec. 14.  COST SHIFT TASK FORCE

Increases in Medicaid rates, reductions in private insurance claims through the nongroup market security trust, a decrease in the number of individuals without insurance, and the provision of minimum preventive services through Catamount Health should reduce the cost shift. The department of banking, insurance, securities, and health care administration shall convene a task force of health care professionals, insurers, hospitals, employers offering private health insurance, and other interested parties to determine how to ensure that reductions in the cost shift are reflected in a reduction or slower rate of growth both in hospital and provider charges and in private insurance premiums.  The task force shall make written recommendations to the commission on health care reform no later than December 1, 2006 regarding statutory or administrative changes needed to ensure that a reduction in the cost shift is reflected in a reduction or slower rate of growth in hospital charges and health insurance premiums.

* * * Catamount Health * * *

Sec. 15.  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 conditions.  Catamount Health will also provide certain minimum preventive services without cost to all Vermonters.

§ 2022.  DEFINITIONS

As used in this subchapter:

(1)  “Administrator” means the private entity that administers and, if applicable, assumes financial risk for Catamount Health.

(2)  “Agency” means the agency of administration.

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

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

(5)  “Chronic care” means health services provided by a health care professional for an established disease, condition, or disability 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 condition or disability, and prevent complications related to chronic conditions or disabilities.  Examples of chronic conditions include diabetes, hypertension, cardiovascular disease, cancer, asthma, pulmonary disease, substance abuse, mental illness, and hyperlipidemia.

(6)  “Chronic care management” means a system of coordinated health care interventions and communications for individuals with chronic conditions or disabilities, 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.

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

(8)  “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.

(9)  “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.

(10)  “Immunizations” means vaccines and the application of the vaccines as recommended by the practice guidelines for children and adults established by the Advisory Committee on Immunization Practices (ACIP) to the Centers for Disease Control and Prevention (CDC).

(11)  “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 a condition or disability.

(12)  “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.

(13)  “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; or

(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.

(14)  “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)(1)  Except as provided in subdivision (2) of this subsection, an individual shall be eligible for Catamount Health if the individual is an uninsured Vermont resident.  Any Vermont resident shall be eligible for the minimum preventive care offered under section 2025 of this title.

(2)  An individual shall not be eligible for Catamount Health if the individual is of the age of majority and is claimed on a tax return as a dependent of a resident of another state.

(b)  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.

(c)  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.

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

(e)(1)  If the monies available in the catamount fund established under section 2028 of this title are insufficient to support ongoing, new enrollment in Catamount Health, the agency shall recommend to the health access oversight committee a plan to cap or limit enrollment.

(2)  The agency’s determinations that monies available are insufficient shall be based on monthly enrollment figures and the official revenue estimates for the catamount fund under section 305a of Title 32.

(3)  A plan to cap or limit enrollment submitted to the health access oversight committee under this section shall be deemed approved unless the committee disapproves the plan within 21 days of submission by the agency.

(4)  If at any time after enrollment is capped or limited under this subsection, expenditures are anticipated to be equal to or less than the aggregate amount of funds appropriated for Catamount Health, the agency shall recommend for approval by the health access oversight committee a plan to open enrollment 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 under Catamount Health beginning October 1, 2007.

(b)(1)  The benefits shall include primary care, preventive and chronic care, acute episodic care, and hospital services.  The benefits shall be actuarially equivalent to the Vermont Freedom Plan with a preferred provider organization, $200.00 deductible, and $10.00 office co‑payment offered by Blue Cross Blue Shield of Vermont in 2006. 

(2)(A)  The agency shall propose to the general assembly reasonable sliding‑scale premiums for individuals up to 300 percent of the federal poverty level, deductibles, co‑payments, benefit limits, or other cost‑sharing amounts applicable to the Catamount Health benefits under this section.  Deductible and other cost-sharing amounts shall not apply to chronic care for individuals in chronic care management or to preventive care.  Individuals with incomes above 300 percent of federal poverty level shall be charged a premium reflecting the actual cost of Catamount Health.

(B)  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 prevention programs offered by health insurers.

(c)  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.

(d)  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.  MINIMUM PREVENTIVE SERVICES

(a)  Notwithstanding the eligibility, premium, and cost-sharing criteria in this subchapter, any Vermont resident may receive minimum preventive services through Catamount Health.  For the purposes of this section, minimum preventive services shall include immunizations and may include additional services as funding permits.

(b)  For the purposes of this section, Catamount Health shall be the secondary payer to Medicaid, the Vermont health access plan, Dr. Dynasaur, Medicare, and any federal health insurance or federal program covering immunizations.

§ 2026.  ADMINISTRATION

(a)  Catamount Health shall be administered by a private entity, which also may contract to assume partial or all financial risk of the program.  Catamount Health shall include a chronic care management program as provided for in section 703 of Title 18.  The agency shall include criteria for an aggressive enrollment strategy by the administrator.  The agency or administrator shall ensure that each individual receives a health risk assessment upon enrollment in Catamount Health.  If Catamount Health is a self-insured product, the agency shall purchase a stop-loss policy for an aggregate claims amount for Catamount Health as a method of managing risk.  The agency shall determine the amount of aggregate stop-loss reinsurance and may purchase additional types of reinsurance if prudent and cost-effective.  The agency may also include in the contract for the administration of Catamount Health any utilization review procedures and other benefit management provisions consistent with section 703 of Title 18 and any federal requirements, if applicable, through the Global Commitment for Health Medicaid Section 1115 waiver.

(b)  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.  To facilitate enrollment, 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, or Catamount Health.  The agency or administrator 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.  If permitted under federal law, the agency or administrator shall require individuals to reapply or recertify no more often than annually.  

(c)  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.

(d)  If pharmacy benefits are offered under Catamount Health, the agency or administrator shall ensure that Catamount Health complies with the pharmacy best practices and cost-control program under subchapter 5 of this chapter.  The agency or administrator shall collaborate with the office of Vermont health access in negotiating prescription drug prices and shall participate in the multi-state drug purchasing pool and the preferred drug list administered by the office of Vermont health access.  To the extent feasible, the agency or administrator shall offer pharmacy benefits through pharmacies able to access the federal Section 340B of U.S. Public Law 102-585 price.

(e)  An individual enrolled in Catamount Health who is 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.

§ 2027.  PAYMENT; HEALTH CARE PROFESSIONALS; HOSPITALS

(a)  Except as provided for in subsection (b) of this section, the agency or administrator shall pay health care professionals using the Medicare payment methodologies at a level at least ten percent greater than for levels paid under the Medicare program.  Payments under this subsection shall be indexed to the Medicare economic index developed by the Centers for Medicare and Medicaid Services.  

(b)  Payments for hospital services shall be calculated using the Medicare payment methodology adjusted for each hospital to ensure payments at 110 percent of the hospital’s actual cost for services.  Payments under this subsection shall be indexed to changes in the Medicare payment rules, but shall not be lower than 102 percent of the hospital’s actual cost for services.

(c)  Payments for chronic care and chronic care management shall meet the requirements in section 703 of Title 18.

(d)  If Medicare does not pay for a service covered under Catamount Health, 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 2024 of this title.

§ 2028.  Catamount Fund

(a)  The Catamount fund is established in the treasury as a special fund to be a source of financing for Catamount Health.

(b)  Into the fund shall be deposited:

(1)  revenue from the employer health care premium contribution pursuant to chapter 25 of Title 21;

(2)  17.5 percent of the revenue from the cigarette tax levied pursuant to chapter 205 of Title 32;

(3)  premium amounts paid by individuals unless paid directly to the administrator; and

(4)  the proceeds from grants, donations, contributions, taxes, and any other sources of revenue as may be provided by statute, rule, or act of the general assembly.

(c)  The fund shall be administered pursuant to subchapter 5 of chapter 7 of Title 32, except that interest earned on the fund and any remaining balance shall be retained in the fund.  The agency shall maintain records indicating the amount of money in the fund at any time.

(d)  All monies received by or generated to the fund shall be used only as allowed by appropriation of the general assembly for the administration and delivery of Catamount Health and for transfers to the state health care resources fund established in section 1901d of this title.

Sec. 16.  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 under subchapter 6 of chapter 19 of Title 33 for the first year in the amounts established in this section and shall index the premiums in future years to the overall growth in spending per enrollee in Catamount Health.  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 of FPL:  the actual cost of Catamount Health, which for fiscal year 2008 is estimated at $350.00 per month.

Sec. 16a.  IMMUNIZATIONS; ADMINISTRATION

(a)  The secretary of administration or designee shall study methods to ensure that all Vermonters have access to immunizations through Catamount Health as provided for in section 2025 of Title 33.  In conducting the study, the secretary shall consult with the immunization program advisory committee, the department of health, the department of banking, insurance, securities, and health care administration, the office of Vermont health access, and other interested parties.

(b)  The study shall include findings and recommendations concerning the following:

(1)  Effective strategies for improving immunization rates, including options for:

(A)  enhancing access to vaccination services in both medical and public health settings; and

(B)  strengthening school and child care immunization requirements;

(2)  Recommendations for expanding the immunization program to adults, including recording of immunizations for adults in the Vermont immunization registry;

(3)  Recommendations for improving quality assurance and quality improvement in assuring proper vaccine storage and handling, measuring immunization coverage rates, and addressing barriers to coverage; and 

(4)  Options for sustainable funding of the purchase and administration of vaccines, including:

(A)  Equitable sharing of cost of the state’s immunization program between public and private resources;

(B)  Payment by the state of a reasonable fee to health care professionals for individuals receiving coverage for immunizations through Catamount Health.

(c)  The secretary shall report the findings and recommendations of the study to the house committee on health care and the senate committee on health and welfare no later than January 15, 2007.

Sec. 17.  RULES PROCESS AND OVERSIGHT

(a)  The secretary of administration or designee shall submit any final proposed rules, developed under chapter 25 of Title 3, 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 joint legislative committee on administrative 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.

(c)  The agency shall submit annual reports on the receipts, expenditures, and balances in the catamount fund established in section 2028 of Title 33 to the joint fiscal committee at its September meeting.

Sec. 18.  GLOBAL COMMITMENT FINANCING

To the extent feasible and allowable under federal law, the agencies of administration and of human services shall finance Catamount Health through the Global Commitment for Health Medicaid Section 1115 waiver.  No later than July 1, 2006, the agencies 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 agencies 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 agencies may administer Catamount Health in the manner required by the Global Commitment.

* * * Nongroup Health Insurance Market * * *

Sec. 19.  8 V.S.A. § 4062d is added to read:

§ 4062d.  NONGROUP MARKET SECURITY TRUST

(a)  The commissioner shall establish the nongroup market security trust for the purpose of lowering the cost of and thereby increasing access to health care coverage in the individual or nongroup health insurance market.

(b)  The nongroup market security trust shall permit nongroup carriers to transfer five percent of the carriers’ claims costs, based on the earned premium as reported on the most recent annual statement of the carrier.  At the close of the year, the commissioner shall reconcile the amount paid against the actual expenses of the carriers and collect or expend the necessary funds to ensure that five percent of the actual expenses are paid under this section.  The individuals incurring the claims shall remain enrolled policyholders, members, or subscribers of the carrier’s or insurer’s plan, and shall be subject to the same terms and conditions of coverage, premiums, and cost sharing as any other policyholder, member, or subscriber.

(c)  The commissioner may develop the nongroup market security trust in a manner that permits the trust to be eligible for a federal grant to administer the trust, including a grant under the federal Trade Adjustment Act.

(d)  All of the revenues appropriated shall be deposited into the nongroup market security trust to be administered by the commissioner for the sole purpose of providing financial support for the nongroup market security trust authorized by this section.  The trust shall be administered in accordance with subchapter 5 of chapter 7 of Title 32, except that interest earned shall remain in the trust.

(e)  The commissioner may adopt rules for the nongroup market security trust relating to:

(1)  Criteria governing the circumstances under which a nongroup carrier may transfer five percent of the claims expenses of the carrier to the trust as provided for in this section.

(2)  Eligibility criteria for providing financial support to carriers under this section, including carrier claims’ expenses eligible for financial support, standards and procedures for the treatment and chronic care management as defined in section 701 of Title 18, and any other eligibility criteria established by the commissioner.

(3)  The operation of the trust.

(4)  Any other standards or procedures necessary or desirable to carry out the purposes of this section.

(f)  As used in this section, “nongroup carrier” means a nongroup carrier registered under section 4080b of this title that has an annual earned premium in excess of $100,000.00.

Sec. 20.  8 V.S.A. § 4080b(n) is amended to read:

(n)  On or before January 15, 1993, the commissioner shall report to the senate finance committee and the house commerce committee concerning implementation of the community rating provisions set forth in subsection (h) of this section, describing areas in which additional legislation may be needed  The commissioner shall ensure that any rates filed by any registered nongroup carrier, whether initial or revised, for nongroup insurance policies reflect the reduction in claims costs attributable to the nongroup market security trust established in section 4062d of this title.

* * * Hospital Uncompensated Care * * *

Sec. 21.  HOSPITAL UNCOMPENSATED CARE; FINDINGS

(a)  The general assembly finds that all of Vermont’s community hospitals are nonprofit charity hospitals which provide care regardless of patient ability to pay.  Any uncompensated care received is paid for by someone other than the patient receiving it.  This uncompensated care is substantial. 

(b)  Uncompensated care is already being paid for.  It is subsidized through the “cost shift” and is absorbed principally by the payers of private health insurance premiums, including self‑insurance plans.  This cost shift functions as a hidden surcharge for the cost of care to lower income individuals.

Sec. 22.  HOSPITAL UNCOMPENSATED CARE; STANDARDS;

              REPORTING

(a)  The commissioner of banking, insurance, securities, and health care administration, in consultation with representatives of the Vermont association of hospitals and health systems, third-party payers, and health care consumers, shall review the uncompensated care and bad debt policies of Vermont’s hospitals and recommend a standard statewide uniform uncompensated care and bad debt policy.  The standard policy shall include criteria for payment forgiveness for the cost of health services received by low income patients, criteria for a sliding scale payment amount for patients under certain income levels, a method for calculating the amount of services received by the patient, and other criteria necessary for ensuring that the care received by the uninsured and underinsured patients is billed in a uniform and consistent manner.  In addition to a standard policy, the commissioner may recommend reasons for and a method of approving deviations from the standard policy by a hospital or may recommend a set of standard policies to be applied to hospitals based on particular criteria, such as a designation as a critical access hospital, the income median in an area, or any other rationale.

(b)  The commissioner, in consultation with the representatives listed in subsection (a) of this section, shall determine a fair and thorough method for calculating and reporting information about uncompensated care and bad debt to the department of banking, insurance, securities, and health care administration to ensure accurate accounting in the hospital budgets and other health care facility planning, as well as collecting information about the types of patients accessing uncompensated care or who are unable to pay for the care received.  The commissioner shall consider collecting information about the patient receiving the care, including the patient’s primary insurance status and employer, the actual cost of the care received, any amounts paid toward the care, and any discounts provided to the patient by the hospital.

(c)  The commissioner’s findings and recommendations shall be submitted in a report to the senate committee on health and welfare and the house committee on health care not later than January 15, 2007.

* * * Health Care Coverage Planning * * *

Sec. 23.  SCHEDULE FOR ATTAINING UNIVERSAL HEALTH CARE

(a)  By February 15, 2007, the commission on health care reform shall recommend to the general assembly a schedule, benchmarks, and additional analysis needed for incremental expansions over time to Vermont’s health care system with the goal of achieving universal health care for all Vermonters no later than 2011.

(b)  In making its recommendations, the commission shall give priority to:

(1)  extending universal access to diagnostic or other services to all Vermonters;

(2)  methods of reducing the cost of health insurance or providing alternative coverage through Catamount Health to individuals who pay 10 percent or more of their gross income for premiums and cost-sharing or medical expenses;

(3)  strategies for reducing the cost of health insurance or providing alternative coverage through Catamount Health to individuals in the individual or other high cost markets; and

(4)  determining needed analysis and criteria for implementing a health insurance requirement on January 1, 2011 if 98 percent of Vermonters do not have health insurance by 2010, including methods of enforcement, providing proof of insurance to individuals, and any other criteria necessary for the requirement to be effective in achieving universal health care coverage.

(c)  Recommendations by the commission shall be based on data received by the secretary of administration or designee, review of the strategic plan developed under section 2222a of Title 3, information on Vermont’s current health care system reform initiatives, other research and assistance provided by the commission’s staff, and public input received by the commission.

Sec. 24.  REQUIRED COVERAGE; HEALTH CARE

If 98 percent of Vermonters do not have coverage for health services by January 1, 2010, every individual who resides in Vermont is required to have coverage under health insurance, employer-sponsored insurance, or a federal or state program providing payment for health services no later than January 1, 2011.

Sec. 25.  COMMUNITY PLANNING; HEALTH CARE COVERAGE

In fiscal year 2007, the department of health shall provide a planning grant of $100,000.00 to one community organization or corporation to assist in establishing a local initiative to provide health care coverage or insurance to a community, region, or geographic area of the state.

Sec. 25a.  21 V.S.A. chapter 25 is added to read:

CHAPTER 25.  EMPLOYERS’ HEALTH CARE PREMIUM CONTRIBUTION

§2001.  PURPOSE

For the purpose of more equitably distributing the costs of health care to uninsured residents of this state an employers’ health care premium contribution is established to provide a fair and reasonable method for sharing health care costs with employers who do not offer their employees health care coverage.

§ 2002.  DEFINITIONS

For the purposes of this chapter:

(1)  “Employee” means an individual over the age of majority employed full-time or part‑time by an employer to perform services in this state.

(2)  “Employer” means a person who is required under subchapter 4 of chapter 151 of Title 32 to withhold income taxes from payments of income with respect to services, but shall not include the government of the United States.

(3)  “Full-time equivalent” or “FTE” means the number of employees expressed as the number of employee hours worked during a calendar quarter divided by 520.

(4)  “Uncovered employee” means:

(A) an employee of an employer who does not offer to pay any part of the cost of health care coverage for its employees.

(B)  an employee who is not eligible for health care coverage offered by an employer to any other employees; or

(C) an employee who is offered and is eligible for coverage by the employer but elects not to accept the coverage and has no other health care coverage under either a private or public plan.

§ 2003.  PREMIUM CONTRIBUTION ASSESSMENT

(a)  The commissioner of labor shall assess and an employer shall pay a quarterly health care premium contribution for each full-time equivalent uncovered employee employed during that quarter in excess of three full-time equivalent employees.

(b)  For any quarter in fiscal year 2007, the amount of the health care premium contribution shall be $91.25 for each full-time equivalent employee.  For each fiscal year after fiscal year 2007, the amount of the health care premium contribution shall be adjusted by a percentage equal to any percentage change in premiums for Catamount Health for that fiscal year. 

(c)  Premium contribution assessments under this chapter shall be determined on a calendar quarter basis, due and payable 30 days after the close of each quarter.  Late filings, late payments and underpayments of the premium contribution assessments due shall be subject to the same fees, interest and penalties as pertain to contributions for unemployment compensation under chapter 17 of this title. The commissioner shall establish rules for the administration and collection of premiums under this chapter.  To the extent feasible any reports required of employers under this chapter shall be combined with other reports and information collected from employers by the department of labor.

(c)  Revenues from the premiums collected shall be deposited into the catamount fund established under 33 V.S.A. § 2029 for the purpose of financing health care coverage under Catamount Health, as provided under subchapter 6 of chapter 19 of Title 33.

Sec. 25b.  EFFECTIVE DATE 

Sec. 25a, establishing an employers’ health care premium contribution assessment, shall take effect January 1, 2007, with the first premium assessments due and payable 30 days after the close of the quarter on April 30, 2007.

* * * Cigarette and tobacco product taxes * * *

Sec. 25c.  32 V.S.A. § 7702 is amended to read:

§ 7702  DEFINITIONS

The following words and phrases, as used in this chapter, shall have the following meanings, unless the context otherwise requires:

(1)  "Cigarette" shall mean the common article of commerce known by this name consisting of a small cylindrical roll composed in whole or in part of finely-cut tobacco, wrapped in paper or in any substance other than tobacco. Cigarette shall also mean any “roll-your-own” tobacco as defined in 33 V.S.A. § 1913.

* * *

(17)  “Little cigar” means any roll of tobacco wrapped in leaf tobacco or any substance containing tobacco (other than any roll of tobacco which is a cigarette within the meaning of subdivision (1) of this section) and as to which one thousand units weigh not more than three pounds.

Sec. 25d.  32 V.S.A. § 7771 is amended to read:

§ 7771.  RATE OF TAX

A tax is imposed on all cigarettes and little cigars held in this state by any person for sale or by any person in possession of more than 10,000 cigarettes or little cigars, unless such cigarettes or little cigars shall be:

(1)  in the possession of a licensed wholesale dealer;

(2)  in the course of transit and consigned to a licensed wholesale dealer or retail dealer; or

(3)  in the possession of a retail dealer who has held the cigarettes or little cigars for 24 hours or less.  Such tax shall be at the rate of 59.5 89.5 mills for each cigarette or little cigar, and the payment thereof to be evidenced by the affixing of stamps to the packages containing the cigarettes or little cigars, as hereinafter provided.  Any cigarette or little cigar on which the tax imposed by this chapter has been paid, such payment being evidenced by the affixing of such stamp, shall not be subject to a further tax under this chapter.  Nothing contained in this chapter shall be construed to impose a tax on any transaction the taxation of which by this state is prohibited by the constitution of the United States.  The amount of taxes advanced and paid by a licensed wholesale dealer or a retail dealer as herein provided shall be added to and collected as part of the retail sale price on the cigarettes or little cigars.  All taxes upon cigarettes or little cigars under this chapter are declared to be a direct tax upon the consumer at retail and shall conclusively be presumed to be precollected for the purpose of convenience and facility only.

Sec. 25e.  32 V.S.A. § 7814 is amended to read:

§ 7814.  FLOOR STOCK TAX

(a)  Tobacco Moist snuff tobacco products.  A floor stock tax is hereby imposed upon every retailer of tobacco products in this state at the excess cost of $1.49 per ounce, or fraction thereof over the rate of 21 41 percent of the wholesale price of each moist snuff tobacco product.  The tax shall apply to moist snuff tobacco products in the possession or control of the retailer at 12:01 a.m. o'clock on July 1, 1995 2006, but shall not apply to retailers who hold less than $500.00 in wholesale value of such tobacco products.  Each retailer subject to the tax shall, on or before July 25, 1995 August 25, 2006 file a report to the commissioner in such form as the commissioner may prescribe showing the moist snuff tobacco products on hand at 12:01 a.m. o'clock on July 1, 1995 2006, and the amount of tax due thereon.  The tax imposed by this section shall be due and payable on or before July 25, 1995 September 25, 2006, and thereafter shall bear interest at the rate established under section 3108 of this title.  In case of timely payment of the tax, the retailer may deduct from the tax due two percent of the tax.  Any moist snuff tobacco product with respect to which a floor stock tax has been imposed and paid under this section shall not again be subject to tax under section 7811 of this title.

(b)  Cigarettes.  Notwithstanding the prohibition against further tax on stamped cigarettes under section 7771 of this title, a floor stock tax is hereby imposed upon every dealer of cigarettes in this state who is either a wholesaler, or a retailer who at 12:01 a.m. o’clock on July 1, 2003 2006, has more than 10,000 cigarettes for retail sale in his or her possession or control.  The rate of tax shall be 13 30 mills for each cigarette in the possession or control of the wholesaler or retailer at 12:01 a.m. o’clock on July 1, 2003 2006, and on which cigarette stamps have been affixed before July 1, 2003 2006.  A floor stock tax is also imposed on each Vermont cigarette stamp in the possession or control of the wholesaler at 12:01 a.m. o’clock on July 1, 2003 2006, and not yet affixed to a cigarette package, and the tax shall be at the rate of 26 60 cents per stamp.  Each wholesaler and retailer subject to the tax shall, on or before September 25, 2003 August 25, 2006, file a report to the commissioner in such form as the commissioner may prescribe showing the cigarettes and stamps on hand at 12:01 a.m. o’clock on July 1, 2003 2006, and the amount of tax due thereon.  The tax imposed by this section shall be due and payable on or before September 25, 2003 2006, and thereafter shall bear interest at the rate established under section 3108 of this title.  In case of timely payment of the tax, the wholesaler or retailer may deduct from the tax due two and three‑tenths of one percent of the tax.  Any cigarettes with respect to which a floor stock tax has been imposed under this section shall not again be subject to tax under section 7771 of this title.

(c)  Little cigars.  A floor stock tax is hereby imposed upon every retailer of tobacco products in this state at the excess of 89.5 mills per little cigar over the rate of 41 percent of the wholesale price of each little cigar.  The tax shall apply to little cigars in the possession or control of the retailer at 12:01 a.m. o'clock on July 1, 2006, but shall not apply to retailers who hold fewer than 10,000 cigarettes or little cigars.  Each retailer subject to the tax shall, on or before August 25, 2006 file a report to the commissioner in such form as the commissioner may prescribe showing the little cigars on hand at 12:01 a.m. o'clock on July 1, 2006, and the amount of tax due thereon.  The tax imposed by this section shall be due and payable on or before September 25, 2006, and thereafter shall bear interest at the rate established under section 7771 of this title.  In case of timely payment of the tax, the retailer may deduct from the tax due two percent of the tax.  Any little cigar with respect to which a floor stock tax has been imposed and paid under this section shall not again be subject to tax under section 7771 of this title.

(d)  Roll-your-own tobacco.  A floor stock tax is hereby imposed upon every retailer of tobacco products in this state at the excess of 89.5 mills per roll-your-own cigarette over the rate of 41 percent of the wholesale price of each roll-your-own cigarette.  The tax shall apply to roll-your-own tobacco in the possession or control of the retailer at 12:01 a.m. o'clock on July 1, 2006, but shall not apply to retailers who hold fewer than 10,000 cigarettes.  Each retailer subject to the tax shall, on or before August 25, 2006 file a report to the commissioner in such form as the commissioner may prescribe showing the cigarettes on hand at 12:01 a.m. o'clock on July 1, 2006, and the amount of tax due thereon.  The tax imposed by this section shall be due and payable on or before September 25, 2006, and thereafter shall bear interest at the rate established under section 7771 of this title.  In case of timely payment of the tax, the retailer may deduct from the tax due two percent of the tax.  Any roll‑your-own tobacco with respect to which a floor stock tax has been imposed and paid under this section shall not again be subject to tax under section 7771 of this title.

Sec. 25f.  32 V.S.A. § 7811 is amended to read: 

§ 7811.  Imposition of tobacco products tax

There is hereby imposed and shall be paid a tax on all tobacco products possessed in the state of Vermont by any person for sale on and after July 1, 1959 which were imported into the state or manufactured in the state after said date, except that no tax shall be imposed on tobacco products sold under such circumstances that this state is without power to impose such tax, or sold to the United States, or sold to or by a voluntary unincorporated organization of the armed forces of the United States operating a place for the sale of goods pursuant to regulations promulgated by the appropriate executive agency of the United States.  Such tax on tobacco products shall be at the rate of 41 percent of the wholesale price for all tobacco products except moist snuff tobacco products which shall be taxed at the rate of $1.49 per ounce, or fractional part thereof, and except little cigars taxed under section 7771 of this title, and is intended to be imposed only once upon any tobacco product.  Provided, however, that upon payment of the tax within ten days, the distributor or dealer may deduct from the tax two percent of the tax due.  It shall be presumed that all tobacco products within the state are subject to tax until the contrary is established and the burden of proof that any tobacco products are not taxable hereunder shall be upon the person in possession thereof.

Sec. 25g.  CIGARETTE AND TOBACCO PRODUCTS; EFFECTIVE DATE;

                 INCREASE

Secs. 25c. through 25g of this act and this section shall take effect July 1, 2006.  On and after July 1, 2008, the cigarette tax under 32 V.S.A. § 7771 shall be at the rate of 99.5 mills for each cigarette, little cigar, and roll-your-own tobacco.  On July 1, 2008, the tax imposed by 32 V.S.A. § 7811 on moist snuff  tobacco products shall be at the rate of $1.66 per ounce, or fractional part thereof.  On July 1, 2008, the floor stock tax imposed by 32 V.S.A. § 7814(b) shall be at the rate of 10 mills for each cigarette, little cigar, or roll-your-own tobacco in the possession or control of a wholesaler or retailer who has more than 10,000 cigarettes, little cigars or roll-your-own tobacco on July 1, 2008, shall be reported by the wholesaler or dealer on or before August 25, 2008, and shall be due and payable on or before September 25, 2008.  On July 1, 2008, the floor stock tax imposed by 32 V.S.A. § 7814(a) shall be at the rate of 17 cents per ounce or fraction thereof on moist snuff  tobacco products in excess of $500.00 in the possession or control of a retailer, shall be reported by the retailer on or before August 25, 2008, and shall be due and payable on or before September 25, 2008.

Sec. 25h.  33 V.S.A. § 1901d is amended to read:

§ 1901d.  STATE HEALTH CARE RESOURCES FUND

(a)  The state health care resources fund is established in the treasury as a special fund to be a source of financing health care coverage for beneficiaries of the state health care assistance programs under the global commitment to health care waiver approved by the Centers for Medicare and Medicaid Services under Section 1115 of the Social Security Act.

(b)  Into the fund shall be deposited:

(1)  revenue from the cigarette and tobacco products tax established in  all revenue from the tobacco products tax and 82.5 percent of the revenue from the cigarette tax levied pursuant to chapter 205 of Title 32;

(2)  revenue from health care provider assessments pursuant to subchapter 2 of chapter 19 of this title; and

(3)  the proceeds from grants, donations, contributions, taxes, and any other sources of revenue as may be provided by statute, rule, or act of the general assembly.

(c)  The fund shall be administered pursuant to subchapter 5 of chapter 7 of Title 32, except that interest earned on the fund and any remaining balance shall be retained in the fund.  The agency shall maintain records indicating the amount of money in the fund at any time.

(d)  All monies received by or generated to the fund shall be used only as allowed by appropriation of the general assembly for the administration and delivery of health care covered through state health care assistance programs administered by the agency under the global commitment Global Commitment for Health Medicaid Section 1115 waiver.

Sec. 25i.  DISTRIBUTION OF REVENUE

The percentage of revenues from the cigarette tax increase in 2008, which is distributed between the state health care resources fund in section 1901d of Title 33 and the catamount fund in section 2028 of Title 33, shall be amended to reflect this increase.

Sec. 25j.  32 V.S.A. § 435(b) is amended to read:

(b)  The general fund shall be composed of revenues from the following sources:

* * *

(8)  Cigarettes and tobacco products taxes levied pursuant to chapter 205 of this title;

* * *

Sec. 25k.  ALLOCATION OF FLOOR STOCK TAX REVENUE

The revenue from the floor stock tax under subsection 7814(b) of Title 32 as amended by this act shall be deposited in the catamount fund.

* * * Pharmacy Provisions * * *

Sec. 25l.  33 V.S.A. § 2005(3) is amended to read:

(3)  The office of the attorney general shall keep confidential all trade secret information , as defined by subdivision 317(b)(9) of Title 1. The disclosure form shall permit the company to identify any information that it claims is a trade secret. as defined in subdivision 317(c)(9) of Title 1. In the event that the attorney general receives a request for any information designated as a trade secret, the attorney general shall promptly notify the company of such request. Within 30 days after such notification, the company shall respond to the requester and the attorney general by either consenting to the release of the requested information or by certifying in writing the reasons for its claim that the information is a trade secret.  Any requester aggrieved by the company’s response may apply to the superior court of Washington County for a declaration that the company’s claim of trade secret is invalid. The attorney general shall not be made a party to the superior court proceeding. Prior to and during the pendency of the superior court proceeding, the attorney general shall keep confidential the information that has been claimed as trade secret information, except that the attorney general may provide the requested information to the court under seal.

* * * Technical Amendments * * *

Sec. 26.  32 V.S.A. § 305a is amended to read:

§ 305a.  OFFICIAL STATE REVENUE ESTIMATE

On or about January 15 and on or about July 15 of each year, and at such other times as the emergency board or the governor deems proper, the joint fiscal office and the secretary of administration shall provide to the emergency board their respective estimates of state revenues in the general, transportation, education, and health access trust Catamount Health, state health care resources, and Global Commitment funds.  The January revenue estimate shall be for the current and next two succeeding fiscal years, and the July revenue estimate shall be for the current and immediately succeeding fiscal years.  Federal fund estimates shall be provided at the same times for the current fiscal year.  Within 10 days of receipt of such estimates, the board shall determine an official state revenue estimate for deposit in the respective funds for the years covered by the estimates.  For the purpose of revising an official revenue estimate only, a majority of the legislative members of the emergency board may convene a meeting of the board.  The health access trust fund estimate secretary shall include estimated caseloads and estimated per member per month expenditures for the current and next succeeding fiscal years for each population category eligible for state health care assistance programs supported by the fund.

* * * Oversight and Reporting * * *

Sec. 27.  REPORT; HEALTH CARE REFORM

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

(1)  the percentage of uninsured Vermonters and the number of insured Vermonters by coverage type;

(2)  an analysis of the trends of Catamount Health costs and trends in the revenue sources for Catamount Health;

(3)  the feasibility of allowing individuals who are not uninsured and employers to buy into Catamount Health at full premium cost; and

(4)  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.

Sec. 28.  COMMISSION ON HEALTH CARE REFORM; FINANCE

Any reports required by this act shall be provided to the senate finance committee and 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. 29.  FUNDING SOURCES

(a)(1)  The amount of $2,500,000.00 of the funds appropriated in Sec. 107 of H.881 of the 2005 adjourned session is to increase Medicaid rates to health care professionals on January 1, 2007, under Sec. 8(a) of this act.

(2)  The amount of $1,000,000.00 of the funds appropriated in Sec. 107 of H.881 of the 2005 adjourned session is to increase Medicaid rates to hospitals on January 1, 2007, under Sec. 8(b) of this act.

(b)  The amount of $100,000.00 appropriated to the department of health in Sec. 271 of H.881 of the 2005 adjourned session is for the planning grant established in Sec. 25 of this act.

(c)  The amount of $1,000,000.00 appropriated in Sec. 271 of H.881 of the 2005 adjourned session is for the establishment, initial administration and development of the infrastructure for the employer-sponsored premium assistance program under Sec. 11 of this act.

Sec. 30.  EFFECTIVE AND IMPLEMENTATION DATES

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

(1)  Secs. 8 (Medicaid reimbursement), 13 (cost shift review), and 25 (community health care planning grant) shall take effect July 1, 2006

(2)  Secs. 9 (VHAP premiums), 10 (Dr. Dynasaur premiums), and Sec. 19 (Nongroup market security trust) shall take effect July 1, 2007

(3)  Sec. 15 (Catamount Health) shall take effect June 30, 2006, for the purposes of establishing and administering the Catamount fund under section 2028 of Title 33, and preparing for administration of and enrollment in Catamount Health; implementation of the Catamount Health program, however, shall not commence until October 1, 2007.

(4)  Sec. 24 (health care coverage requirement) shall take effect on January 1, 2011.

Sec. 31.  TECHNICAL PROVISION

It is the intent of the general assembly that the provisions of Sec. 3 of this act, adding section 2222a of Title 3, are complementary to the provisions in Sec. 15 of S.310 (2006), an act relating to common sense initiatives, also adding section 2222a of Title 3.  Any additional provisions contained in Sec. 3 of this act that are not contained in Sec. 15 of S.310 shall not be superseded.  Any technical revisions necessary to ensure accuracy or conformity between the sections, such as the numbering of subdivisions, may be made by the office of legislative council.



Published by:

The Vermont General Assembly
115 State Street
Montpelier, Vermont


www.leg.state.vt.us