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BILL AS INTRODUCED 2007-2008

Introduced by

H.887

Introduced by Committee on Health Care

Date:

Subject:  Health care; health insurance; Catamount Health; Vermont HealthyLiving; Medicaid; VHAP; information technology

Statement of purpose:  This bill proposes to expand access to affordable health coverage by (1) creating a new health insurance product, Vermont HealthyLiving, which rewards healthy lifestyles with enhanced insurance benefits; (2) allowing a former spouse to remain eligible for health care benefits after a divorce or dissolution; (3) expanding dependent coverage for young adults to age 24; (4) laying the framework for a reduction in the uninsured waiting period in Catamount Health from 12 months to six months; (5) providing for a one-time amnesty from the preexisting condition exclusion in Catamount Health; and (6) eliminating the 75-percent coverage rule for small group health plans. 

In addition, the bill would reduce the rate of increase of medical costs by

(1) establishing a number of studies aimed at preventing chronic conditions through healthy lifestyles; (2) considering healthy nutrition in the food service industry; (3) allowing secondary schools to use a model module developed by the department of health to provide health education on cervical cancer and the human papillomavirus; (4) directing the Vermont area health education centers (AHEC) to establish a counter-detailing project; and (5) instructing the commission on health care reform to conduct a study of the Medicaid cost shift.

The bill would support health information technology by (1) authorizing limited liability for the Vermont information technology leaders (VITL) in their operation of the health information exchange network; (2) requiring VITL to update annually the health information technology plan for the state; and (3) requiring a study of the feasibility of a statewide e-prescriber program.

The bill would make investments in the state’s health care system and workforce by (1) expanding Vermont’s loan forgiveness fund; (2) establishing a telemedicine pilot in child psychiatry; (3) increasing nursing faculty salaries and authorizing a study of expanding capacity in state nursing; (4) funding a health care employee pipeline collaborative between the University of Vermont College of Medicine Office of Primary Care and AHEC; and (5) establishing fair standards for medical provider contracts with insurers.

Finally, the bill would implement the recommendations of the commission on health care reform by directing the commission to facilitate several studies, including (1) assessing the feasibility of community-based payment reform and integration of care; (2) considering options for merging health care risk pools; (3) exploring the use of universal standards for payment models, benefit design, and administrative processes; and (4) examining public health care financing options. 

AN ACT RELATING TO HEALTH CARE REFORM

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

* * * Findings and Intent * * *

Sec. 1.  FINDINGS AND INTENT

(a)  The general assembly hereby finds that:

(1)  Health care costs continue to rise at two to three times the rate of inflation, from approximately $3,000.00 per person per year in Vermont in 1997 to $3,800.00 in 2000 and $6,300.00 in 2006.  These increases cause hardships to individuals, families, businesses, taxpayers, and public institutions and make the need for comprehensive health care reform urgent.

(2)  The rising prevalence of chronic illnesses and the new medical approaches to treat them account for nearly two-thirds of the increase in health care spending.  Health care reform must address the cost drivers that underlie this rise in spending.  First, more effective use of preventive care and chronic care management is needed to prevent or slow the progression of chronic diseases and reduce disease complications, which is the focus of the Blueprint for Health.  Second, reform needs to include a sustained public health approach to decrease the likelihood of individuals developing a chronic illness in the first place.  Reducing major health risks such as poor diet, lack of physical activity, tobacco use, and alcohol and drug abuse will stem the rising incidence of chronic diseases linked to these factors over the long term.  This approach involves supporting healthy choices and healthy living in homes, schools, worksites, neighborhoods, and other community settings.  A sustained commitment can result in a long-term payoff by avoiding substantial downstream costs of chronic disease treatment.  This integrated approach of chronic care management and public health is likely to have the most beneficial impacts on both health care costs and Vermonters’ health status in the short term and the long term.

(3)  The Health Care Affordability for Vermonters Act of 2006 has started significant new initiatives to transform the health care system by improving access, controlling costs, and changing the way we pay for and deliver health care.  These system changes will take many years and are dependent upon continued funding and implementation.  To date, these efforts have provided coverage to thousands of Vermonters, instituting changes in the care of chronic conditions, and enabling greater use of health information technology. 

(4)  There continues to be a large number of Vermonters who have no health insurance or are underinsured.  For this population, health care is unaffordable and, as a result, often not received in the most timely and effective manner.

(5)  In 2008, an estimated 15,000 uninsured Vermonters at or below 50 percent of the applicable federal poverty guideline are eligible for VHAP and Medicaid with no financial barriers to receiving covered medical care. 

(6)  The current financing of health care is complex, fragmented, and inequitable, resulting in inefficiencies and creating unnecessary administrative burdens.

(7)  Although the quality of health care services in Vermont is generally very good, there is a need to improve quality, efficiency, and safety.  Improvements in health care quality will result in improved health and reduced costs.  A new payment system that relates reimbursement to improved health would encourage greater efficiency than the existing fee-for-service system.  And the implementation and effective use of health information technology will significantly improve patient safety by reducing medical errors and improving the reliability of patient care processes.

(8)  Vermont currently does not have a clearly defined, integrated health care system.  Fragmentation and disorganization at both the regional and statewide levels lead in some instances to excessive care or inadequate care and create barriers to coordination and accountability among health care professionals, payers, and patients.

(9)  Success in controlling medical costs depends on integrating the delivery of care more effectively and providing electronic health information to providers and patients. 

(10)  Federal laws and programs, such as Medicaid, Medicare, and the Employee Retirement Income Security Act of 1974 (ERISA), constrain Vermont’s ability to establish immediately an integrated health care system.  In addition, the current federal administration’s unwillingness to allow states to implement innovative approaches to health care reform has hampered Vermont’s ability to make extensive improvements to its own system.

(11)  The health care workforce in Vermont, especially the primary care workforce, is facing challenges.  Shortages of clinical staff lead to restricted access to care, especially among Medicaid recipients.  Current surveys of physician supply indicate that Vermont’s physician capacity is not equally distributed both among specialties and among geographic regions.  Only five of 14 counties have sufficient primary care capacity; the remaining nine have shortages.  The median age of physicians in Vermont is already 49 years.  The nationwide nursing shortage is well documented, as is the link between nursing shortages and reductions in the quality of care.  A 2007 Vermont survey found statewide RN vacancy rates of six percent in hospitals, eight percent in home health agencies, nine percent in long‑term care facilities and six percent in office practices.  The five nursing programs in Vermont have been responding to the nursing shortage by increasing enrollment, developing new programs, and adding distance learning sites.  However, our nursing institutions are stymied by the challenges posed by recruiting and retaining qualified nurse faculty.  Nurse faculty members are required to have at least a Master’s degree, yet salaries at the public education institutions are quite low relative to other states.  Nursing graduates are regularly starting at salaries higher than their professors.  Members of the nursing faculties are eligible for the AHEC loan repayment program, which is widely regarded as helpful in recruitment, especially among younger faculty, although the program is underfunded.

(12)  The remote nature of many primary care settings in our rural state, coupled with the low volume of available patients, may not justify full-time staff with particular expertise (for example, psychiatrists), especially when the supply of such experts is already limited.  Technological tools at the provider and patient level could alleviate some of the stresses on our health care delivery system as well as help to increase access to quality care in rural areas. 

(b)  Fully addressing the important problems of the health care workforce and access to care requires a multi-faceted solution that not only looks at how to bolster the numbers and professional capacity of the providers in Vermont, but also looks at new and innovative efforts to leverage that capacity to reach more patients in a more comprehensive and cost-effective way.  The existing health care system is not, in fact, a system; rather it is a collection of services and organizations that carry out multiple functions, though not in a systematic manner.  Achieving real success in health care reform, including maximizing productivity and potential cost savings, will require investment in the public health infrastructure at both the state and community levels. 

(c)  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.  Building on the reforms enacted in the Health Care Affordability for Vermonters Act of 2006, the general assembly finds that effective next steps to achieving these goals include expanding affordable coverage, reducing the rate of the increase of medical costs, reforming the financing of health care, supporting health information technology, and investing in Vermont’s health care system and workforce.

* * * Building Blocks for Health Care Reform * * *

Sec. 2.  OVERVIEW

(a)  The commission on health care reform is charged with making recommendations to meet the goal of section 902 of Title 2 that “by 2009, Vermont has an integrated system of care that provides all Vermonters access to affordable, high quality health care that is financed in a fair and equitable manner.”  Achieving this will require a series of fundamental changes which cumulatively will build a more integrated system with aligned financial incentives.  The commission on health care reform shall coordinate the following series of studies to develop key building blocks for moving toward such a system in Vermont and shall seek outside sources of financing to assist in funding them.

(b)  Vermont has already implemented significant health care reform initiatives, including expanding affordable coverage through Catamount Health, improving the treatment and prevention of chronic conditions through the Blueprint for Health, and improving the availability of electronic health information to patients and providers through the Vermont information technology leaders (VITL).  The commission on health care reform shall evaluate these health care reform initiatives and their progress to date.  This evaluation will synthesize the various plans and reports already required from the health care reform initiatives and identify critical performance gaps and key missing pieces needed to meet the long‑term goals of health care reform. 

(c)  One of the objectives of these studies is to position Vermont as first in line for federal health care reform.  Health care reform will be a major priority of the next federal administration, and the federal government is likely to be much more supportive of health care reform efforts at the state level.  Vermont is uniquely situated to be a statewide laboratory for health care reform and needs to be positioned to receive early approval for increased flexibility in areas traditionally constraining reform, such as Medicare demonstrations and waivers and electronic health record demonstrations.  The commission on health care reform’s evaluation should explicitly identify federal and other barriers to the critical steps in health care reform and determine how best to position Vermont at the forefront of progress in health care reform.

Sec. 3.  FEASIBILITY STUDY FOR COMMUNITY‑BASED PAYMENT

             REFORM AND INTEGRATION OF CARE

(a)  The Health Care Affordability for Vermonters Act of 2006 expressly stated the general assembly’s intention to ensure that all Vermonters receive affordable and appropriate health care, and that health care costs be contained over time.  Continued increases in health care costs at unsustainable rates represent a threat to successful health care reform.  Symptoms of this problem include: 

(1)  High per‑capita medical costs and an unsustainable rate of increase;

(2)  The failure of the existing health care system to deliver appropriate care in approximately 50 percent of all cases involving patients with chronic conditions and one to five percent of all common inpatient admissions;

(3)  Wide variations in performance and the counterintuitive finding that more care often results in poorer outcomes;

(4)  An estimated 25 to 40 percent of medical services provided unnecessarily due to preventable errors and no evidence of value; and

(5)  Avoidable administrative complexity and cost.

(b)  Despite the continued progress of cost control efforts enacted in 2006, it is clear that additional steps are necessary to address this complex issue.  The commission on health care reform shall facilitate a study to assess the feasibility of alternative designs for a pilot project to test using a system-wide budgeting initiative at the regional level within the state, including a design based on the accountable care organization model.  The study should consider building on current significant efforts to build new forms of integrated community health systems, such as the FQHC model being implemented by Springfield Medical Care Systems and the medical staff reorganization being considered by Southwest Vermont Medical Center. 

(c)  The goals of the pilot project are to achieve the Institute for Healthcare Improvement’s Triple Aims of improving population health, reducing total per‑capita costs, and enhancing the patient experience and to address cost controls via the following three strategic issues:

(1)  How to foster the development of local organizations which integrate the delivery of care at the local community level across the full spectrum of services;

(2)  How to counter the belief that more care is always better by providing balanced information on risks and benefits; and

(3)  How to reform the payment system to move away from the current system which rewards more care for high margin treatments and toward a shared risk and shared savings approach which rewards the Triple Aims.

(d)  The design of the pilot should build on the initiatives being developed in the Blueprint for Health, particularly the payment reform for primary care physicians, the adoption of the medical home model, and the development of community‑based care coordination teams. 

(e)  The commission on health care reform shall present its recommendations for the pilot to the general assembly and the secretary of administration by January 15, 2009.  If the pilot is approved, implementation should begin with a target of the first pilot being operational by January 1, 2010.

(f)  The sum of $25,000.00 is appropriated from the general fund to the commission on health care reform in fiscal year 2009 to develop this pilot program.

Sec. 4.  STUDY OF MERGING FRAGMENTED RISK POOLS

(a)  The continued fragmentation of risk pools and structural issues with the individual and small group markets present major obstacles to achieving universal coverage and stable premium rates.  The department of banking, insurance, securities, and health care administration, in collaboration with the commission on health care reform and in consultation with interested stakeholders, shall prepare a preliminary design for the merger by calendar year 2011 of the nongroup (including Catamount Health), small group, and association markets.  The design shall be completed and delivered to the commission on health care reform and the secretary of administration by January 15, 2010.  The design shall include:

(1)  An assessment of the impact on premiums for each market segment;

(2)  A recommendation for a rating method or methods to be used in the consolidated market;

(3)  Options for mitigating the impact on specific groups, such as blending old and new rates during a transition period; and

(4)  A plan for a phased-in merger of the pools over time to minimize the impact on premiums for specific groups. 

(b)  The sum of $25,000.00 per year is appropriated from the general fund to the commission on health care reform in fiscal years 2009 and 2010 to conduct this study. 

Sec. 5.  UNIVERSAL STANDARDS FOR BENEFITS PACKAGES,

             PAYMENT METHODS, AND ADMINISTRATIVE PROCESSES

(a)  The proliferation of benefit designs, including prescription drug benefits; payment models; and administrative requirements contributes to increased administrative costs, system complexity, and confusion on the part of both patients and providers.  The state has begun exploring how to standardize benefits, payments, and administration through efforts such as the Blueprint for Health’s recommendations on care of chronic conditions and the common claims simplification work group. 

(b)  It is vital that the state continue to expand these efforts into additional areas of benefit design and administration, including an evaluation of the use of Medicare payment methodology by all payers.  Building on the work already under way in the state, the commission on health care reform shall conduct a thorough assessment of universal standards for benefits, including prescription drug benefits; payments; and administrative processes and present its recommendations on implementing universal standards to the senate committee on health and welfare and the house committee on health care by January 15, 2010.

Sec. 6.  FINANCING OPTIONS

(a)  The commission on health care reform, in consultation with interested stakeholders, shall design and conduct a study to expand upon the completed financing analysis called for in Sec. 277d of No. 215 of the Acts of the 2005 Adj. Sess. (2006) to create a common analytic basis for policy decisions on the financing of health care.  The new study shall:

(1)  Build a financial model for public financing of comprehensive health care for all Vermonters, including wellness and prevention, primary care, and hospital care.  The model shall also allow for assessment of specific segments of the health care system, specifically primary care and hospital care.

(2)  Explore several combinations of broad-based revenue sources, including payroll taxes, income taxes, consumption taxes, provider taxes, and other revenue sources to identify the most equitable distribution.  For each combination of financing, the study shall estimate the net change from the current financing system for employers, consumers, and health care providers and consider the additional impacts on municipal and school board budgets, premium payments for individuals, and employers’ payrolls.

(3)  Identify major issues that would have to be addressed by the federal government if a single state attempted such a public financing experiment, such as federal exemptions from ERISA, cross‑border issues for employers and residents, and Medicare and Medicaid waivers.

(4)  Assess the impact of different financing options on the underlying cost drivers in health care, including prevention, chronic care management, administration, errors or reliability or both, cost and usage of prescription drugs, and utilization rates.

(b)  The commission on health care reform shall present its preliminary design for the study to the senate committee on health and welfare and the house committee on health care by October 1, 2008, and deliver the results of the study to these committees no later than April 15, 2009.

(c)  The sum of $75,000.00 is appropriated from the general fund to the commission on health care reform in fiscal year 2009 for the design and completion of the financing study.

* * * Expanding Affordable Coverage * * *

Sec. 7.  8 V.S.A. § 4080g is added to read:

§ 4080g.  VERMONT HEALTHYLIVING

(a)  As used in this section:

(1)  “Carrier” means a registered small group carrier as defined in section 4080a of this title.

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

(3)  “Chronic care management” means a system of coordinated health care interventions and communications for individuals with chronic conditions, including significant patient self-care efforts, system supports for the practitioner‑patient relationship, and a plan of care emphasizing prevention of complications, utilization of 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)  “Commissioner” means the commissioner of banking, insurance, securities, and health care administration.

(5)  “Department” means the department of banking, insurance, securities, and health care administration.

(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 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 medically necessary services to assist in activities of daily living.

(8)  “Participant” means any individual covered by a Vermont HealthyLiving policy, including policyholders, spouses, and dependents.

(9)  “Policyholder” means any individual who has entered into a contract with a carrier for health care services or for services related to but not limited to the processing, administration, or payment of claims for health care services or on whose behalf such an arrangement has been made.

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

(11)  “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.

(12)  “Vermont HealthyLiving” means the plan designed to promote good health, prevent disease, and encourage healthier lifestyles without penalizing individuals due to disability, poor health, or socioeconomic status, and to provide coverage of primary care, preventive care, chronic care, acute episodic care, and hospital services as established in this section to be provided through a carrier which meets the requirements of this section.

(b)  Vermont HealthyLiving shall provide coverage for primary care, preventive care, chronic care, acute episodic care, and hospital services.  Carriers may offer one or more Vermont HealthyLiving products. 

(c)(1)  Each Vermont HealthyLiving product shall provide two benefit levels, to be known as a basic benefit and a preferred benefit.  Both benefit levels shall provide for a waiver of the deductible and other cost-sharing payments for chronic care for individuals participating in a healthier lifestyle or care management program through a Vermont HealthyLiving plan and for preventive care.  The premium for both benefit levels shall be the same, with the difference in benefit levels reflected in co-payments, coinsurance, deductibles, out-of-pocket maximums, or a combination of these options.

(2)  All adult participants shall receive the preferred benefit for the first 90 days after enrollment.

(3)  In order to continue to be eligible for the preferred benefit beyond the initial period, within the first 90 days after enrollment, adult participants shall:

(A)  choose a primary care practitioner;

(B)  complete a uniform validated health risk assessment (HRA) adopted by the director of the Blueprint for Health in consultation with the Vermont HealthyLiving carriers; and

(C)  meet with their primary care practitioner for an evaluation, at which time the practitioner shall assess the participant for the modifiable risk factors, including:

(i)  tobacco use;

(ii)  high blood pressure;

(iii)  cholesterol;

(iv)  diabetes; and

(v)  obesity.

(4)  The health insurer shall make the HRA available in both an online and a paper version and shall transmit a copy of the results to the participant’s primary care practitioner.

(5)  The primary care practitioner shall develop with the participant a written plan for a healthier lifestyle or care management program to address any modifiable risk factors found upon evaluation not to meet the healthy lifestyle criteria established by the participant’s carrier and consistent, to the extent applicable, with the Blueprint for Health pursuant to chapter 13 of Title 18.  The practitioner shall submit a copy of any such plan to the carrier.

(6)  Upon completion of the requirements set forth in subdivision (3) of this subsection, participants who meet the healthy lifestyle criteria or commit to participation in a healthier lifestyle or care management program similar to the chronic care management program created under chapter 13 of Title 18 shall continue to receive the preferred benefit.  A participant who does not complete the required visit and HRA or who does not exhibit a healthy lifestyle and is unwilling to commit to participation in a healthier lifestyle or care management program shall be eligible only for the basic benefit upon expiration of the initial 90-day period.  Carriers shall offer healthier lifestyle and care management programs for all identified and measured risk factors and, to the extent applicable, all programs shall be consistent with the Blueprint for Health pursuant to chapter 13 of Title 18.

(7)  Participants engaging in a healthier lifestyle or care management program shall meet with their primary care practitioner as directed by such clinician to ensure compliance with the program.

(8)  Participants who exhibit a healthy lifestyle or are engaged and participating in their recommended healthier lifestyle or care management program shall continue to be eligible for the preferred benefit upon expiration of the initial 90-day period.  Participants who do not exhibit a healthy lifestyle and are not engaged and participating in their recommended healthier lifestyle or care management program after the initial 90-day period shall be eligible only to receive the basic benefit.  At least annually, carriers shall allow participants to take the steps necessary to become eligible for the preferred benefit.

(9)  In order to remain eligible for the preferred benefit beyond the first year of their enrollment, participants shall:

(A)  complete a new HRA each year;

(B)  meet with their primary care practitioner at least annually, or more often as directed by the practitioner; and

(C)  have their primary care practitioner complete and submit to the carrier a common validated wellness checklist adopted by the director of the Blueprint for Health in consultation with the Vermont HealthyLiving carriers documenting the participant’s status with respect to meeting the healthy lifestyle criteria and compliance with any required healthier lifestyle or care management program.

(10If a policyholder’s spouse is on the policy, both spouses must meet the requirements of this subsection in order for the couple or family to be eligible for the preferred benefit.  Failure of one or both spouses to meet any or all of the requirements shall render all members of the family ineligible for the preferred benefit.

(d)  Employers offering Vermont HealthyLiving shall promote a healthy work environment for their employees by committing to activities that support wellness, including providing a smoke-free workplace and encouraging employees to participate in wellness programs.

(e)  A health care facility or health care provider that agrees to participate in a Vermont HealthyLiving network that provides services for a Vermont HealthyLiving insured shall not balance bill the insured by charging the insured amounts in addition to the reimbursement provided for by the plan’s participating provider agreement.

(f)  A carrier shall guarantee acceptance for each dependent of an individual in Vermont HealthyLiving, subject to the provision of subdivision (c)(8) of this section. 

(g)  The commissioner, in consultation with the commissioner of health, shall review carriers’ Vermont HealthyLiving plans to ensure that the healthy lifestyle criteria create appropriate opportunities and incentives for employers, providers, carriers, and participants to engage in certain behaviors, including:

(1)  Focus on primary care, prevention, and wellness;

(2)  Actively manage the chronically ill population, in connection with the activities set forth in section 702 of Title 18;

(3)  Use the least cost, most appropriate setting; and

(4)  Use evidence-based quality care.

(h)(1)  Approval of rates and forms for Vermont HealthyLiving shall be pursuant to the process established and rules adopted pursuant to this section.  Premium rates shall target a 10 percent reduction in rates below the premium of a comparable product at the preferred benefit level in the relevant marketThe difference between the actuarial value of the benefits in the basic and preferred benefit levels shall be no greater than 20 percent, and insurers shall not be permitted to impose additional rate deviations.

(2)  No rate or form shall be approved if it contains any provision which is unjust, unfair, inequitable, misleading, or contrary to the law of this state.  A rate shall be approved if it is sufficient not to threaten the financial safety and soundness of the carrier, reflects efficient and economical management, provides Vermont HealthyLiving at the most reasonable price consistent with actuarial review and the target premium identified in subdivision (1) of this subsection, is not unfairly discriminatory, and complies with the other requirements of this section.

(i)  With each rate filing, a carrier shall file a certification by a member of the American Academy of Actuaries of the carrier’s compliance with this section.  The requirements for certification shall be as the commissioner by rule prescribes.

(j)  Vermont HealthyLiving shall be offered with a rate structure which at least differentiates among single-person, two-person, and family rates, and the rates shall be guaranteed for 12 months from the date the individual enrolls.

(k)  Vermont HealthyLiving shall be made available by October 1, 2009.  Rates and forms may be filed and approved prior to that date, and marketing and sales targeted to an effective date of October 1, 2009 shall be allowed at the discretion of the commissioner.

(l)  A letter of intent, proposed rates, and proposed forms shall be filed consistent with the requirements of this section and the rules adopted pursuant to this section.

(1)  Forms shall be filed initially and upon any change.  Forms may not be used unless and until approved as described in this section.  The department shall notify the carrier within 45 days whether the form meets the requirements set by statute and rule.

(2)  Rates shall be filed prior to use and thereafter at least annually on a schedule and in a manner established by rule.  The department shall notify the carrier within 45 days whether the rates meet the requirements set by statute and rule.

(3)  In any notice denying approval of a rate or form, the commissioner shall state that a hearing will be granted within 20 days upon written request of the carrier, provided that the written request for hearing is filed with the department within 30 days of the notice of disapproval.  After the expiration of 30 days from the filing of any such form or premium rate, or at any time after having given written approval, the commissioner may, after a hearing of which at least 20 days’ written notice has been given to the carrier using such form or premium rate, withdraw approval on any of the grounds stated in this section.  Such disapproval shall be effected by written order of the commissioner which shall state the ground for disapproval and the date, not less than 30 days after such hearing, when the withdrawal of approval shall become effective.

(m)(1)  The commissioner shall encourage carriers doing business in this state to offer Vermont HealthyLiving. 

(2)  In adopting rules to implement this section, the commissioner shall endeavor to maximize participation of consumers, employers, providers, and carriers in Vermont HealthyLiving.  Such rules may allow carriers to offer products with a substantially similar design and purpose, subject to the approval of the commissioner. 

(3)  In connection with a rate decision, the commissioner may make reasonable supplemental orders and may attach reasonable conditions and limitations to such orders as he or she finds, on the basis of competent and substantial evidence, necessary to carry out the purposes of this section.

Sec. 8.  EXPEDITED RULEMAKING

No later than October 1, 2008 and notwithstanding the provisions of chapter 25 of Title 3, the department of banking, insurance, securities, and health care administration shall adopt rules to implement the provisions of Vermont HealthyLiving established in section 4080g of Title 8 and the healthy lifestyle insurance discount established in subsection 4080a(h) of Title 8 pursuant to the following expedited rulemaking process:

(1)  After publication in three daily newspapers with the highest average circulation in the state of a notice of the rules to be adopted pursuant to this process and at least a 14-day public comment period following publication, the department shall file final proposed rules with the legislative committee on administrative rules.

(2)  The legislative committee on administrative rules shall review and may approve or may object to the final proposed rules under section 842 of Title 3, except that its action shall be completed by the committee no later than 14 days after the final proposed rules are filed with the committee.

(3)  The department may adopt a properly filed final proposed rule:

(A)  after the passage of 14 days from the date of filing final proposed rules with the legislative committee on administrative rules;

(B)  after receiving notice of approval from the committee; or

(C)  if the department has received a notice of objection from the legislative committee on administrative rules, after having responded to the objection from the committee pursuant to section 842 of Title 3.

(4)  Rules adopted under this section shall be effective upon being filed with the secretary of state and shall have the full force and effect of rules adopted pursuant to chapter 25 of Title 3.  Rules filed by the department with the secretary of state pursuant to this section shall be deemed to be in full compliance with section 843 of Title 3 and shall be accepted by the secretary of state if filed with a certification by the commissioner of banking, insurance, securities, and health care administration that the rule is required to meet the purposes of this section.


Sec. 9.  STATE EMPLOYEES’ HEALTH BENEFITS PLAN

The possibility of providing Vermont HealthyLiving or a similar plan in addition to the other state employee health plan offerings shall be a subject of bargaining pursuant to section 904 of Title 3, and shall be considered during the next negotiations following the effective date of this act.

Sec. 10.  3 V.S.A. § 2222a(c) is amended to read:

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

* * *

(10)  Vermont HealthyLiving, established in section 4080g of Title 8, which provides a health coverage option that encourages participants to engage in healthy lifestyles and wellness behaviors.

(10)(11)  The uniform hospital uncompensated car care policies.

Sec. 11.  8 V.S.A. § 4100b is amended to read:

§ 4100b.  COVERAGE OF CHILDREN

(a)  As used in this subchapter:

(1)  “Health plan” shall include, but not be limited to, a group health plan as defined under Section 607(1) of the Employee Retirement Income Security Act of 1974, a nongroup plan as defined in section 4080b of this title, and a Catamount Health plan as defined in section 4080f of this title, and a Vermont HealthyLiving plan as defined in section 4080g of this title.


* * * Health Insurance Coverage After Divorce or Dissolution * * *

Sec. 12.  8 V.S.A. § 4090h is added to read:

§ 4090h.  HEALTH INSURANCE COVERAGE AFTER DIVORCE OR DISSOLUTION

(a)  Any group or blanket accident and health insurance policy covering a resident of Vermont shall contain the following provisions:

(1)  Upon a final decree of divorce or dissolution or a legal separation, if one spouse is a member of a group or blanket accident and health insurance policy, the former spouse who is a family member or eligible dependent under said policy prior to the date of the decree shall be and remain eligible for group benefits as a family member or eligible dependent under the policy, without additional premium or examination, as if the decree had not been issued.  Such eligibility shall not be required if the decree expressly provides otherwise.

(2)  The former spouse shall be eligible for coverage pursuant to this section through the member’s participation in a group or blanket accident and health insurance policy, while such policy remains in force or is replaced by another group or blanket policy covering the member, until the earliest of the following events occurs:

(A)  The three-year anniversary of the final decree of divorce or dissolution or a legal separation;

(B)  The remarriage or civil union of the former spouse;

(C)  The remarriage or civil union of the member;

(D)  The death of the member;

(E) The enrollment of a domestic partner of the member in the member’s insurance policy; or

(F)  Such earlier time as provided by the final decree of divorce or dissolution or a legal separation.

(3)  Upon the occurrence of the earliest of the events set forth in subdivision (2) of this subsection, other than remarriage of the former spouse, the former spouse shall have the right to continuation coverage.  An insurer may charge a premium for the former spouse’s continuation coverage under this subdivision (3).  The former spouse shall request enrollment in writing, within 30 days after the first occurring of the events set forth in subdivision (2) of this subsection, provided that the former spouse may not request enrollment upon remarriage of the former spouse.

(b)  In the event of the former spouse’s remarriage, the former spouse shall notify the insurer, in writing, within 30 days after the date of remarriage, and the effective date of termination of the former spouse’s eligibility pursuant to this section shall be the date of remarriage.

(c)  The member or former spouse shall submit to the insurer evidence of the former spouse’s eligibility under this section within 30 days after the final decree of divorce or dissolution or a legal separation.  If the group or blanket accident and health insurance policy existing as of the date of the decree is replaced by another group or blanket policy covering the member that is issued by a different insurer, said insurer may request that the member or former spouse submit evidence of the former spouse’s eligibility under this section within 30 days of the effective date of the member’s coverage under the replacement policy.  A former spouse’s coverage under the member’s group or blanket accident and health insurance policy pursuant to this section shall be effective as of the date of the final decree of divorce, dissolution, or legal separation in the case of a then-existing policy, or, in the case of a replacement policy, the effective date of the member’s coverage under such policy.

(d)  The former spouse shall notify the insurer, in writing, of any address other than the member’s address to which notices and correspondence pertaining to the former spouse’s coverage should be mailed, including notice of cancellation and any right to reinstate coverage, and the carrier shall use such address until it receives written notice from the former spouse of a change.

(e)  Upon termination of the eligibility of a former spouse for group coverage pursuant to this section, the former spouse may apply for individual coverage.


Sec. 13.  8 V.S.A. § 4090i is added to read:

§ 4090i.  PAYMENT FOR POST-DIVORCE COVERAGE 

Upon a decree of divorce or dissolution or a legal separation, if one spouse is a member of a group health insurance plan and the employer or any other sponsor is responsible for the payment of the premium required by the insurer as the consideration for providing coverage to an ex-spouse, such premium shall be paid either by the health insurance plan member, the

ex-spouse of the member, or by both the member and the ex-spouse as they shall agree or as shall be ordered in the decree by the court.  The provisions of this section shall apply to dental coverage provided by such group health insurance plan and shall apply whether or not the ex-spouse is receiving child support payments.

* * * Expanding Dependent and Young Adult Coverage to Age 24 * * *

Sec. 14.  8 V.S.A. § 4089d is amended to read: 

§ 4089d.  COVERAGE; DEPENDENT AND YOUNG ADULT CHILDREN

(a)  As used in this section, “health insurance plan” shall mean any group or individual policy, nonprofit hospital or medical service corporation, subscriber contract, health maintenance organization contract, self-insured group plan, and prepaid health insurance plans delivered, issued for delivery, renewed, replaced, or assumed by another insurer, or in any other way continued in force in this state means any health insurance policy or health benefit plan offered by a health insurer, as defined in section 9402 of Title 18, and any health benefit plan offered or administered by the state or any subdivision or instrumentality of the state.

* * *

(e)  Notwithstanding any other provision of this section, a family health insurance plan shall include the adult children up to the age of 24, so long as the child is unmarried, has no dependents of his or her own, is a resident of the state of Vermont, and does not have health insurance coverage through any branch of the military. 

Sec. 15.  EXPANDING ACCESS TO CATAMOUNT HEALTH

(a)  No later than March 1, 2009, the secretary of human services shall apply to the federal Centers for Medicare and Medicaid Services for a waiver to allow Vermont to lower the waiting period for coverage under Catamount Health and the Vermont health access plan to six months from the current 12 months.  Within 60 days following approval of the waiver, the secretary of administration shall submit to the commission on health care reform a recommendation on whether to proceed with reducing the waiting period.  Upon receipt of the secretary’s recommendation, the commission on health care reform created pursuant to section 901 of Title 2 shall consider whether to recommend to the emergency board:

(1)  to proceed with the implementation of the reduced waiting period in Catamount Health; or

(2)  to delay the implementation of the waiting period.

(b)  After receiving a recommendation from the commission on health care reform, the emergency board shall consider the commission’s recommendation, including:

(1)  availability of resources;

(2)  issues surrounding implementation; and

(3)  potential benefits to the health care system.

(c)  Within 30 days after receipt of the commission’s recommendation, the emergency board shall make a determination whether to proceed with implementation of the reduced waiting period or to delay implementation.

Sec. 16.  8 V.S.A. § 4080f(a)(9) is amended to read: 

(9)  “Uninsured” means an individual who does not qualify for Medicare, Medicaid, the Vermont health access plan, or Dr. Dynasaur, and 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 private insurance or employer-sponsored coverage ended because of:

(i)  loss of employment, including a reduction in hours that results in ineligibility for employer-sponsored coverage, unless the employer has terminated its employees or reduced their hours for the primary purpose of discontinuing employer-sponsored coverage and establishing their eligibility for Catamount Health;

(ii)  death of the principal insurance policyholder;

(iii)  divorce or dissolution of a civil union;

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

(v)  no longer receiving 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, decreased enrollment below a threshold set for continued coverage, or otherwise terminated studies.

Sec. 17.  33 V.S.A. § 1973(e) is amended to read: 

(e)  For purposes of this section, “uninsured” means:

(1)  an individual with household income, after allowable deductions, at or below 75 percent of the federal poverty guideline for households of the same size;

(2)  an individual who 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

(3)  an individual who lost private insurance or employer-sponsored coverage during the prior 12 months for the following reasons:

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

(i)  loss of employment, including an involuntary or voluntary reduction in hours that results in ineligibility for employer-sponsored coverage, unless the employer has terminated its employees or reduced their coverage for the primary purpose of discontinuing employer-sponsored coverage and establishing their eligibility for Catamount Health;

(ii)  death of the principal insurance policyholder;

(iii) divorce or dissolution of a civil union;

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

(v)  no longer receiving 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, decreased enrollment below a threshold set for continued coverage, or otherwise terminated studies.

Sec. 18.  33 V.S.A. § 1974(c) is amended to read: 

(c)  Uninsured individuals; premium assistance.

(1)  For the purposes of this subsection:

* * *

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

(i)  the individual’s private insurance or employer-sponsored coverage ended because of:

(I)  loss of employment, including an involuntary or voluntary reduction in hours that results in ineligibility for employer-sponsored coverage, unless the employer has terminated its employees or reduced their hours for the primary purpose of discontinuing employer-sponsored coverage and establishing their eligibility for Catamount Health;

(II)  death of the principal insurance policyholder;

(III)  divorce or dissolution of a civil union;

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

(V)  no longer receiving COBRA, VIPER, or other state continuation coverage; or

(ii)  college- or university-sponsored health insurance became unavailable to the individual because the individual graduated, took a leave of absence, decreased enrollment below a threshold set for continued coverage, or otherwise terminated studies.

* * *

Sec. 19.  33 V.S.A. § 1982(2) is amended to read: 

(2)  “Uninsured” means an individual who does not qualify for Medicare, Medicaid, the Vermont health access plan, or Dr. Dynasaur, and 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 private insurance or employer‑sponsored coverage ended because of:

(i)  loss of employment, including a reduction in hours that results in ineligibility for employer-sponsored coverage, unless the employer has terminated its employees or reduced their hours for the primary purpose of discontinuing employer‑sponsored coverage and establishing their eligibility for Catamount Health;

(ii)  death of the principal insurance policyholder;

(iii)  divorce or dissolution of a civil union;

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

(v)  no longer receiving 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, decreased enrollment below a threshold set for continued coverage, or otherwise terminated studies.

* * * Preexisting Conditions under Catamount Health * * *

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

(e)(1)  For a 12‑month period from the effective date of coverage earliest date of application, a carrier offering Catamount Health may limit coverage of preexisting conditions which existed during the 12‑month period before the effective date of coverage earliest date of application, except that such exclusion or limitation shall not apply to chronic care if the individual is participating in a chronic care management program, nor apply to pregnancy.  A carrier shall waive any preexisting condition provisions for all individuals and their dependents who produce evidence of continuous creditable coverage during the previous nine months.  If an individual has a preexisting condition excluded under a subsequent policy, such exclusion shall not continue longer than the period required under the original contract or 12 months, whichever is less.  The carrier shall credit prior coverage that occurred without a break in coverage of 63 days or more.  A break in coverage shall be tolled after the earliest date of application, subject to reasonable time limits, as defined by the commissioner, for the individual to complete the application process.  For an eligible individual, as such term is defined in Section 2741 of Title XXVII of the Public Health Service Act the Health Insurance Portability and Accountability Act of 1996, a carrier offering Catamount Health shall not limit coverage of preexisting conditions.

(2)  Notwithstanding subdivision (1) of this subsection, a carrier offering Catamount Health shall not limit coverage of preexisting conditions for subscribers who apply before November 1, 2008.  This subdivision (2) shall not apply to claims incurred prior to the effective date of this section.

* * * Elimination of 75 Percent Rule * * *

Sec. 21.  REPEAL

8 V.S.A. § 4080a(l) (minimum enrollment in a small group health benefit plan) is repealed.


* * * Reducing the Rate of Increase of Medical Costs * * *

* * * Preventing Chronic Conditions Through Healthy Lifestyles * * *

Sec. 22.  LEGISLATIVE FINDINGS AND INTENT

(a)  The general assembly recognizes that reducing the occurrence of chronic conditions across Vermont’s population is an essential component of improving the health of Vermonters and controlling medical cost increases.  Obesity is now recognized as a serious public health epidemic and a significant underlying cause of morbidity and mortality in the United States.  If current trends continue, obesity will soon surpass cigarette smoking as the leading cause of preventable disease and death.  A 2004 estimate of annual medical expenses in Vermont attributable to adult obesity totaled approximately $141 million.

(b)  National obesity rates have more than doubled in the past 20 years, leading to a substantial increase in negative health consequences.  More than one in five Vermont adults is obese, and another two-fifths of adults are at risk of being obese.  Among Vermont’s school-aged youth in grades 8-12, 11 percent are considered obese (at or above the 95th percentile for body mass index) and 15 percent are at risk for being obese (between the 85th and 95th percentile).  Obesity puts children and adolescents at lifelong risk for other chronic conditions such as diabetes, heart disease, stroke, high blood pressure, arthritis, respiratory diseases, and certain cancers. 

(c)  It is the intent of the general assembly to use a statewide community prevention model to promote healthy lifestyles for all Vermonters.  It is intended that this initiative will build on the leadership, public health planning expertise, and statewide district office infrastructure of the Vermont department of health.  It is also intended to build on and enhance the ongoing collaboration with other state agencies and community partners.

Sec. 23.  COMMUNITY PLANS

The commissioner of health, through the 12 district health offices, shall work with communities in each region to develop comprehensive plans that identify and prioritize community needs relating to wellness and healthy living.  The 12 district health offices shall involve schools, worksites, and other stakeholders interested in improving community health and shall consult existing sources of community‑level population health data.  In drafting the plans, the commissioner shall work with community stakeholders to develop an inventory of policy and environmental supports related to wellness and healthy living.  Such plans shall be made available to the public. 

Sec. 24.  18 V.S.A. § 104b is amended to read:

§ 104b.  COMMUNITY HEALTH AND WELLNESS GRANTS

(a)  The commissioner shall establish a program for awarding competitive, substantial, multi-year grants to comprehensive community health and wellness projects.  Successful projects must:

* * *

(4)  use strategies that have been demonstrated to be effective in reaching the desired outcome; and

(5)  provide data for evaluating and monitoring progress;

(6)  include a plan for ensuring that all food vending machines located in public buildings within the control of the grant recipient contain foods and portion sizes consistent with the Vermont nutrition and fitness policy guidelines or other relevant science-based resources; and

(7)  address socioeconomic or other barriers that stand in the way of fit and healthy lifestyles in their communities.

(b)  The commissioner, through the 12 district health offices, shall assist communities by:

(1)  providing technical assistance to support communities in following a consistent and coordinated approach to planning and implementation, including practices such as needs assessment, defined priorities, action plans, and evaluation;

(2)  providing access to best and promising practices and approved public policies;

(3)  providing assistance to help communities develop public awareness materials and communication tools with well-researched and well-coordinated messaging;

(4)  helping projects communities obtain and maximize funding from all applicable sources; and

(4)(5)  providing other assistance as appropriate.

* * *

(e)  By January 15 1 of each year, the commissioner shall report on the status of the program to the general assembly, the senate committee on health and welfare, and the house committees on human services and on health care by including a section on prevention grants in the annual report of the Blueprint for Health.

* * *

Sec. 25.  INVENTORY OF COORDINATED SCHOOL HEALTH

               PROGRAMS

The commissioner of health, in collaboration with the commissioner of education and the secretaries of agriculture, food and markets and of transportation, shall compile an inventory of all programs both inside and outside the agencies and departments that award grants or similar funding and that provide technical assistance to supervisory unions and school districts to address issues such as nutrition and physical activity (both indoor and outdoor) for students and staff, obesity, tobacco use, and substance abuse.  The inventory shall include for each program a description of the program purposes, priorities, and any restrictions on the use of funds or technical assistance.  The inventory shall be accompanied by recommendations on how state agencies and other state funding sources may improve coordination of grant awards and technical assistance for school health initiatives and how to work with school districts with a more comprehensive and coordinated approach to planning and implementation, including practices such as needs assessment, defined priorities, action plans, and evaluations and the involvement of school health teams and school health coordinators in community planning efforts.  The recommendations shall also propose a coordinated process for awarding grants to support school health, such as coordination or integration with the community grants process in section 104b of Title 18.  The inventory and recommendations must be submitted to the senate committees on health and welfare and the house committees on health care, on human services, and on education, and made available on the internet for review by town offices and school districts, no later than January 15, 2009.

Sec. 26.  NUTRITION GUIDELINES FOR COMPETITIVE FOOD AND

               BEVERAGE SALES IN SCHOOLS

(a)  The commissioner of education shall collaborate with the commissioner of health and the secretary of agriculture, food and markets to update the current Vermont nutrition policy guidelines applicable to competitive foods and beverages sold outside the federally reimbursable school nutrition programs.  The revised guidelines shall rely on science-based nutrition standards recommended by the alliance for a healthier generation, the institute of medicine, and other relevant science-based resources and shall be available to school districts before the 2008–2009 school year.

(b)  By January 15, 2009, the commissioners of education and of health shall report to the house committees on agriculture, on education, on health care, and on human services, and the senate committees on health and welfare and on education regarding the number of school districts that have and have not adopted a nutrition policy that is substantially the same as the Vermont nutrition policy guidelines applicable to competitive foods and beverages as revised in accordance with subsection (a) of this section.  The report shall include specific information about how policies adopted by the school boards may differ from the Vermont nutrition policy guidelines and include recommendations on how to ensure that all Vermont school districts will meet the state school nutrition guidelines by July 1, 2011.

Sec. 27.  HEALTHY COMMUNITY DESIGN AND ACCESS TO

               HEALTHY FOODS

(a)  The commissioner of health, in consultation with the secretaries of agriculture, foods and markets and of transportation, the commissioners of the departments of education, of housing and community affairs, and of forests, parks, and recreation, and the regional planning association, shall make recommendations on how to strengthen strategies for environmental and policy change to increase healthy choices in Vermont communities and how to enhance coordination among existing programs and funding.  In addition, the commissioner, through the 12 district health offices, shall work with communities to support efforts in planning, implementation, and obtaining funding from applicable sources.  Recommended environmental and policy change strategies shall include ways to:

(1)  Promote and support opportunities for physical activity at the community level through increasing access to walking and bicycle paths, bicycle lanes, safe routes to schools, indoor and outdoor recreational facilities, and parks and other recreational areas;

(2)  Increase access to healthy foods in Vermont communities, including local foods, through strategies such as food pricing and economic approaches, food and beverage marketing and promotion, improving access to affordable healthy foods in low income communities, and other promising food‑related policy and environmental strategies; and

(3)  Promote the goals of physical activity, nutrition, and healthy living in planning processes that involve zoning and land use, growth centers, and downtown revitalization.

(b)  The commissioner shall make recommendations in a consolidated report on healthy living initiatives to the senate committee on health and welfare and the house committees on health care and on human services on priorities and recommendations no later than January 15, 2009.

Sec. 28.  HEALTHY WORKSITES

(a)(1)  The commissioner of health shall convene a work group to identify priorities and develop recommendations to enhance collaborative learning and interactive sharing of best practices in worksite wellness and employee health management, through approaches such as statewide or regional worksite wellness conferences, web‑enhanced resources and seminars, and the worksite recognition awards of the governor’s council on physical fitness and sports.

(2)  The work group should examine best practices in Vermont and other states that include:

(A)  Use of premium discounts, reduced cost sharing, or other financial incentives to encourage employee participation in wellness and health promotion activities;

(B)  Strategies to spread the adoption of workplace policies and practices that support breastfeeding for mothers;

(C)  Strategies to reach out to small employers and their employees who lack access to worksite wellness programs, such as the use of the VT 2‑1‑1 information and referral service as an information resource for healthy diet and physical activity, and the use of hospital‑based programs offering classes and one-to-one counseling similar to hospital-based tobacco use prevention programs; and

(D)  Use of financial incentives (such as small grants or tax credits) for small employers to establish worksite wellness programs, and the feasibility of group‑purchasing arrangements to help small employers gain access to worksite wellness products at a lower cost.

(b)  The commissioner shall make recommendations in a consolidated report on healthy living initiatives to the senate committee on health and welfare and the house committees on health care and on human services on priorities and recommendations no later than January 15, 2009.

Sec. 29.  PROMOTING HEALTHY WEIGHT THROUGH PRIMARY

               CARE

(a)  The commissioner of health shall coordinate with the Blueprint for Health director on practice‑based pilot projects to promote effectiveness in implementing evidence-based recommendations for the promotion of healthy weight and for the assessment, prevention, and treatment of obesity in primary care settings, in consultation with the Vermont child health improvement program and the area health education centers program.  The pilot projects shall focus on best practices in implementation by working with members of the medical practice to design, test, and evaluate strategies for changing office systems to better support efforts to promote healthy weight and prevent obesity in children and adults. 

(b)(1)  The commissioner shall convene a work group comprising the three major insurance carriers in Vermont, the office of Vermont health access, self‑insured employers, school health personnel and students, and health care providers to review recommended best practices in primary care settings for the promotion of healthy weight and for the for the assessment, prevention, and treatment of child and adolescent overweight and obesity and to recommend changes in coverage and payment policies as needed to support best practices that have a high health impact and cost-effectiveness.  As part of its review, the work group should:

(A)  Review models of successful obesity prevention and care strategies developed by insurance carriers and primary care practices in Vermont and other states;

(B)  Identify the respective roles of health practitioners shown to be most effective and cost-effective in the promotion of healthy weight and the assessment, prevention, and treatment of obesity, including physicians, dieticians, nonmedical counselors, self‑management groups, weight management programs, physical activity counselors, and others;

(C)  Review models for standard third party payment of breastfeeding education and support services;

(D)  Develop a plan for promoting measurement and tracking of the body mass index (BMI) percentile for children and adolescents, such as through the collection of data relating to BMI, lack of physical exercise, and inappropriate diet and eating habits using the ICD‑9‑DM V‑codes in the ninth edition of International Classification of Disease Codes;

(E) Include in the tracking plan guidelines for how such information will be coordinated and shared in order to maintain reasonable expectations of privacy; and 

(F)  Identify ways that payment policies might encourage stronger relationships among primary care practices, public health supports (such as WIC clinics for children under the age of six years), and school health personnel.

(2)  The commissioner shall make recommendations in a consolidated report on healthy living initiatives to the senate committee on health and welfare and the house committees on health care and on human services on priorities and recommendations no later than January 15, 2009.

Sec. 30.  18 V.S.A. § 11 is amended to read: 

§ 11.  CARDIOVASCULAR HEALTH: COALITION FOR

           HEALTHY ACTIVITY, MOTIVATION, AND PREVENTION

           PROGRAMS (CHAMPPS)/FIT AND HEALTHYAdvisory

           Council

The department of health shall:

* * *

(6)  Convene a CHAMPPS/Fit and Healthy advisory council chaired by the commissioner of health or designee and composed of state agencies and private sector partners which shall advise the commissioner on developing, implementing, and coordinating initiatives to increase physical activity and improve nutrition and reduce overweight and obesity. 

(A)  The functions and duties of the council shall include:

(i)  Recommending ways that the department of health and other state agencies can reach out to communities, schools, worksites, and municipal and regional planners to assist them in creating environments and policies conducive to healthy living for all Vermonters; and

(ii)  Assessing available resources and funding streams, recommending how best to coordinate those initiatives and resources across state agencies and private sector organizations for the greatest impact, and recommending new initiatives and priorities utilizing data and best-practice guidelines. 

(B)  The department of health shall review the fit and healthy Vermonters prevention plan and the status of its major initiatives with the advisory council at least every three years.  The advisory council shall advise and make recommendations to the department of health as the department develops an annual work plan setting forth prioritized strategies to implement a three-year prevention plan.

Sec. 31.  FOODS CONTAINING ARTIFICIAL TRANS FAT AND MENU

              LABELING

(a)  The general assembly finds:

(1)  The U.S. Food and Drug Administration has required listing trans fat content on the nutrition labels of packaged foods since 2006.

(2)  A large percentage of the food consumed by Vermonters is prepared in restaurants and other food service establishments where disclosing the presence of trans fat in food is not required.

(3)  Consumption of trans fat contributes to increased LDL (“bad”) cholesterol levels which cause increased risks of coronary heart disease and heart attacks.

(4)  Artificial trans fat can be replaced with heart-healthier oils and fats without changing the taste of foods.

(b)  The Vermont department of health, in collaboration with the Vermont hospitality council, the American Heart Association, and representatives of the food service industry in Vermont, shall develop proposed restaurant labeling, a healthy facility designation, or both, that will inform consumers of healthy nutrition choices and the presence thereof in food service facilities.  The department of health shall also recommend methods for making Vermont free of artificial trans fats in prepared foods by 2012.  Recommendations shall be presented to the senate committee on health and welfare and the house committee on health care by January 15, 2009.

Sec. 32.  16 V.S.A. § 133(c) is added to read: 

(c)  Vermont school districts may include a module within the secondary school health class curricula relating to cervical cancer and the human papillomavirus.  The department of education shall work with relevant medical authorities to update the current model module to reflect up-to-date information and practices for health education in this area.

Sec. 33.  AHEC COUNTER DETAILING PROJECT

(a)  The Vermont area health education centers (AHEC) shall establish an evidence‑based prescription drug education program for health care professionals designed to provide information and education to physicians, pharmacists, and other health care professionals on the therapeutic and cost‑effective utilization of prescription drugs.  The program shall use the evidence-based standards developed by the Blueprint for Health, and AHEC shall collaborate with other states that are working on similar programs.  AHEC shall share information that would potentially strengthen programs or leverage limited resources and shall notify prescribers about commonly used brand-name drugs for which the patent has expired within the past 12 months or will expire in the coming 12 months.  The Vermont department of health and the office of Vermont health access shall collaborate in issuing notices.  To the extent permitted by funding, the program may include the distribution of vouchers for samples of generic medicines.

(b)  The sum of $100,000.00 is appropriated from the general fund to AHEC in fiscal year 2009 to support the counter-detailing project. 

Sec. 34.  18 V.S.A. § 9409b is added to read:

§ 9409b.  COST SHIFT STUDY

(a)  During the 2008 legislative interim, the commission on health care reform, in consultation with the secretary of administration or his or her designee and with administrative support from the joint fiscal office, shall build upon the annual cost shift analysis conducted by the department of banking, insurance, securities, and health care administration in conducting a detailed analysis of the Medicaid cost shift to develop:

(1)  a definition of the Medicaid cost shift by considering different standards, including Medicare and provider costs;

(2)  ways to quantify the contribution of Vermont’s Medicaid program to the Medicaid cost shift;

(3)  ways to quantify the effects of the cost shift on other health care spending, including health insurance premiums and out-of-pocket spending, as well as an estimate of the impact on property taxes; and

(4)  a five‑year plan to ensure sustainable financing for Vermont’s health care programs, including Medicaid and Catamount Health.

(b)  Beginning January 15, 2009 and annually thereafter, the commission on health care reform shall report to the general assembly:

(1)  in total and for each of the four major provider types which account for the largest share of the Medicaid cost shift an estimate of the amount of the Medicaid cost shift for the current and following fiscal years;

(2)  an analysis of whether Catamount Health and other health plans receiving state monies have sustainable funding sources, including an analysis of the impact on the cost shift of any changes to such plans;

(3)  an estimate of the impact of the cost shift on other health care prices;

(4)  an estimate of the state funds necessary to eliminate the Vermont component of the Medicaid cost shift; and

(5)  an analysis of progress toward sustainable financing of health care in this state.

(c)  Beginning with the 2009 legislative session and annually thereafter, within 90 days following passage of the appropriations act, the joint fiscal office shall provide to the general assembly an estimate of the projected impact on the cost shift and other health care spending of legislation passed during the current legislative session, if the general assembly is still in session, or the health access oversight committee, if the general assembly is no longer in session.

* * * Supporting Health Information Technology * * *

Sec. 35.  22 V.S.A. § 903 is amended to read:

§ 903.  health information technology

* * *

(c)(1)  The commissioner shall contract with provide a grant to the Vermont information technology leaders (VITL), a broad‑based health information technology advisory group that includes providers, payers, employers, patients, health care purchasers, information technology vendors, and other business leaders, to develop the health information technology plan, including applicable standards, protocols, and pilot programs.  In carrying out their responsibilities under this section, members of VITL shall be subject to conflict of interest policies established by the commissioner to ensure that deliberations and decisions are fair and equitable.

(2)  VITL shall be designated in the plan to operate the exclusive statewide health information exchange network for this state, notwithstanding the provisions of subsection (g) of this section requiring the recommendation of the commissioner and the approval of the general assembly before the plan can take effect.  To the extent of its involvement with the operation of the network, VITL shall be immune from civil, criminal, or administrative liability as a result of any action made in good faith; but nothing in this section shall be construed to establish immunity for the failure to exercise due care.  Nothing in this section shall impede local community providers from the exchange of electronic medical data. 

* * *

(g)  On or before January 1, 2007, VITL shall submit to the commission on health care reform, the secretary of administration, the commissioner of information and innovation, the commissioner of banking, insurance, securities, and health care administration, the director of the office of Vermont health access, the senate committee on health and welfare, and the house committee on health care a preliminary health information technology plan for establishing a statewide, integrated electronic health information infrastructure in Vermont, including specific steps for achieving the goals and objectives of this section. A final plan shall be submitted July 1, 2007.  The plan shall include also recommendations for self-sustainable funding for the ongoing development, maintenance, and replacement of the health information technology system.  Upon recommendation by the commissioner of information and innovation and approval by the general assembly, the plan shall serve as the framework within which certificate of need applications for information technology are reviewed under section 9440b of Title 18 by the commissioner.  VITL shall update the plan annually to reflect emerging technologies, the state’s changing needs, and such other areas as VITL deems appropriate and shall submit the updated plan to the commissioner.  Upon approval by the commissioner, VITL shall distribute the updated plan to the commission on health care reform; the secretary of administration; the commissioner of banking, insurance, securities, and health care administration; the director of the office of Vermont health access; the senate committee on health and welfare; the house committee on health care; affected parties; and interested stakeholders.

* * *

(h)  Beginning January 1, 2006, and annually thereafter, VITL shall file a report with the commission on health care reform, the secretary of administration, the commissioner, the commissioner of banking, insurance, securities, and health care administration, the director of the office of Vermont health access, the senate committee on health and welfare, and the house committee on health care.  The report shall include an assessment of progress in implementing the provisions of this section, recommendations for additional funding and legislation required, and an analysis of the costs, benefits, and effectiveness of the pilot program authorized under subsection (e) of this section, including, to the extent these can be measured, reductions in tests needed to determine patient medications, improved patient outcomes, or reductions in administrative or other costs achieved as a result of the pilot program.  In addition, VITL shall file quarterly progress reports with the secretary of administration and the health access oversight committee and shall publish minutes of VITL meetings and any other relevant information on a public website.

* * *

Sec. 36.  E‑PRESCRIBING STUDY

(a)  The director of the commission on health care reform and the VITL project review committee shall conduct a planning and feasibility study to determine the impact of implementing a statewide e‑prescriber program. 

(b)  The study shall address:

(1)  a consideration of the best methods of access to e‑prescribing, including the use of freestanding handheld devices, web-based options, and e‑prescribing modules integrated with electronic medical records; 

(2)  identification of an appropriate business model, including incentives to encourage provider participation;

(3)  an inventory of current e-prescribing activities and existing capacity for e-prescribing in this state;

(4)  a cost-benefit analysis of creating a statewide e-prescriber program;

(5)  the ability of an e-prescriber program to ensure the privacy and security of prescription data, including controls over data-mining;

(6)  state and national studies and reports on data-mining in e-prescribing and the appropriate use of e-prescription information;

(7)  the use of practice management systems and electronic claims data sources through the Vermont health information exchange;

(8)  existing state and national initiatives such as the National

e-Prescribing Patient Safety Initiative and Massachusetts’s Partners Health Care; and

(9)  an assessment of the readiness of pharmacies to participate in e‑prescribing and the impact on independent pharmacies.

(c)  No later than January 15, 2009, the director of the commission on health care reform shall report on the findings of the study to the commission on health care reform, the house committee on health care, and the senate committee on health and welfare.

* * * Investing in Vermont’s Health Care System and Workforce * * *

Sec. 37.  HEALTH IMPROVEMENT APPROPRIATIONS

The following amounts are appropriated:

(1)  Of the Global Commitment fund appropriation in fiscal year 2009, $1,645,000.00 shall be deposited into the Vermont educational loan repayment fund and used for the purposes of loan repayment for health care providers and health care educators pursuant to section 10a of Title 18 to be allocated as follows:

(A)  $745,000.00 to primary care practitioners;

(B)  $200,000.00 to dentists;

(C)  $425,000.00 to nurses;

(D)  $75,000.00 to nurse educators;

(E)  $50,000.00 to disciplines based on emerging health care needs and workforce shortages.

(2)  Of the amount appropriated in subdivision (1) of this section, $150,000.00 is allocated for the loan forgiveness/incentive scholarship fund and used for the purposes of loan forgiveness programs for health care providers through the dental hygienist incentive loan program and nursing incentive loan program. 

(3)  The amount of $100,000.00 is appropriated from the general fund to the Vermont department of health for the child psychiatry division in the Vermont Center for Children, Youth, and Families (VCCYF) to support child tele-psychiatry pilots in community health centers that will: 

(A)  Pair Vermont health centers’ medical, nursing, social work, and psychology staff with the UVM VCCYF child psychiatric consultative team;

(B)  Provide monthly training and education resources for health center staff by UVM faculty;

(C)  Help strengthen and expand the newly established UVM child psychiatry fellowship program; and

(D)  Provide critical child psychiatry assessment and consulting services across the state that will establish relationships to help recruit and retain new child psychiatrists for Vermont.

(4)  The amount of $425,000.00 is appropriated from the general fund for the Vermont State College system and the University of Vermont to be used to increase base salaries for difficult‑to‑fill nurse educator positions, subject to existing collective bargaining agreements.  In addition, the Vermont State Colleges system and the University of Vermont shall undertake a study to examine how to increase the state’s capacity to educate nursing students and shall provide a report on the study by January 15, 2009 to the house committees on health care and on human services and the senate committee on health and welfare.

Sec. 38.  HEALTH CARE PIPELINE COLLABORATIVE

The sum of $50,000.00 is appropriated from the general fund to the University of Vermont College of Medicine office of primary care and the area health education centers (AHEC) program office to fund an employee pipeline collaborative that will increase the number of students pursuing allied health careers in Vermont.  AHEC shall act as the fiduciary agent for the state and shall have a designated project manager who will generate written subgrant agreements with deliverables, provide oversight to the statewide project, collect reports from each AHEC office, and file the statewide activities, measures, and financial reports as required by the state.  On a regional basis, day-to-day activities shall be overseen by each AHEC director.  Existing director meetings shall include regular updates on the sharing of information, ideas for innovation, and barriers to implementation.  As part of the AHEC network activities, all directors shall meet monthly to discuss AHEC work.

* * * Fair Standards for Provider Contracts with Insurers * * *

Sec. 39.  18 V.S.A. § 9418 is amended to read:

§ 9418.  payment for health care services

* * *

(i)  If In addition to any other remedy provided by law, if the commissioner finds that a health plan has engaged in a pattern and practice of violating this section, the commissioner may impose an administrative penalty against the health plan of no more than $500.00 for each violation, and may order the health plan to cease and desist from further violations and order the health plan to remediate the violation.  In determining the amount of penalty to be assessed, the commissioner shall consider the following factors:

(1) The appropriateness of the penalty with respect to the financial resources and good faith of the health plan.

(2) The gravity of the violation or practice.

(3) The history of previous violations or practices of a similar nature.

(4) The economic benefit derived by the health plan and the economic impact on the health care facility or health care provider resulting from the violation.

(5) Any other relevant factors.

(j)  A health insurer in this state shall not impose on any provider any retrospective denial of a previously paid claim or any part of that previously paid claim, unless: 

(1)  The health insurer has provided at least 30 days’ notice of any retrospective denial or overpayment recovery or both in writing to the provider.  The notice must include:

(A)  the patient’s name;

(B)  the service date;

(C)  the payment amount;

(D)  the proposed adjustment; and

(E)  a reasonably specific explanation of the proposed adjustment.

(2)  The time that has elapsed since the date of payment of the previously paid claim does not exceed 12 months. 

(k)  The retrospective denial of a previously paid claim shall be permitted beyond 12 months from the date of payment for any of the following reasons: 

(1)  The insurer has a reasonable belief that fraud or other intentional misconduct has occurred;

(2)  The claim payment was incorrect because the provider of the insured was already paid for the health services identified in the claim;

(3)  The health care services identified in the claim were not delivered by the provider; 

(4)  The claim payment is the subject of adjustment with another health insurer; or

(5)  The claim payment is the subject of legal action.

(l)  Nothing in this section shall be construed to prohibit a health insurer from applying payment policies that are consistent with applicable federal or state laws and regulations, or to relieve a health insurer from complying with payment standards established by federal or state laws and regulations, including rules adopted by the commissioner pursuant to section 9408 of this title relating to claims administration and adjudication standards, and rules adopted by the commissioner pursuant to section 9414 of this title and section 4088f of Title 8 relating to pay for performance or other payment methodology standards.

Sec. 40.  18 V.S.A. § 9418a is added to read:

§ 9418a.  PROCESSING CLAIMS, DOWNCODING, AND ADHERENCE

                TO CODING RULES

(a)  As used in this section:

(1)  “Claim” means any claim, bill or request for payment for all or any portion of provided health care services that is submitted by:

(A)  A health care provider or a health care facility pursuant to a contract or agreement with the health plan; or

(B)  A health care provider, a health care facility or a patient covered by the health plan.

(2)  “Contest” means the circumstance in which the health plan was not provided with:

(A)  Sufficient information needed to determine payer liability; or

(B)  Reasonable access to information needed to determine the liability or basis for payment of the claim.

(3)  “Health plan” means a health insurer, disability insurer, health maintenance organization, medical or hospital service corporation, or a workers’ compensation policy of a casualty insurer licensed to do business in Vermont.  “Health plan” also includes a health plan that requires its medical groups, independent practice associations, or other independent contractors to pay claims for the provision of health care services.

(b)  Health insurers shall accept and initiate the processing of all health care claims submitted by a health care provider pursuant to and consistent with the current version of the American Medical Association’s current procedural terminology (CPT) codes, reporting guidelines and conventions; the Centers for Medicare and Medicaid Services health care common procedure coding system (HCPCS); the National Correct Coding Initiative; or other appropriate standards, guidelines, or conventions approved by the commissioner. 

(c)  Nothing in this section shall preclude a health insurer from determining that any such claim is not eligible for payment in full or in part, based on a determination that: 

(1)  The claim is contested as defined in subdivision 9418(a)(3) of this title;

(2)  The service provided is not a covered benefit under the contract, including a determination that such service is not medically necessary or is experimental or investigational;

(3)  The insured did not obtain a referral, prior authorization, or precertification, or satisfy any other condition precedent to receiving covered benefits from the health care provider;

(4)  The covered benefit exceeds the benefit limits of the contract;

(5)  The person is not eligible for coverage or is otherwise not compliant with the terms and conditions of his or her coverage agreement;

(6)  The insurer has a reasonable belief that fraud or other intentional misconduct has occurred; or

(7)  The insurer determines through coordination of benefits that another health insurer is liable for the claim.  

(d)  Nothing in this section shall be deemed to require a health insurer to pay or reimburse a claim, in full or in part, or to dictate the amount of a claim to be paid by a health insurer to a health care provider. 

(e)  No health insurer shall automatically reassign or reduce the code level of evaluation and management codes billed for covered services (downcoding), except that a health insurer may reassign a new patient visit code to an established patient visit code based solely on CPT codes, CPT guidelines, and CPT conventions.  

(f)  Notwithstanding the provisions of subsection (d) of this section, and other than the edits contained in the conventions in subsection (a) of this section, health insurers shall continue to have the right to deny, pend, or adjust claims for covered services on other bases and shall have the right to reassign or reduce the code level for selected claims for covered services based on a review of the clinical information provided at the time the service was rendered for the particular claim or a review of the information derived from a health insurer’s fraud or abuse billing detection programs that create a reasonable belief of fraudulent or abusive billing practices, provided that the decision to reassign or reduce is based primarily on a review of clinical information. 

(g)  Every health insurance plan shall publish on its provider website and in its provider newsletter the name of the commercially available claims editing software product that the health insurer utilizes and any significant edits, as determined by the health insurer, added to the claims software product after the effective date of this section, which are made at the request of the health insurer.  The health insurer shall also provide such information upon written request of a health care provider who is a participating member in the health insurer’s provider network. 

(h)  In addition to any other remedy provided by law, if the commissioner finds that a health plan has engaged in a pattern and practice of violating this section, the commissioner may impose an administrative penalty against the health plan of no more than $500.00 for each violation, and may order the health plan to cease and desist from further violations and order the health plan to remediate the violation.  In determining the amount of penalty to be assessed, the commissioner shall consider the following factors:

(1)  The appropriateness of the penalty with respect to the financial resources and good faith of the health plan.

(2)  The gravity of the violation or practice.

(3)  The history of previous violations or practices of a similar nature.

(4)  The economic benefit derived by the health plan and the economic impact on the health care facility or health care provider resulting from the violation.

(5)  Any other relevant factors.

(i)  Nothing in this section shall be construed to prohibit a health insurer from applying payment policies that are consistent with applicable federal or state laws and regulations, or to relieve a health insurer from complying with payment standards established by federal or state laws and regulations, including rules adopted by the commissioner pursuant to section 9408 of this title relating to claims administration and adjudication standards, and rules adopted by the commissioner pursuant to section 9414 of this title and section 4088f of Title 8 relating to pay for performance or other payment methodology standards.

Sec. 41.  18 V.S.A. § 9418b is added to read:

§ 9418b.  PRIOR AUTHORIZATION

(a)  As used in this section:

(1)  “Claim” means any claim, bill or request for payment for all or any portion of provided health care services that is submitted by:

(A)  A health care provider or a health care facility pursuant to a contract or agreement with the health plan; or

(B)  A health care provider, a health care facility or a patient covered by the health plan.

(2)  “Health plan” means a health insurer, disability insurer, health maintenance organization, medical or hospital service corporation or a workers’ compensation policy of a casualty insurer licensed to do business in Vermont.  “Health plan” also includes a health plan that requires its medical groups, independent practice associations or other independent contractors to pay claims for the provision of health care services.

(b)  Health insurers shall pay claims for health care services for which prior authorization was required by and received from the health insurer, unless:

(1)  The insured was not a covered individual at the time the service was rendered;

(2)  The insured’s benefit limitations were exhausted;

(3)  The prior authorization was based on materially inaccurate information from the health care provider;

(4)  The insurer has a reasonable belief that fraud or other intentional misconduct has occurred; or 

(5)  The insurer determines through coordination of benefits that another health insurer is liable for the claim.

(c)  Notwithstanding the provisions of subsection (a) of this section, nothing in this section shall be construed to prohibit a health insurer from denying continued or extended coverage as part of concurrent review, denying a claim if the health insurer is not primarily obligated to pay the claim, or applying payment policies that are consistent with an applicable law, rule, or regulation. 

(d)  A health insurer shall furnish, upon request from a health care provider, a current list of services and supplies requiring prior authorization. 

(e)  A health insurer shall post a current list of services and supplies requiring prior authorization to the insurer’s website. 

(f)  In addition to any other remedy provided by law, if the commissioner finds that a health plan has engaged in a pattern and practice of violating this section, the commissioner may impose an administrative penalty against the health plan of no more than $500.00 for each violation, and may order the health plan to cease and desist from further violations and order the health plan to remediate the violation.  In determining the amount of penalty to be assessed, the commissioner shall consider the following factors:

(1)  The appropriateness of the penalty with respect to the financial resources and good faith of the health plan.

(2)  The gravity of the violation or practice.

(3)  The history of previous violations or practices of a similar nature.

(4)  The economic benefit derived by the health plan and the economic impact on the health care facility or health care provider resulting from the violation.

(5)  Any other relevant factors.

(g)  Nothing in this section shall be construed to prohibit a health insurer from applying payment policies that are consistent with applicable federal or state laws and regulations, or to relieve a health insurer from complying with payment standards established by federal or state laws and regulations, including rules adopted by the commissioner pursuant to section 9408 of this title relating to claims administration and adjudication standards, and rules adopted by the commissioner pursuant to section 9414 of this title and section 4088f of Title 8 relating to pay for performance or other payment methodology standards.

Sec. 42.  18 V.S.A. § 9408a is amended to read: 

§ 9408a.  uniform provider credentialing

* * *

(d)  An insurer or a A hospital shall notify a provider concerning the status of the provider’s completed credentialing application not later than:

(1)  Sixty days after the insurer or hospital receives the completed credentialing application form; and

(2)  Every 30 days after the notice is provided under subdivision (1) of this subsection, until the hospital makes a final credentialing determination concerning the provider. 

* * *

(f)  An insurer shall act upon and finish the credentialing process of a completed application submitted by a provider within 60 calendar days of receipt of the application. 


Sec. 43.  FAIR CONTRACTING STANDARDS STUDY

The Vermont medical society, in collaboration with the department of banking, insurance, securities, and health care administration; the Vermont association of hospital and health systems; insurers; practice managers; and other interested parties, shall work to address the following issues and report to the house committee on health care and the senate committee on health and welfare or before January 15, 2009:

(1)  Fair and transparent contracting standards for providers participating in health insurance plans;

(2)  Categories of coverage;

(3)  Rental networks; and

(4)  Most favored nation clauses. 

Sec. 44.  RESTRICTIVE COVENANTS STUDY

The Vermont medical society, in collaboration with the department of health, the area health education centers program, and the Vermont association of hospitals and health systems, shall work to address the issue of the use of restrictive covenants in employment contracts of health care professionals and the impact of restrictive covenants on recruitment and retention of health care professionals in Vermont and shall report to the senate committee on health and welfare and the house committee on health care on or before January 15, 2009. 

Sec. 45.  WORKERS’ COMPENSATION STUDY

The Vermont medical society, in collaboration with the Vermont association of hospitals and health systems; the department of banking, insurance, securities, and health care administration; the department of labor; workers’ compensation carriers; the Vermont medical society; practice managers; and other interested parties, shall work to address the following issues and shall report to the senate committees on health and welfare and on economic development, housing and general affairs and the house committees on health care and on commerce on or before January 15, 2009:

(1)  Timely payment of workers’ compensation claims;

(2)  Notification and resolution process for contested claims;

(3)  Enforcement of timely payment, including assessment of interest and penalties;

(4)  Charges for examinations, reviews, and investigations in connection with workers’ compensation claims;

(5)  Filing of carriers’ written claims processing practices with the department of labor; and 

(6)  Development of online claim processing and claim tracking systems accessible to health care providers. 

Sec. 46.  EFFECTIVE DATES

This act shall take effect on passage, except that:

(1)  Secs. 12 and 13 (post-divorce coverage) and Sec. 14 (young adult coverage) shall take effect on October 1, 2008 and shall apply to all health benefit plans on and after October 1, 2008 on such date as a health insurer offers, issues, or renews the health benefit plan, but in no event later than October 1, 2009. 

(2)  If the emergency board determines to proceed with implementation of the reduced waiting period established in Sec. 15 of this act, the following statutory sections shall be amended as follows, to take effect immediately upon such determination: 

(A)  8 V.S.A. § 4080f(a)(9) is amended to read: 

(9)  “Uninsured” means an individual who does not qualify for Medicare, Medicaid, the Vermont health access plan, or Dr. Dynasaur, and:  who had no private insurance or employer-sponsored coverage that includes both hospital and physician services within 12 six months prior to the month of application,; or who lost private insurance or employer-sponsored coverage during the prior 12 six months for the following reasons:

* * *

(B)  33 V.S.A. § 1973(e) is amended to read: 

(e)  “Uninsured” means an individual who does not qualify for Medicare, Medicaid, the Vermont health access plan, or Dr. Dynasaur, and who had no privatate insurance or employer-sponsored coverage that includes both hospital and physician services within 12 six months prior to the month of application,; or who lost private insurance or employer-sponsored coverage during the prior 12 six months for the following reasons:

* * *

(C)  33 V.S.A. § 1974(c) is amended to read: 

(c)  Uninsured individuals; premium assistance.

(1)  For the purposes of this subsection:

* * *

(B)  “Uninsured” means an individual who does not qualify for Medicare, Medicaid, the Vermont health access plan, or Dr. Dynasaur, and who had no private insurance or employer-sponsored coverage that includes both hospital and physician services within 12 six months prior to the month of application,; or who lost private insurance or employer-sponsored coverage during the prior 12 six months for the following reasons:

* * *

(D)  33 V.S.A. § 1982(2) is amended to read: 

(2)  “Uninsured” means an individual who does not qualify for Medicare, Medicaid, the Vermont health access plan, or Dr. Dynasaur, and who had no private insurance or employer‑sponsored coverage that includes both hospital and physician services within 12 six months prior to the month of application,; or who lost private insurance or employer‑sponsored coverage during the prior 12 six months for the following reasons:

* * *

(E)  33 V.S.A. § 1983(b) is amended to read: 

(b)(1)  An individual receiving benefits under Medicaid, the Vermont health access plan, Dr. Dynasaur, or premium assistance for employer-sponsored insurance under section 1974 of this title or any other health benefit plan authorized under Title XIX or Title XX of the Social Security Act within 12 six months of applying for Catamount Health assistance shall not be required to wait 12 six months to be eligible.

(2)  An individual who has been enrolled in Catamount Health without assistance shall not be subject to a 12month six‑month waiting period before becoming eligible for assistance under this subchapter.



Published by:

The Vermont General Assembly
115 State Street
Montpelier, Vermont


www.leg.state.vt.us