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Introduced by   Senator Racine of Chittenden District

Referred to Committee on


Subject:  Health; managed care organizations; Blueprint for Health

Statement of purpose:  This bill proposes to require all health insurance plans available in Vermont to be offered, issued, and administered consistent with the Blueprint for Health; to direct managed care organizations to establish chronic care programs consistent with the Blueprint for Health; and to allow the commissioner of banking, insurance, securities, and health care administration to conduct comprehensive examinations of managed care organizations.


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

Sec. 1.  18 V.S.A. § 9414(a)(1), (b), and (e) are amended to read:

(a)  The commissioner shall have the power and responsibility to ensure that each managed care organization provides quality health care to its members, in accordance with the provisions of this section.

(1)  In determining whether a managed care organization meets the requirements of this section, the commissioner shall annually review and examine, in accordance with subsection (e) of this section, the organization’s administrative policies and procedures, quality management and improvement procedures, utilization management, credentialing practices, members' rights and responsibilities, preventive health services, medical records practices, grievance and appeal procedures, member services, financial incentives or disincentives, disenrollment, provider contracting, and systems and data reporting capacities.  The commissioner may establish, by rule, specific criteria to be considered under this section.

(b)(1)  A managed care organization shall assure that the health care services provided to members are consistent with prevailing professionally recognized standards of medical practice.  

(2)  A managed care organization shall establish a chronic care program as needed to implement the Blueprint for Health established in chapter 13 of this title.  The program shall include:

(A)  appropriate benefit plan design;

(B)  informational and infrastructure supports for members and providers; and

(C)  incentives to encourage provider participation. 

(3)  Each managed care organization shall have procedures to assure availability, accessibility and continuity of care, and ongoing procedures for the identification, evaluation, resolution, and follow-up of potential and actual problems in its health care administration and delivery.

(e)  The commissioner shall evaluate review a managed care organization's performance under the requirements of this section at least once every three years and more frequently as the commissioner deems proper.  If upon review the commissioner determines that the organization’s performance with respect to one or more requirements warrants further examination, the commissioner shall conduct a comprehensive or targeted examination of the organization’s performance.  The commissioner may designate another organization to conduct any evaluation under this subsection.  Any such independent designee shall have a confidentiality code acceptable to the commissioner, or shall be subject to the confidentiality code adopted by the commissioner under subdivision (f)(3) of this section.  In conducting an evaluation under this subsection, the commissioner or the commissioner's designee shall employ, retain, or contract with persons with expertise in medical quality assurance.

Sec. 2.  8 V.S.A. § 4088f is added to read:


(a)  A health insurance plan shall be offered, issued, and administered consistent with the Blueprint for Health established in chapter 13 of Title 18, as determined by the commissioner.

(b)  As used in this section, “health insurance plan” means any individual or group health insurance policy, any hospital or medical service corporation or health maintenance organization subscriber contract, or any other health benefit plan offered, issued, or renewed for any person in this state by a health insurer, as defined in section 9402 of Title 18.  The term shall include the health benefit plan offered by the state of Vermont to its employees and any health benefit plan offered by any agency or instrumentality of the state to its employees.  The term shall not include benefit plans providing coverage for specific disease or other limited benefit coverage unless so directed by the commissioner.

Published by:

The Vermont General Assembly
115 State Street
Montpelier, Vermont