Title 18, Health

§ 9414. Quality assurance for managed care (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 manag…

§ 9414a. Annual reporting by health insurers (a) As used in this section: (1) “Adverse benefit determination” means a denial, reduction, modification, or termination of, or a failure to provide or make payment in whole or in part for, a benefit, including: (A) a denial, reduction…

§ 9416. Vermont Program for Quality in Health Care (a) The Commissioner of Health shall contract with the Vermont Program for Quality in Health Care, Inc. to implement and maintain a statewide quality assurance system to evaluate and improve the quality of health care services re…

§ 9417. Tax-advantaged accounts for health-related expenses; administration; rulemaking (a) As used in this section: (1) “Flexible spending account” or “FSA” has the same meaning as in 26 U.S.C. § 106(c)(2). (2) “Health reimbursement arrangement” or “HRA” means any account-based …

§ 9418. Payment for health care services (a) Except as otherwise specified, as used in this subchapter: (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 c…

§ 9418a. Processing claims, downcoding, and adherence to coding rules (a) Health plans, contracting entities, covered entities, and payers shall accept and initiate the processing of all health care claims submitted by a health care provider pursuant to and consistent with the cu…

§ 9418b. Prior authorization (a) Health plans shall pay claims for health care services for which prior authorization was required by and received from the health plan, unless: (1) the insured was not a covered individual at the time the service was rendered; (2) the insured’s be…

§ 9418c. Fair contract standards (a) Required information. (1) Each contracting entity shall provide and each health care contract shall obligate the contracting entity to provide participating health care providers information sufficient for the participating provider to determi…

§ 9418d. Contract amendments (a) A health care contract may be amended by mutual agreement of the parties. (b) Absent mutual agreement of the parties, a health care contract may be amended only as follows: (1) The contracting entity shall provide to the participating provider not…

§ 9418e. Most favored nation clauses prohibited Not later than 180 days after the effective date of this section, no contracting entity shall do any of the following: (1) offer to a provider, hospital, pharmacist, or pharmacy a health care contract that includes a most favored na…

§ 9418f. Rental network contracts (a) Definitions. As used in this section: (1) “Health care services” means services for the diagnosis, prevention, treatment, or cure of a health condition, illness, injury, or disease. (2)(A) “Provider” means a physician, a physician organizatio…

§ 9418g. Enforcement In addition to any other remedy provided by law, the Commissioner may, in the Commissioner’s sole discretion, enforce the provisions of this subchapter as specified in this section. In determining whether to undertake an enforcement action, the Commissioner m…

§ 9419. Charges for access to medical records (a) A custodian may impose a charge that is no more than a flat $5.00 fee or no more than $0.50 per page, whichever is greater, for providing copies of an individual’s health care record. A custodian shall provide an individual or the…

§ 9420. Conversion of nonprofit hospitals (a) Policy and purpose. The State has a responsibility to ensure that the assets of nonprofit entities, which are impressed with a charitable trust, are managed prudently and are preserved for their proper charitable purposes. (b) Definit…

§ 9421. Pharmacy benefit management; registration; insurer audit of pharmacy benefit manager activities [Repealed effective July 1, 2029] (a) A pharmacy benefit manager shall not do business in this State without first registering with the Commissioner on a form and in a manner p…

§ 9422. Credit card payments optional for providers (a) As used in this section: (1) “Credit card payment” means a type of electronic funds transfer in which a health insurer or its contracted vendor issues a single-use series of numbers associated with payment for health care se…

§ 9431. Policy and purpose (a) It is declared to be the public policy of this State that the general welfare and protection of the lives, health, and property of the people of this State require that all new health care projects be offered or developed in a manner that avoids unn…

§ 9432. Definitions As used in this subchapter: (1) “Ambulatory surgical center” means a facility or portion of a facility that provides surgical care not requiring an overnight stay. The office of a dentist in which activities are limited to dentistry and oral or maxillofacial s…

§ 9433. Administration (a) The Green Mountain Care Board shall exercise such duties and powers as necessary for the implementation of the certificate of need program as provided by and consistent with this subchapter. The Board shall issue or deny certificates of need and adminis…

§ 9434. Certificate of need; general rules (a) A health care facility shall not develop or have developed on its behalf a new health care project without issuance of a certificate of need by the Board. For purposes of this subsection, a “new health care project” means any of the …

§ 9435. Exclusions (a) Excluded from this subchapter are offices of physicians, dentists, or other practitioners of the healing arts, meaning the physical places that are occupied by such providers on a regular basis in which such providers perform the range of diagnostic and tre…

§ 9437. Criteria A certificate of need shall be granted if the applicant demonstrates that the project serves the public good and the Board finds: (1) The proposed project aligns with statewide health care reform goals and principles because the project: (A) takes into considerat…

§ 9439. Competing applications (a) The Board shall provide by rule a process by which any person wishing to offer or develop a new health care project may submit a competing application when a substantially similar application is pending. The competing application must be filed a…

§ 9440. Procedures (a) Notwithstanding 3 V.S.A. chapter 25, a certificate of need application shall be in accordance with the procedures of this section. (b)(1) The application shall be in such form and contain such information as the Board establishes. In addition, the Board may…

§ 9440a. Applications, information, and testimony; oath required (a) Each application filed under this subchapter, any written information required or permitted to be submitted in connection with an application or with the monitoring of an order, decision, or certificate issued b…

§ 9440b. Information technology; review procedures Notwithstanding the procedures in section 9440 of this title, the Board shall establish by rule standards and expedited procedures for reviewing applications for the purchase or lease of health care information technology that ot…

§ 9441. Fees (a) The Board shall charge a fee for the filing of certificate of need applications. The fee shall be calculated at the rate of 0.125 percent of project costs. (b) The maximum fee shall not exceed $20,000.00 and the minimum filing fee is $250.00 regardless of project…

§ 9442. Bonds In any circumstance in which bonds are to be or may be issued in connection with a new health care project subject to the provisions of this subchapter, the certificate of need shall include the requirement that all information required to be provided to the bonding…

§ 9443. Expiration of certificates of need (a) Unless otherwise specified in the certificate of need, a project shall be implemented within five years or the certificate shall be invalid. (b) Not later than 180 days before the expiration date of a certificate of need, an applican…

§ 9444. Revocation of certificates; material change (a) The Board may revoke a certificate of need for substantial noncompliance with the scope of the project as designated in the application, or for failure to comply with the conditions set forth in the certificate of need grant…

§ 9445. Enforcement (a) Any person who offers or develops any new health care project within the meaning of this subchapter without first obtaining a certificate of need as required by this subchapter, or who otherwise violates any of the provisions of this subchapter or any rule…

§ 9446. Home health agencies; geographic service areas The terms of a certificate of need relating to the boundaries of the geographic service area of a home health agency may be modified by the Board, in consultation with the Commissioner of Disabilities, Aging, and Independent …

§ 9451. Definitions As used in this subchapter: (1) “Hospital” means a hospital licensed under chapter 43 of this title, except a hospital that is conducted, maintained, or operated by the State of Vermont. (2) “Hospital network” means a system comprising two or more affiliated h…

§ 9453. Powers and duties (a) The Board shall: (1) adopt uniform formats that hospitals shall use to report financial, scope-of-services, and utilization data and information; (2) designate a data organization with which hospitals shall file financial, scope-of-services, and util…

§ 9454. Hospitals; duties (a) Hospitals shall file the following information at the time and place and in the manner established by the Board: (1) a budget for the forthcoming fiscal year; (2) financial information, including costs of operation, revenues, assets, liabilities, fun…

§ 9456. Budget review (a) The Board shall conduct reviews of each hospital’s proposed budget based on the information provided pursuant to this subchapter and in accordance with a schedule established by the Board. Notwithstanding any provision of 3 V.S.A. chapter 25 to the contr…

§ 9457. Information available to the public (a) Information required to be filed under this subchapter shall be made available to the public upon request in accordance with 1 V.S.A. chapter 5, subchapter 3 (Public Records Act), except that information that directly or indirectly …

§ 9458. Hospital networks; structure; financial operations (a) The Board may review and evaluate the structure of a hospital network to determine: (1) whether any network operations should be organized and operated out of a hospital instead of at the network; and (2) whether the …

§ 9461. Quality measures (a) The Department of Financial Regulation shall develop performance quality measures to evaluate and ensure that health insurers, including managed care organizations that contract with health insurers to administer the insurers’ mental health benefits, …

§ 9462. Quality improvement projects The Green Mountain Care Board shall consider the results of any quality improvement projects not otherwise confidential or privileged undertaken by managed care organizations for mental health and substance abuse care and treatment pursuant to…

§ 9471. Definitions [Repealed effective July 1, 2029] As used in this subchapter: (1) “Beneficiary” means an individual enrolled in a health plan in which coverage of prescription drugs is administered by a pharmacy benefit manager and includes his or her dependent or other perso…

§ 9472. Pharmacy benefit managers; required practices with respect to health insurers and covered persons [Repealed effective July 1, 2029] (a) A pharmacy benefit manager that provides pharmacy benefit management for a health plan has a fiduciary duty to its health insurer client…

§ 9473. Pharmacy benefit managers; required practices with respect to pharmacies [Repealed effective July 1, 2029] (a) Within 14 calendar days following receipt of a pharmacy claim, a pharmacy benefit manager or other entity paying pharmacy claims shall do one of the following: (…

§ 9474. Enforcement [Repealed effective July 1, 2029] (a) Except as provided in subsection (d) of this section, in addition to any remedy available to the Commissioner under this title and any other remedy provided by law, a violation of this subchapter shall be considered a viol…

§ 9481. Definitions As used in this subchapter: (1) “Amount generally billed” means the amount a large health care facility generally bills to individuals for emergency or other medically necessary health care services, determined using the “look-back method” set forth in 26 C.F.…

§ 9482. Financial assistance policies for large health care facilities (a) Each large health care facility in this State shall develop a written financial assistance policy that, at a minimum, complies with the provisions of this subchapter and any applicable federal requirements…