Page 1 of 18 Section H.202 As Introduced H.202 As Passed the House Throughout Changed name of Vermont Health Reform Board to Green Mountain Care Board 1 Principles for health care reform It is the policy of the state of Vermont to ensure universal access to and coverage for essential health services for all Vermonters. Spending growth must be consistent with economic growth. The health care system must be transparent. The health care infrastructure must be supported to ensure access and must be sustainable. Vermonters should choose their primary care provider. Vermonters should understand how much their health services cost. The system must respect the provider-patient relationship. The system must continuously improve and be highquality. The system must contain costs. The financing of health care in Vermont must be sufficient, fair, sustainable, and shared equitably. State government must ensure that the health care system satisfies the principles in this section. Changed the term single-payer to universal throughout Moved to Sec. 3 and merged with principles for the Green Mountain Care Board Roadmap to a Universal and Unified Health System
2 Strategic Plan for a Single-Payer and Unified Health System Upon receipt of necessary waivers, all Vermonters are eligible for Green Mountain Care (GMC) o Includes Medicaid and Medicare, employers who choose to participate, and state and local employees Vermont Health Reform Board is created to establish cost-containment mechanisms, budgets, and payment reform. Secretary of Administration or designee shall seek all necessary waivers Secretary of Administration or designee shall implement following: o November 1, 2013: exchange enrolls individuals and employer groups <100 o November 1, 2016: exchange enrolls employer groups >100 o January 1, 2014: BISHCA requires that all individual and small group insurance products are sold through the exchange o January 1, 2014: BISHCA requires all large group health insurance to align with that which is offered in the exchange Report-backs (See Secs. Below for additional details) o Integration plan (Sec. 8) How to fully integrate or align coverage for Medicaid, Medicare, private insurance, state employees, municipal employees in exchange o Financing plan (Sec. 9) How to finance care for full coverage through exchange and Page 2 of 18 Removed reference to small group size deferred decision to next year after a report from BISHCA. Moved Medical Malpractice language from Sec. 14 to Sec. 2 o Secretary of administration to submit a medical malpractice proposal o Proposal to address defensive medicine, reduce health care costs, adequate protections for patients and consideration of a no fault system o Designed to take effect on or before implementation of GMC
through GMC -- and other needed initiatives o Health Information Technology Assessment (Sec. 10) o Health System Planning, Regulation, Public Health (Sec. 11) o Payment Reform; Regulatory Process (Sec. 12) o Workforce Issues (Sec. 13) o Medical Malpractice Study (Sec. 14) Page 3 of 18 Cost Containment, Budgeting, and Payment Reform 3 Vermont Health Reform Board, 18 V.S.A. Chapter 220, 9371 et seq. Green Mountain Care Board, 18 V.S.A. Chapter 220, subchapter 1 9371 Principals Principals from Sec. 1 codified and revised. It is the policy of the state of Vermont to ensure universal access to and coverage for health services for all Vermonters. Overall health care costs must be contained and spending growth should be consistent with economic growth. The health care system must be transparent. Primary care must be preserved and enhanced. The health care infrastructure must be supported to ensure access and must be sustainable. Vermonters should choose their primary care provider. Vermonters should be aware of how much their health services cost. Individuals have a personal responsibility to maintain their own health and to use health resources wisely. The system must recognize the primacy of the
Page 4 of 18 provider-patient relationship. The system must continuously improve and be highquality. The system must contain costs. The financing of health care in Vermont must be sufficient, fair, sustainable, and shared equitably. The system must consider the effects of payment reform on individuals and health care professionals. Vermont s system must operate as a partnership between consumers, employers, health care professionals, hospitals, and the state and federal government. State government must ensure that the health care system satisfies the principles in this section. 9371. Purpose 9372. Definitions 9372. Purpose Added language that the board looks at the public good 9373. Definitions Clarifying changes 9373. Board Membership Appointed by Governor with the advice & consent of the Senate, six-year terms (staggered), chair is paid full-time and others are paid half-time 5 Members: expert in health policy; practicing health care professional; hospital rep; health insurance purchaser; consumer rep 9374. Board Membership 5 members (full-time chair; part-time members) Appointed by the Governor with advice and consent of the Senate --- after a new nominating committee process in section 9390 (see below similar to judicial nominating board); 6 year terms are staggered, with initial term of the chair being 7 years and all members serving for first 3 years Conflict of interest language added Board shall establish an advisory board & shall also
9374. Duties: Objectives Triple Aim : access, quality & cost. Additional considerations relevant to planning & impacts of changes on patients and providers October 1, 2011 On cost: o Establish cost containment targets and budgets for each sector of the health care system review BISHCA regulatory structures and suggest improvements (CON; Hospital Budgets) o Develop global budget o Review BISHCA decisions on insurance rates o Develop and implement payment reform pilots July 1, 2013 On cost: o Review and approve global budgets and capitated payments o Review and approve fee-for-service payments o Provide guidance to exchange re: rates paid to insurers On quality: o Evaluate system-wide performance On payment methodologies: o Eliminate cost shifting o Negotiate consistent provider reimbursement across payers o Identify innovative payment methodologies Upon implementation of Green Mountain care o Approve benefit package o Approve budget Page 5 of 18 consult with the health care ombudsman 9375. Duties Clarified and consolidated duties Changes to cost & payment methodology duties o Required rule-making for payment methods and cost-containment mechanisms o Adds review and approval of insurance rates, CON and hospital budget process On quality same Adds duties related to other health reform: o Adds review and approval of HIT plan o Adds development of health care workforce strategic plan o Adds monitoring of health care related migration, if any, and any impacts Modifications relating to GMC: o Provides for a 3 year budget with annual adjustments Adds reports to General Assembly on: o proposed methodologies o benefit packages o Annual Report on all duties
o Provide applicable budgeting and funding estimates to the general assembly 9375. Payment Amounts & Methods Intent to provide fair and equitable payment regardless of funding source Negotiate payment amounts with health care professionals, provider groups, and accountable care organizations Establish payment methods consistent with payment reform 9376. Payment reform pilots: Develop pilot projects to: manage total health care costs, improve health care outcomes, provide a positive health care experience for patients and providers, align with the Blueprint for Health strategic plan Requires insurer participation, provides for enforcement, and appeal process. Establishes mechanism for state supervision over the process to avoid anti-trust issues. The first pilot - no later than January 1, 2012, and two or more additional pilot projects - no later than July 1, 2012 9377. Agency Cooperation must provide information requested by the Board. 9378. Rules authority to establish rules under the Administrative Procedures Act Page 6 of 18 9376. Payment Amounts & Methods Broadens intent language Cross references existing law regarding provider bargaining groups Adds language to ensure antitrust protection for health care professionals 9377. Payment reform pilots: Clarifies the board s role with DVHA s role Cross-references codified principles Strengthens language providing antitrust protections for health care professionals and insurers 9378. Public Process Adds a process for soliciting public input prior to establishing the Green Mountain Care benefits 9379. Agency Cooperation - same 9380. Rules - same 9381. Appeals Directs the Board to establish procedures for an administrative appeal and allows for an appeal to the Supreme Court. Subchapter 2. GMC Nominating Committee Creates an 11 member nominating committee to provide recommendations to the Governor for the Green Mountain
Page 7 of 18 Care board appointments based on criteria for qualifications. Membership includes: 2 members appointed by the Governor 2 members appointed by the Speaker of the House 2 members appointed by the Senate Committee on Committees 1 member appointed by VAHHS (in consultation with all hospitals) 1 member appointed by Vt Medical Society 3a 8 V.S.A. 4089w Adds references to the Health Care Ombudsman (HCO) monitoring policies developed by the Green Mountain Care board to the statute creating the HCO 3b Green Mountain Care Board and Exchange Positions Adds language establishing GMC Board s positions and transferring 10 positions from the HCA in BISHCA. Creates the deputy commissioner for the health benefit exchange position (this is not funded from federal exchange funds, once available) 3c 18 V.S.A. 4631a Applies the ban on gifts and limits on expenditures from pharmaceutical manufacturers to the GMC Board members 3d 18 VSA 4632 Applies provisions re: disclosure of any allowable expenditures to GMC board members under existing process Vermont Health Benefit Exchange 4 Vermont Health Benefit Exchange 33 V.S.A. chapter 18, subchapter 1 1801. Purpose a step toward single payer; facilitate the purchase of affordable, qualified health Vermont Health Benefit Exchange 33 V.S.A. chapter 18, subchapter 1 1801. Purpose Minor wording changes
plans o reduce the number of uninsured and underinsured; o reduce disruption when individuals lose employer-based insurance; o reduce administrative costs in the insurance market; o promote health, prevention, and healthy lifestyles by individuals; o improve quality of health care 1802. Definitions Department = Dept of Vermont health access Qualified employer o Up to 100 employees o Vermont business all employees regardless of residence o Vermont employees of out-of-state business Qualified individual o Vermont resident o Not incarcerated (federal) o Citizen, national, or lawfully present immigrant (federal) 1803. Vermont Health Benefit Exchange One exchange for individuals and businesses - contracts selectively with insurer(s) o If must contract with multiple insurers, can create a single channel for claims processing and benefit management Prior to qualifying a plan, reviews historic rate increases by the insurer (federal) May offer plans to additional populations if allowed under federal law o Medicaid Page 8 of 18 1802. Definitions Adds definitions of qualified entity to incorporate federal limitations 1803. Vermont Health Benefit Exchange Changes references from deputy commissioner to commissioner & other clarifying changes
o Medicare o State and municipal employees May offer plans in lieu of workers compensation Unless PPACA waiver is obtained, Exchange also provides access to two federal plans 1804. Qualified Employers Uses current law on how to calculate number of employees 50% of work days in preceding quarter employ 100 or less; don t count employees working less than 30 hours week. Employer can continue to purchase if they grow beyond 100 employees 1805. Duties those required by federal law Determines eligibility for Medicaid or other state/federal health insurance programs (Sec. 5 & 6 moves eligibility from DCF to DVHA) Negotiates and collects premiums 1806. Qualified health benefit plans Sets requirements for plans sold by the exchange Determines if plan is in the best interest of Vermonters Essential benefits as defined by HHS + additional benefits by rule At least silver level plan or higher, meeting costsharing requirements of the federal law plus additional restrictions on cost-sharing by rule Minimum quality and wellness standards Participate in the Blueprint for Health Uniform forms/benefit explanations Must office at least one silver and one gold plan Must meet rate review requirements in BISHCA Page 9 of 18 1804. Qualified Employers Reserves this section & removes text. The House adds a study on whether small employer should be defined as 50 employees or less until 2016 (federal law requires small employer to be 100 employees or less at that time, but allows the state to change the definition before then). 1805. Duties Clarifying changes 1806. Qualified health benefit plans Clarifying changes
Must charge same premium for same produce in & out of the exchange 1807. Navigators assist individuals and employers in enrolling in a qualified health benefit plan exchange selects individuals and entities qualified to serve as navigators and awards grants to navigators Duties include: o Conduct public education activities o Distribute fair and impartial information re: qualified health plans, premium tax credits and cost-sharing reductions; o Facilitate enrollment in qualified health plans, Medicaid, Dr. Dynasaur, VPharm, and VermontRx; o referrals to the office of health care ombudsman and any other appropriate agency o Provide information in a manner that is culturally and linguistically appropriate o Distribute information to health care professionals, community organizations, and others to facilitate the enrollment of individuals who are eligible for Medicaid, Dr. Dynasaur, VPharm, VermontRx, or the Vermont health benefit exchange 1808. Financial Integrity - Keep accurate records & cooperate with federal audits; some restrictions on use of funds (e.g. staff retreats) 1809. Publication of Costs must publish any fees and exchange administration costs 1807. Navigators Clarifying changes 1808. Financial Integrity Clarifying changes Page 10 of 18 1809. Publication of Costs and Satisfaction Surveys Adds requirement to publicize de-identified results of the
1810. Rules gives agency rule-making authority satisfaction surveys and other evaluations Page 11 of 18 4 Green Mountain Health 33 V.S.A. chapter 18, subchapter 1 1821. Purpose provide comprehensive, affordable, high-quality health care coverage for all Vermont residents regardless of income, assets, health status, or availability of other health insurance contain costs: by providing incentives to residents to avoid preventable health conditions, promote health, and avoid unnecessary emergency room visits; by innovative payment mechanisms to health care professionals, such as global payments; and by encouraging the management of health services through the Blueprint for Health. 1822. Definitions Primary care includes mental health Smart Card: enables health care professionals to access patients health records and facilitates payment Vermont resident: standard legal definition intent to maintain a principal dwelling place in Vermont. Agency establishes standards for verification. 1823. Eligibility All Vermont residents regardless of whether employer offers insurance. Back-end eligibility for federal programs if required. Temporary absence from Vermont doesn t terminate eligibility Nonresidents (or their insurers) are billed for services. 1810. Rules Clarifying changes Green Mountain Health 33 V.S.A. chapter 18, subchapter 1 1821. Purpose Adds public good references 1822. Definitions Clarifying changes Removes definition of smart card Modifies definition of GMC to describe a single-payer Vermont resident adds that individuals claimed as a dependent on an out of state resident s tax return are not considered a resident. 1823. Eligibility Adds a penalty for falsely claiming residency & for failure to report a change in residency; requires notice of the penalties on the application Requires rules on temporary absence
Employers may choose to offer retiree benefits or may keep them as is. Must maintain a robust provider network. 1824. Health Benefits Broad outlines of benefit package (primary care, preventive care, chronic care, acute episodic care, & hospital services) If funds, basic dental and vision Vermont health care reform board establishes benefit details o Includes waiver of cost-sharing for preventive care & primary care (like Catamount Health) Medicaid remains the same as 1/1/14, EPSDT included Medicare remains the same as 1/1/14 1825. Blueprint for Health Individuals have a primary care professional involved in the Blueprint agency to set up a process for approving a specialist as a primary care provider (i.e. some individuals would want their mental health provider to be their primary care) 1826. Administration may contract out certain elements of GMC (for example claims processing) Provides for supplemental insurance market Prohibits balance billing Requests to be Medicare administrator GMC is secondary payer to other federal payers if state does not get permission to include them (for example, VA) Moves subsections on retiree benefits and on provider networks to administrative section Page 12 of 18 1824. Health Benefits Benefit package will be the covered services provided for by Catamount Health Blue on Jan 1, 2011 Includes intent that the cost-sharing be actuarially equivalent to 87% of full value (Catamount Blue is 82%) GMC Bd considers whether to include dental, vision, and hearing benefits GMC Bd approved benefit package and presents to the general assembly as part of the benefit package Medicaid and Medicare - clarifying changes 1825. Blueprint for Health Clarifies that individuals may have primary care professional who does not participate in the Blueprint 1826. Administration Clarifying language re: bidding and contracting components of the program Adds a conflict of interest provision & a preference for Vermont businesses Moves retiree benefits language re: GMC as secondary payer to this section Moves provider network language here & clarifies that
Part of the pharmacy program/statewide drug formulary Appeal rights 1827. Budget Proposal Agency proposes budget to general assembly for appropriations Based on approved payment amounts & methods from the Vermont health reform board 1828. Green Mountain Care Fund Establishes a fund for appropriations to Green Mountain Care 1829. Implementation Green Mountain Care is implemented upon receipt of a waiver under Sec. 1331 of the ACA. Page 13 of 18 GMC should allow for appropriate portability outside of the state 1827. Budget Proposal Requires 3 year budget proposal, to be annually adjusted 1828. Green Mountain Care Fund Clarifying changes 1829. Implementation GMC is implemented 90 days following the last of the waiver, enactment of the financing, the approval of the benefit package by the GMC Bd, and receipt of the waiver 5 & 6 Composition of DHVA; Transfer of positions Moves positions that determine health care eligibility from Dept for Children and Families to DVHA 7 & 33(a) Consumer and Health Care Professional Advisory Board 33 V.S.A. 402 In 2014, creates a new advisory board to provide information and policy advice to the Commissioner of DVHA related to Medicaid and the Exchange Replaces the Medicaid advisory board (in 2014 MAB stays the same until then) 1830. Collective Bargaining Rights Adds a provision clarifying that GMC does not limit collective bargaining negotiations for employer-sponsored health care plans. Composition of DHVA; Transfer of positions Actual move of the positions delayed (after March 15, 2012 but no later than July 1, 2013); adds report to general assembly Medicaid and Exchange Advisory Board 33 V.S.A. 402 Name change Effective date moved from 2014 to July 1, 2012 Membership is ¼ Medicaid recipients; ¼ enrollees in the Exchange; ¼ providers; and ¼ consumer groups Expands per diem to all members, unless they are paid by their employer to attend Allows 1/3 or more of the members to call up to 4
Page 14 of 18 meetings Expands number of meetings to 10 (+4 above) Planning Initiatives 8 Integration plan Integration plan How to fully integrate or align Medicaid, Medicare, private insurance, state employees, municipal employees in exchange Whether to establish Basic Health Plan option to Clarifying changes to Basic HP language ensure affordable coverage for low-income Vermonters Specific changes needed to integrate private Adds analysis re: defining small group as up to 50 or up to 100 insurance and whether to continue to allow employees associations Create a common benefit package in the exchange, Adds studies of: including analysis of current insurance mandates drug purchasing and affordability of cost-sharing supplemental coverage inside or outside of GMC how to monitor health care related migration into and out of the state how to coverage young adults up to age 26 who live out of state, but whose parents are Vermont residents Whether to have a financial reserve requirement or reinsurance for GMC Feasibility of including workers compensation in GMC 9 Financing Plans 2 financing plans provided Jan 15, 2013 For 2014 - How to finance care for full coverage through exchange, how to ensure adequate primary care workforce, and other initiatives After implementation of Green Mountain Care Adds provision that nothing in this section limits collective bargaining rights. Financing Plans Cross references principles in 18 VSA 9371 Adds studies of funding needed to: Address shortages of specialty providers, as well as primary care providers address Medicare eligibility
how to finance universal coverage through a public financing system provide incentives for health lifestyles impacts related to retiree benefits Page 15 of 18 10 Health Information Technology Assessment Reassess HIT progress in light of new goals o Overall infrastructure o Smart card o VHCURES May be done through an outside contractor or internally 11 Health System Planning, Regulation, Public Health Recommend modifications to unify existing systems engaging in planning, public health and quality 12 Payment Reform; Regulatory Process Reviews current regulation that may apply to payment reform pilots to determine if it is in alignment with goals 13 Workforce Issues How to optimize licensing and scope of practice for current primary care workforce Create a plan for workforce retraining to address dislocation due to administrative simplification when Green Mountain Care is implemented Adds a public engagement process with a report on the findings and recommendations due January 15, 2012 to committees of jurisdiction Health Information Technology Assessment Removes smart card Health System Planning, Regulation, Public Health Adds study of reorganizing health care functions in state government Adds report on how to modify CON & hospital budget statutes with the GMC Bd duties Payment Reform; Regulatory Process Moved date to March 15 to reflect new nomination process for the Board Workforce Issues Adds study by the GMC board to include shortages of specialty providers Adds study due Jan 15, 2013 by sec of administration on ensuring all Vermonters have a medical home through the Blueprint Adds monitoring of health care professional migration to general workforce study Adds study of exempting doctors from prior
Page 16 of 18 authorization requirements if their requests are usually approved 14 Medical Malpractice Study Med Malpractice moved to Sec. 2 Broad review of medical malpractice reforms Secretary of administration to submit a medical o No fault malpractice proposal o What other states have done Proposal to address defensive medicine, reduce health o Opportunities for captives care costs, adequate protections for patients and o SorryWorks consideration of a no fault system Impacts on health care professionals and patients Designed to take effect on or before implementation of GMC New Sec. 14 Cost Estimates Requires JFO and BISHCA to provide a draft cost estimate of the current health care system compared to a reformed health care system no later than April 21, 2011, with the final estimates due November 1, 2011 Immediate Initiatives 15 15d. Insurance Rate Review 8 VSA 4062 Insurance Rate Review 8 VSA 4062 Provides for final review of rate increases by the Clarifying changes Vermont Health Reform Board Broadens rate review criteria to include affordability, quality, and access Adds that insurers would file a plain language summary for any rate increases over 5% using the forms required by the PPACA Provides for a public comment period on rate increases starting January 1, 2012 Applies language to BC/BS and HMOs 16 Employer Health Benefit Information 21 V.S.A. 2004 Requires employers to provide employees with an annual statement of total premium costs for health benefits to inform employees of total premium costs Employer Health Benefit Information 21 V.S.A. 2004 Adds that the annual statement will include the total monthly premium cost, the employer and the emp0loyee s shares of the monthly premium, and any other amount contributed by the employer.
Page 17 of 18 Exempts employers who reports the costs of coverage as provided for under the PPACA 17 Sec. 17. Review of Ban on Discretionary Clauses Requires BISHCA to report on the advantages and disadvantages of adopting the NAIC model bill on discretionary clauses. Report due Jan 15, 2012 17 24 Statewide Preferred Drug List, 18 V.S.A. 4635 Directs the Drug Utilization Review Board to create a statewide preferred drug list to be used by Medicaid, insurers, and state and municipal employees Allows self-insured employers to elect to use the PDL Provides for variants from the PDL for Medicaid where supplemental rebates are cost-effective Conforming amendments to existing law establishing Medicaid PDL and rebates Sec. 18. Statewide Preferred Drug List, 18 V.S.A. 4635 Replaces PDL authorizing language with a report from DVHA on how to implement a PDL, including purchasing drugs at the Medicaid or 340B price. Also adds a study of single method for negotiating rebates & creating uniformity in drug benefit management. 30(b) Repeals the Public Oversight Commission Reduces administrative burden for certificate of need requests Needs additional conforming amendments to CON statutes Same. Conforming Amendments 25 Secretary of Administration 3 V.S.A. 2222a Revises current statute directing Sec. of Administration to coordinate heath reform to reflect new and changed initiatives Clarifying changes.
26 Department of Health 18 V.S.A. 5 Updates and revises duties to include a state health improvement plan 27 VHCURES 18 V.S.A. 9410(a)(1) Ensures Vermont Health Reform Board has use of VHCURES data 28 PPACA Grants Extends date from July 1, 2011 to July 1, 2014 Allows agencies to apply for federal grants Clarifying changes. Conforming changes. Same. Page 18 of 18 29 Primary Care Workforce Committee Same. Amends Act 128 committee to allow additional year of work o New recommendations due in March 2011 30 Repeals Medical Care Advisory Board 2014 Repeals MAB on July 1, 2012 when new Medicaid and Exchange Advisory Bd begins. POC July 1, 2011 31 Effective Dates Conforming changes