The Vermont Statutes Online

Title 18: Health

Chapter 013: Chronic Care Infrastructure and Prevention Measures

• § 701. Definitions

  As used in this chapter:

  (1) “Blueprint for Health” or “Blueprint” means the State’s program for integrating a system of health care for patients, improving the health of the overall population, and improving control over health care costs by promoting health maintenance, prevention, and care coordination and management.

  (2) “Board” means the Green Mountain Care Board established in chapter 220 of this title.

  (3) “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 highest function, minimize the negative effects of the condition, prevent complications related to chronic conditions, engage in advanced care planning, and promote appropriate access to palliative care and pain and symptom management. Examples of chronic conditions include diabetes, hypertension, cardiovascular disease, cancer, asthma, pulmonary disease, substance abuse, mental condition or psychiatric disability, spinal cord injury, hyperlipidemia, dementia, and chronic pain.

  (4) “Chronic care information system” means the electronic database developed under the Blueprint for Health that shall include information on all cases of a particular disease or health condition in a defined population of individuals.

  (5) “Chronic care management” means a system of coordinated health care interventions and communications for individuals with chronic conditions, including significant patient self-care efforts, systemic supports for licensed health care practitioners and their patients, and a plan of care emphasizing, on an ongoing basis and with the goals of improving overall health and meeting patients’ needs:

  (A) prevention of complications utilizing evidence-based practice guidelines;

  (B) patient empowerment strategies;

  (C) evaluation of clinical, humanistic, and economic outcomes; and

  (D) advance care planning, palliative care, pain management, and hospice services, as appropriate.

  (6) “Global payment” means a payment from a health insurer, Medicaid, Medicare, or other payer for the health services of a defined population of patients for a defined period of time. Such payments may be adjusted to account for the population’s underlying risk factors, including severity of illness and socioeconomic factors that may influence the cost of health care for the population.

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

  (8) “Health benefit plan” shall have the same meaning as health insurance plan in 8 V.S.A. § 4088h.

  (9) “Health insurer” shall have the same meaning as in section 9402 of this title.

  (10) “Health service” means any treatment or procedure delivered by a health care professional to maintain an individual’s physical or mental health or to diagnose or treat an individual’s physical or mental condition or intellectual disability, including services ordered by a health care professional, chronic care management, preventive care, wellness services, and medically necessary services to assist in activities of daily living.

  (11) “Hospital” shall have the same meaning as in section 9451 of this title.

  (12) “Integrated delivery system” means a group of health care professionals, associated either through employment by a single entity or through a contractual arrangement, that provides health services for a defined population of patients and is compensated through a global payment.

  (13) “Payment reform” means modifying the method of payment from a fee for-service basis to one or more alternative methods for compensating health care professionals, health care provider bargaining groups created pursuant to section 9409 of this title, integrated delivery systems and other health care professional arrangements, manufacturers of prescribed products, medical supply companies, and other companies providing health services or health supplies, for the provision of high-quality and efficient health services, products, and supplies while measuring quality and efficiency. The term may include shared savings agreements, bundled payments, episode-based payments, and global payments.

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

  (15) “Wellness services” means health services, programs, or activities that focus on the promotion or maintenance of good health. (Added 2005, No. 191 (Adj. Sess.), § 5; amended 2009, No. 25, § 8; 2009, No. 128 (Adj. Sess.), § 13; 2011, No. 48, § 3c; 2011, No. 60, § 5, eff. June 1, 2011; 2011, No. 171 (Adj. Sess.), § 37, eff. May 16, 2012; 2013, No. 96 (Adj. Sess.), § 90.)

• Subchapter 001: BLUEPRINT FOR HEALTH

• § 702. Blueprint for Health; strategic plan

  (a)(1) The Department of Vermont Health Access shall be responsible for the Blueprint for Health.

  (2) The Director of the Blueprint, in collaboration with the Commissioners of Health, of Mental Health, of Vermont Health Access, and of Disabilities, Aging, and Independent Living, shall oversee the development and implementation of the Blueprint for Health, including a strategic plan describing the initiatives and implementation timelines and strategies. Whenever private health insurers are concerned, the Director shall collaborate with the Commissioner of Financial Regulation and the Chair of the Green Mountain Care Board.

  (b)(1)(A) The Commissioner of Vermont Health Access shall establish an executive committee to advise the Director of the Blueprint on creating and implementing a strategic plan for the development of the statewide system of chronic care and prevention as described under this section. The Executive Committee shall include:

  (i) the Commissioner of Health;

  (ii) the Commissioner of Mental Health;

  (iii) a representative from the Green Mountain Care Board;

  (iv) a representative from the Department of Vermont Health Access;

  (v) an individual appointed jointly by the President Pro Tempore of the Senate and the Speaker of the House of Representatives;

  (vi) a representative from the Vermont Medical Society;

  (vii) a representative from the Vermont Nurse Practitioners Association;

  (viii) a representative from a statewide quality assurance organization;

  (ix) a representative from the Vermont Association of Hospitals and Health Systems;

  (x) two representatives of private health insurers;

  (xi) a consumer;

  (xii) a representative of the complementary and alternative medicine professions;

  (xiii) a primary care professional serving low-income or uninsured Vermonters;

  (xiv) a licensed mental health professional with clinical experience in Vermont;

  (xv) a representative of the Vermont Council of Developmental and Mental Health Services;

  (xvi) a representative of the Vermont Assembly of Home Health Agencies who has clinical experience;

  (xvii) a representative from a self-insured employer who offers a health benefit plan to its employees; and

  (xviii) a representative of the State employees’ health plan, who shall be designated by the Commissioner of Human Resources and who may be an employee of the third-party administrator contracting to provide services to the State employees’ health plan.

  (B) The Executive Committee shall engage a broad range of health care professionals who provide health services, health insurers, professional organizations, community and nonprofit groups, consumers, businesses, school districts, and State and local government in developing recommendations over time for modifications to statewide implementation of the Blueprint.

  (2)(A) [Repealed.]

  (B) The Director shall convene a payer implementation work group, which shall meet no fewer than six times annually, to design the medical home and community health team enhanced payments, including modifications over time, and to make recommendations to the Executive Committee. The work group shall include representatives of the participating health insurers, representatives of participating medical homes and community health teams, and the Commissioner of Vermont Health Access or designee. The work group shall comply with open meeting and public record requirements in 1 V.S.A. chapter 5.

  (c) The Blueprint shall be developed and implemented to further the following principles:

  (1) The Blueprint community health team should serve a central role in the coordination of medical care and social services and shall be compensated appropriately for this effort.

  (2) Use of information technology should be maximized.

  (3) Local service providers should be used and supported, whenever possible.

  (4) Transition plans should be developed by all involved parties to ensure a smooth and timely transition from the current model to the Blueprint model of health care delivery and payment.

  (5) Implementation of the Blueprint in communities across the State should be accompanied by payment to providers sufficient to support care management activities consistent with the Blueprint, recognizing that interim or temporary payment measures may be necessary during early and transitional phases of implementation.

  (6) Interventions designed to prevent chronic disease and improve outcomes for persons with chronic disease should be maximized, should target specific chronic disease risk factors, and should address changes in individual behavior; the physical, mental, and social environment; and health care policies and systems.

  (7) Providers should assess trauma and toxic stress to ensure that the needs of the whole person are addressed and opportunities to build resilience and community supports are maximized.

  (d) The Blueprint for Health shall include the following initiatives:

  (1) Technical assistance as provided for in section 703 of this title to implement:

  (A) a patient-centered medical home;

  (B) community health teams; and

  (C) a model for uniform payment for health services by health insurers, Medicaid, Medicare if available, and other entities that encourage the use of the medical home and the community health teams.

  (2) Collaboration with Vermont Information Technology Leaders established in section 9352 of this title to assist health care professionals and providers to create a statewide infrastructure of health information technology in order to expand the use of electronic medical records through a health information exchange and a centralized clinical registry on the Internet.

  (3) In consultation with employers, consumers, health insurers, and health care providers, the development, maintenance, and promotion of evidence-based, nationally recommended guidelines for greater commonality, consistency, and coordination among health insurers in care management programs and systems.

  (4) The adoption and maintenance of clinical quality and performance measures for each of the chronic conditions included in Medicaid’s care management program established in 33 V.S.A. § 1903a. These conditions include asthma, chronic obstructive pulmonary disease, congestive heart failure, diabetes, and coronary artery disease.

  (5) The adoption and maintenance of clinical quality and performance measures, aligned with, but not limited to, existing indicators related to outcomes set forth in 3 V.S.A. § 2311 that are relevant to the Agency of Human Services, to be reported by health care professionals, providers, or health insurers and used to assess and evaluate the impact of the Blueprint for Health and cost outcomes. In accordance with a schedule established by the Blueprint Executive Committee, all clinical quality and performance measures shall be reviewed for consistency with those used by the Medicare program and updated, if appropriate.

  (6) The adoption and maintenance of clinical quality and performance measures for pain management, palliative care, and hospice care.

  (7) The use of surveys to measure satisfaction levels of patients, health care professionals, and health care providers participating in the Blueprint.

  (8) The use of quality improvement facilitation and other means to support quality improvement activities, including using integrated clinical and claims data, where available, to evaluate patient outcomes and promoting best practices regarding patient referrals and care distribution between primary and specialty care.

  (e) The strategic plan developed under subsection (a) of this section shall be reviewed biennially and amended as necessary to reflect changes in priorities. Amendments to the plan shall be included in the report established under section 709 of this title. (Added 2005, No. 191 (Adj. Sess.), § 5; amended 2007, No. 70, § 21; 2007, No. 71, § 5; 2009, No. 128 (Adj. Sess.), § 13; 2009, No. 156 (Adj. Sess.), § I.19; 2011, No. 63, § G.101; 2011, No. 171 (Adj. Sess.), § 28, eff. May 16, 2012; 2015, No. 11, § 17; 2017, No. 204 (Adj. Sess.), § 6; 2019, No. 128 (Adj. Sess.), § 7; 2021, No. 167 (Adj. Sess.), § 6, eff. June 1, 2022.)

• § 703. Health prevention; chronic care management

  (a) The Director shall develop a model for integrating a system of health care for patients, improving the health of the overall population, and improving control over health care costs by promoting health maintenance, prevention, and care coordination and management through an integrated system, including a patient-centered medical home and a community health team, and uniform payment for health services by health insurers, Medicaid, Medicare if available, and other entities that encourage the use of the medical home and the community health teams.

  (b) When appropriate, the model may include the integration of social services provided by the Agency of Human Services or may include coordination with a team at the Agency of Human Services to ensure the individual’s comprehensive care plan is consistent with the Agency’s case management plan for that individual or family.

  (c) In order to maximize the participation of federal health care programs and to maximize federal funds available, the model for care coordination and management may meet the criteria for medical home, community health team, or other related demonstration projects established by the U.S. Department of Health and Human Services and the criteria of any other federal program providing funds for establishing medical homes, community health teams, or associated payment reform.

  (d) The model for care coordination and management shall include the following components:

  (1) A process for identifying individuals with or at risk for chronic disease and to assist in the determination of the risk for or severity of a chronic disease, as well as the appropriate type and level of care management services needed to manage those chronic conditions.

  (2) Evidence-based clinical practice guidelines, which shall be aligned with the clinical quality and performance measures provided for in section 702 of this title.

  (3) Models for the collaboration of health care professionals in providing care, including through a community health team.

  (4) Education for patients on how to manage conditions or diseases, including prevention of disease; programs to modify a patient’s behavior; and a method of ensuring compliance of the patient with the recommended behavioral change.

  (5) Education for patients on health care decision-making, including education related to advance directives, palliative care, hospice care, and timely referrals to palliative and hospice care, when appropriate.

  (6) Measurement and evaluation of the process and health outcomes of patients.

  (7) A method for all health care professionals treating the same patient on a routine basis to report and share information about that patient.

  (8) Requirements that participating health care professionals and providers have the capacity to implement health information technology that meets the requirements of 42 U.S.C. § 300jj in order to facilitate coordination among members of the community health team, health care professionals, and primary care practices and, where applicable, to report information on quality measures to the Director of the Blueprint.

  (9) A sustainable, scalable, and adaptable financial model reforming primary care payment methods through medical homes supported by community health teams that lead to a reduction in avoidable emergency room visits and hospitalizations and a shift of health insurer expenditures from disease management contracts to financial support for local community health teams in order to promote health, prevent disease, and manage care in order to increase positive health outcomes and reduce costs over time.

  (e) The Director of the Blueprint shall provide technical assistance and training to health care professionals, health care providers, health insurers, and others participating in the Blueprint. (Added 2009, No. 128 (Adj. Sess.), § 13; amended 2011, No. 60, § 6, eff. June 1, 2011.)

• § 704. Medical home

  (a) Consistent with federal law to ensure federal financial participation, a health care professional providing a patient’s medical home shall:

  (1) provide comprehensive prevention and disease screening for his or her patients and managing his or her patients’ chronic conditions by coordinating care;

  (2) enable patients to have access to personal health information through a secure medium, such as through the Internet, consistent with federal health information technology standards;

  (3) use a uniform assessment tool provided by the Blueprint in assessing a patient’s health;

  (4) collaborate with the community health teams, including by developing and implementing a comprehensive plan for participating patients;

  (5) ensure access to a patient’s medical records by the community health team members in a manner compliant with the Health Insurance Portability and Accountability Act; 12 V.S.A. § 1612; sections 1852, 7103, 9332, and 9351 of this title; and 21 V.S.A. § 516; and

  (6) meet regularly with the community health team to ensure integration of a participating patient’s care.

  (b) A naturopathic physician licensed pursuant to 26 V.S.A. chapter 81 may serve as a patient’s medical home. (Added 2009, No. 128 (Adj. Sess.), § 13; amended 2011, No. 96 (Adj. Sess.), § 3, eff. May 2, 2012.)

• § 705. Community health teams

  (a) Consistent with federal law to ensure federal financial participation, the community health team shall consist of health care professionals from multiple disciplines, including obstetrics and gynecology, pharmacy, nutrition and diet, social work, behavioral and mental health, chiropractic, other complementary and alternative medical practice licensed by the State, home health care, public health, and long-term care.

  (b) The Director shall assist communities to identify the service areas in which the teams work, which may include a hospital service area or other geographic area.

  (c) Health care professionals participating in a community health team shall:

  (1) Collaborate with other health care professionals and with existing State agencies and community-based organizations in order to coordinate disease prevention, manage chronic disease, coordinate social services if appropriate, and provide an appropriate transition of patients between health care professionals or providers. Priority may be given to patients willing to participate in prevention activities or patients with chronic diseases or conditions identified by the Director of the Blueprint.

  (2) Support a health care professional or practice that operates as a medical home, including by:

  (A) assisting in the development and implementation of a comprehensive care plan for a patient that integrates clinical services with prevention and health promotion services available in the community and with relevant services provided by the Agency of Human Services. Priority may be given to patients willing to participate in prevention activities or patients with chronic diseases or conditions identified by the Director of the Blueprint;

  (B) providing a method for health care professionals, patients, caregivers, and authorized representatives to assist in the design and oversight of the comprehensive care plan for the patient;

  (C) coordinating access to high-quality, cost-effective, culturally appropriate, and patient- and family-centered health care and social services, including preventive services, activities that promote health, appropriate specialty care, inpatient services, medication management services provided by a pharmacist, and appropriate complementary and alternative (CAM) services;

  (D) providing support for treatment planning, monitoring the patient’s health outcomes and resource use, sharing information, assisting patients in making treatment decisions, avoiding duplication of services, and engaging in other approaches intended to improve the quality and value of health services;

  (E) assisting in the collection and reporting of data in order to evaluate the Blueprint model on patient outcomes, including collection of data on patient experience of care, and identification of areas for improvement; and

  (F) providing a coordinated system of early identification and referral for children at risk for developmental or behavioral problems, such as through the use of health information technology or other means as determined by the Director of the Blueprint.

  (3) Provide care management and support when a patient moves to a new setting for care, including by:

  (A) providing on-site visits from a member of the community health team, assisting with the development of discharge plans and medication reconciliation upon admission to and discharge from the hospital, nursing home, or other institution setting;

  (B) generally assisting health care professionals, patients, caregivers, and authorized representatives in discharge planning, including by assuring that postdischarge care plans include medication management as appropriate;

  (C) referring patients as appropriate for mental and behavioral health services;

  (D) ensuring that when a patient becomes an adult, his or her health care needs are provided for; and

  (E) serving as a liaison to community prevention and treatment programs. (Added 2009, No. 128 (Adj. Sess.), § 13.)

• § 706. Health insurer participation

  (a) As provided for in 8 V.S.A. § 4088h, health insurance plans shall be consistent with the Blueprint for Health as determined by the Commissioner of Financial Regulation.

  (b) Health insurers shall participate in the Blueprint for Health as a condition of doing business in this State as provided for in this section and in 8 V.S.A. § 4088h. Under 8 V.S.A. § 4088h, the Commissioner of Financial Regulation may exclude or limit the participation of health insurers offering a stand-alone dental plan or specific disease or other limited benefit coverage in the Blueprint for Health. Health insurers shall be exempt from participation if the insurer only offers benefit plans that are paid directly to the individual insured or the insured’s assigned beneficiaries and for which the amount of the benefit is not based upon potential medical costs or actual costs incurred.

  (c)(1) The Blueprint payment reform methodologies shall include per-person per-month payments to medical home practices by each health insurer and Medicaid for their attributed patients and for contributions to the shared costs of operating the community health teams. Per-person per-month payments to practices shall be based on the official National Committee for Quality Assurance’s Physician Practice Connections-Patient Centered Medical Home (NCQA PPC-PCMH) score to the extent practicable and shall be in addition to their normal fee-for-service or other payments.

  (2) Consistent with recommendations of the Blueprint Executive Committee, the Director of the Blueprint may recommend to the Commissioner of Vermont Health Access changes to the payment amounts or to the payment reform methodologies described in subdivision (1) of this subsection, including by providing for enhanced payment to health care professional practices that operate as a medical home, including primary care naturopathic physicians’ practices; payment toward the shared costs for community health teams; or other payment methodologies required by the Centers for Medicare and Medicaid Services (CMS) for participation by Medicaid or Medicare.

  (3) Health insurers shall modify payment methodologies and amounts to health care professionals and providers as required for the establishment of the model described in sections 703 through 705 of this title and this section, including any requirements specified by the Centers for Medicare and Medicaid Services (CMS) in approving federal participation in the model to ensure consistency of payment methods in the model.

  (4) In the event that the Secretary of Human Services is denied permission from the Centers for Medicare and Medicaid Services (CMS) to include financial participation by Medicare, health insurers shall not be required to cover the costs associated with individuals covered by Medicare.

  (d) An insurer may appeal a decision to require a particular payment methodology or payment amount to the Commissioner of Vermont Health Access, who shall provide a hearing in accordance with 3 V.S.A. chapter 25. An insurer aggrieved by the decision of the Commissioner may appeal to the Superior Court for the Washington District within 30 days after the Commissioner issues his or her decision. (Added 2009, No. 128 (Adj. Sess.), § 13; amended 2011, No. 78 (Adj. Sess.), § 2, eff. April 2, 2012; 2011, No. 96 (Adj. Sess.), § 4, eff. May 2, 2012; 2015, No. 172 (Adj. Sess.), § E.306.2; 2019, No. 128 (Adj. Sess.), § 8; 2023, No. 6, § 105, eff. July 1, 2023.)

• § 707. Participation by health care professionals and hospitals

  (a) Hospitals shall participate in the Blueprint for Health by creating or maintaining connectivity to the State’s Health Information Exchange Network as provided in this section and in section 9456 of this title.

  (b) The Director of Health Care Reform or designee shall ensure hospitals have access to State and federal resources to support connectivity to the State’s Health Information Exchange Network.

  (c) The Director of the Blueprint shall engage health care professionals and providers to encourage participation in the Blueprint, including by providing information and assistance. (Added 2009, No. 128 (Adj. Sess.), § 13; amended 2013, No. 79, § 33, eff. June 7, 2013; 2023, No. 6, § 106, eff. July 1, 2023.)

• § 708. Repealed. 2013, No. 79, § 52(b), effective June 7, 2013.

• § 709. Annual report

  (a) The Director of the Blueprint shall report annually, on or before January 31, on the status of implementation of the Vermont Blueprint for Health for the prior calendar year and shall provide the report to the House Committee on Health Care, the Senate Committee on Health and Welfare, and the Health Reform Oversight Committee.

  (b) The report required by subsection (a) of this section shall include the number of participating insurers, health care professionals, and patients; the progress made in achieving statewide participation in the chronic care management plan, including the measures established under this subchapter; the expenditures and savings for the period; the results of health care professional and patient satisfaction surveys; the progress made toward creation and implementation of privacy and security protocols; information on the progress made toward the requirements in this subchapter; and other information as requested by the Committees. The provisions of 2 V.S.A. § 20(d) (expiration of required reports) shall not apply to the report to be made under subsection (a) of this section. (Added 2009, No. 128 (Adj. Sess.), § 13; amended 2011, No. 63, § G.102; 2011, No. 171 (Adj. Sess.), § 41c; 2013, No. 142 (Adj. Sess.), § 33; 2017, No. 113 (Adj. Sess.), § 55.)

• Subchapter 002: PAYMENT REFORM

• §§ 721-725. Repealed. 2011, No. 171 (Adj. Sess.), § 41(e), effective May 16, 2012.

• §§ 741-744. Repealed. 1977, No. 147 (Adj. Sess.).