The Vermont Statutes Online

Title 18: Health

Chapter 229: Office of the Health Care Advocate

• § 9601. Definitions

  As used in this chapter:

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

  (2) “Health insurance plan” means a policy, service contract, or other health benefit plan offered or issued by a health insurer and includes beneficiaries covered by the Medicaid program unless they are otherwise provided with similar services.

  (3) “Health insurer” shall have the same meaning as in section 9402 of this title. (Added 2013, No. 79, § 35a, eff. Jan. 1, 2014.)

• § 9602. Office of the Health Care Advocate; composition

  (a) The Agency of Human Services shall maintain the Office of the Health Care Advocate by contract with any nonprofit organization.

  (b) The Office shall be administered by the Chief Health Care Advocate, who shall be an individual with expertise and experience in the fields of health care and advocacy. The Advocate may employ legal counsel, administrative staff, and other employees and contractors as needed to carry out the duties of the Office. (Added 2013, No. 79, § 35a, eff. Jan. 1, 2014; amended 2017, No. 85, § E.300.4, eff. June 28, 2017.)

• § 9603. Duties and authority

  (a) The Office of the Health Care Advocate shall:

  (1) Assist health insurance consumers with health insurance plan selection by providing information, referrals, and assistance to individuals about means of obtaining health insurance coverage and services. The Office shall accept referrals from the Vermont Health Benefit Exchange and Exchange navigators created pursuant to 33 V.S.A. chapter 18, subchapter 1, to assist consumers experiencing problems related to the Exchange.

  (2) Assist health insurance consumers to understand their rights and responsibilities under health insurance plans.

  (3) Provide information to the public, agencies, members of the General Assembly, and others regarding problems and concerns of health insurance consumers as well as recommendations for resolving those problems and concerns.

  (4) Identify, investigate, and resolve complaints on behalf of individual health insurance consumers, and assist those consumers with filing and pursuit of complaints and appeals.

  (5) Provide information to individuals regarding their obligations and responsibilities under the Patient Protection and Affordable Care Act (Pub. L. No. 111-148).

  (6) Analyze and monitor the development and implementation of federal, State, and local laws, rules, and policies relating to patients and health insurance consumers.

  (7) Facilitate public comment on laws, rules, and policies, including policies and actions of health insurers.

  (8) Suggest policies, procedures, or rules to the Green Mountain Care Board in order to protect patients’ and consumers’ interests.

  (9) Promote the development of citizen and consumer organizations.

  (10) Ensure that patients and health insurance consumers have timely access to the services provided by the Office.

  (11) Submit to the Governor; the House Committees on Health Care, on Ways and Means, and on Appropriations; and the Senate Committees on Health and Welfare, on Finance, and on Appropriations, on or before January 1 of each year, a report on the activities, performance, and fiscal accounts of the Office during the preceding calendar year.

  (b) The Office of the Health Care Advocate may:

  (1) Review the health insurance records of a consumer who has provided written consent. Based on the written consent of the consumer or his or her guardian or legal representative, a health insurer shall provide the Office with access to records relating to that consumer.

  (2) Pursue administrative, judicial, and other remedies on behalf of any individual health insurance consumer or group of consumers.

  (3) Represent the interests of the people of the State in cases requiring a hearing before the Green Mountain Care Board established in chapter 220 of this title.

  (4) Adopt policies and procedures necessary to carry out the provisions of this chapter.

  (5) Take any other action necessary to fulfill the purposes of this chapter.

  (c) The Office of the Health Care Advocate shall be able to speak on behalf of the interests of health care and health insurance consumers and to carry out all duties prescribed in this chapter without being subject to any retaliatory action; provided, however, that nothing in this subsection shall limit the authority of the Agency of Human Services to enforce the terms of the contract. (Added 2013, No. 79, § 35a, eff. Jan. 1, 2014; amended 2017, No. 85, § E.300.6, eff. June 28, 2017; 2017, No. 154 (Adj. Sess.), § 24, eff. May 21, 2018; 2019, No. 14, § 60, eff. April 30, 2019.)

• § 9604. Duties of State agencies

  All State agencies shall comply with reasonable requests from the Office of the Health Care Advocate for information and assistance. The Agency of Human Services may adopt rules necessary to ensure the cooperation of State agencies under this section. (Added 2013, No. 79, § 35a, eff. Jan. 1, 2014; amended 2017, No. 85, § E.300.7, eff. June 28, 2017.)

• § 9605. Confidentiality

  In the absence of written consent by a complainant or an individual using the services of the Office or by his or her guardian or legal representative or the absence of a court order, the Office of the Health Care Advocate, its employees, and its contractors shall not disclose the identity of the complainant or individual. (Added 2013, No. 79, § 35a, eff. Jan. 1, 2014.)

• § 9606. Conflicts of interest

  The Office of the Health Care Advocate, its employees, and its contractors shall not have any conflict of interest relating to the performance of their responsibilities under this chapter. For the purposes of this chapter, a conflict of interest exists whenever the Office of the Health Care Advocate, its employees, or its contractors or a person affiliated with the Office, its employees, or its contractors:

  (1) has a direct involvement in the licensing, certification, or accreditation of a health care facility, health insurer, or health care provider;

  (2) has a direct ownership interest or investment interest in a health care facility, health insurer, or health care provider;

  (3) is employed by or participating in the management of a health care facility, health insurer, or health care provider; or

  (4) receives or has the right to receive, directly or indirectly, remuneration under a compensation arrangement with a health care facility, health insurer, or health care provider. (Added 2013, No. 79, § 35a, eff. Jan. 1, 2014.)

• § 9607. Funding; allocation of expenses

  (a) The Office of the Health Care Advocate shall specify in its annual report filed pursuant to this chapter the sums expended by the Office in carrying out its duties, including identifying the specific amount expended for actuarial services.

  (b)(1) Expenses incurred by the Office of the Health Care Advocate for services related to the Green Mountain Care Board’s and Department of Financial Regulation’s regulatory and supervisory duties shall be borne as follows:

  (A) 27.5 percent by the State from State monies;

  (B) 24.2 percent by the hospitals;

  (C) 24.2 percent by nonprofit hospital and medical service corporations licensed under 8 V.S.A. chapter 123 or 125; and

  (D) 24.2 percent by health insurance companies licensed under 8 V.S.A. chapter 101.

  (2) Expenses under subdivision (1) of this subsection shall be billed to persons licensed under Title 8 based on premiums paid for health care coverage, which for the purposes of this section shall include major medical, comprehensive medical, hospital or surgical coverage, and comprehensive health care services plans, but shall not include long-term care or limited benefits, disability, credit or stop loss, or excess loss insurance coverage.

  (3) The Green Mountain Care Board shall administer the bill back authority created in this subsection on behalf of the Agency of Human Services in support of the Agency’s contract with the Office of the Health Care Advocate pursuant to section 9602 of this title to carry out the duties set forth in this chapter.

  (c) It is the intent of the General Assembly that the Office of the Health Care Advocate shall maximize the amount of federal and grant funds available to support the activities of the Office. (Added 2013, No. 79, § 35a, eff. Jan. 1, 2014; amended 2015, No. 134 (Adj. Sess.), § 28; 2017, No. 85, § E.300.5, eff. June 28, 2017.)