§ 706. Health insurer participation
(a) As set forth in 8 V.S.A. § 4025, 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. § 4025.
(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; 2025, No. 11, § 15, eff. September 1, 2025.)