§ 9376. Payment amounts; methods
(a) Intent. It is the intent of the General Assembly to ensure payments to health care professionals
that are consistent with efficiency, economy, and quality of care and will permit
them to provide, on a solvent basis, effective and efficient health services that
are in the public interest. It is also the intent of the General Assembly to eliminate
the shift of costs between the payers of health services to ensure that the amount
paid to health care professionals is sufficient to enlist enough providers to ensure
that health services are available to all Vermonters and are distributed equitably.
(b) Rate-setting.
(1) The Board shall set reasonable rates for health care professionals, health care provider
bargaining groups created pursuant to section 9409 of this title, manufacturers of prescribed products, medical supply companies, and other companies
providing health services or health supplies based on methodologies pursuant to section 9375 of this title, in order to have a consistent reimbursement amount accepted by these persons. In
its discretion, the Board may implement rate-setting for different groups of health
care professionals over time and need not set rates for all types of health care professionals.
In establishing rates, the Board may consider legitimate differences in costs among
health care professionals, such as the cost of providing a specific necessary service
or services that may not be available elsewhere in the State, and the need for health
care professionals in particular areas of the State, particularly in underserved geographic
or practice shortage areas.
(2) Nothing in this subsection shall be construed to:
(A) limit the ability of a health care professional to accept less than the rate established
in subdivision (1) of this subsection (b) from a patient without health insurance
or other coverage for the service or services received; or
(B) reduce or limit the covered services offered by Medicare or Medicaid.
(c) Methodologies. The Board shall approve payment methodologies that encourage cost-containment; provision
of high-quality, evidence-based health services in an integrated setting; patient
self-management; access to primary care health services; and healthy lifestyles. Such
methodologies shall be consistent with payment reform and with evidence-based practices,
and may include fee-for-service payments if the Board determines such payments to
be appropriate.
(d) Supervision. To the extent required to avoid federal antitrust violations and in furtherance of
the policy identified in subsection (a) of this section, the Board shall facilitate
and supervise the participation of health care professionals and health care provider
bargaining groups in the process described in subsection (b) of this section.
(e) Reference-based pricing.
(1)(A) The Board shall establish reference-based prices that represent the maximum amounts
that hospitals shall accept as payment in full for items provided and services delivered
in Vermont. The Board may also implement reference-based pricing for services delivered
outside a hospital by setting the minimum amounts that shall be paid for items provided
and services delivered by nonhospital-based health care professionals. The Board shall
consult with health insurers, hospitals, other health care professionals as applicable,
the Office of the Health Care Advocate, and the Agency of Human Services in developing
reference-based prices pursuant to this subsection (e), including on ways to achieve
all-payer alignment on the design and implementation of reference-based pricing.
(B) The Board shall implement reference-based pricing in a manner that does not allow
health care professionals to charge or collect from patients or health insurers any
amount in excess of the reference-based amount established by the Board.
(2)(A) Reference-based prices established pursuant to this subsection (e) shall be based
on a percentage of the Medicare reimbursement for the same or a similar item or service
or on another benchmark, as appropriate, provided that if the Board establishes prices
that are referenced to Medicare, the Board may opt to update the prices in the future
based on a reasonable rate of growth that is separate from Medicare rates, such as
the Medicare Economic Index measure of inflation, in order to provide predictability
and consistency for health care professionals and payers and to protect against federal
funding pressures that may impact Medicare rates in an unpredictable manner. The Board
may also reference to, and update based on, other payment or pricing systems where
appropriate.
(B) In establishing reference-based prices for a hospital pursuant to this subsection
(e), the Board shall consider the composition of the communities served by the hospital,
including the health of the population, demographic characteristics, acuity, payer
mix, labor costs, social risk factors, and other factors that may affect the costs
of providing care in the hospital service area, as well as the hospital’s role in
Vermont’s health care system.
(3)(A) The Board shall begin implementing reference-based pricing as soon as practicable
but not later than hospital fiscal year 2027 by establishing the maximum amounts that
Vermont hospitals shall accept as payment in full for items provided and services
delivered. After initial implementation, the Board shall review the reference-based
prices for each hospital annually as part of the hospital budget review process set
forth in chapter 221, subchapter 7 of this title.
(B) The Board, in collaboration with the Department of Financial Regulation, shall monitor
the implementation of reference-based pricing to ensure that any decreases in amounts
paid to hospitals also result in decreases in health insurance premiums. The Board
shall post its findings regarding the alignment between price decreases and premium
decreases annually on its website.
(4) The Board shall identify factors that would necessitate terminating or modifying the
use of reference-based pricing in one or more hospitals, such as a measurable reduction
in access to or quality of care.
(5) The Green Mountain Care Board, in consultation with the Agency of Human Services and
the Vermont Steering Committee for Comprehensive Primary Health Care established pursuant
to section 9403b of this title, may implement reference-based pricing for services delivered outside a hospital,
such as primary care services, and may increase or decrease the percentage of Medicare
or another benchmark as appropriate, first to enhance access to primary care and later
for alignment with the Statewide Health Care Delivery Strategic Plan established pursuant
to section 9403 of this title, once established. The Board may consider establishing reference-based pricing for
services delivered outside a hospital by setting minimum amounts that shall be paid
for the purpose of prioritizing access to high-quality health care services in settings
that are appropriate to patients’ needs in order to contain costs and improve patient
outcomes.
(6) The Board’s authority to establish reference-based prices pursuant to this subsection
shall not include the authority to set amounts applicable to items provided or services
delivered to patients who are enrolled in Medicare or Medicaid. (Added 2011, No. 48, § 3, eff. May 26, 2011; amended 2015, No. 54, § 8, eff. June 5, 2015; 2025, No. 68, § 3, eff. June 12, 2025.)