§ 9382. Oversight of accountable care organizations
[Subsection (a) effective until January 1, 2027; see also subsection (a) effective
January 1, 2027, set out below]
(a) In order to be eligible to receive payments from Medicaid or commercial insurance
through any payment reform program or initiative, including an all-payer model, each
accountable care organization shall obtain and maintain certification from the Green
Mountain Care Board. The Board shall adopt rules pursuant to 3 V.S.A. chapter 25 to establish standards and processes for certifying accountable care organizations.
To the extent permitted under federal law, the Board shall ensure these rules anticipate
and accommodate a range of ACO models and sizes, balancing oversight with support
for innovation. In order to certify an ACO to operate in this State, the Board shall
ensure that the following criteria are met:
(1) The ACO’s governance, leadership, and management structure is transparent, reasonably
and equitably represents the ACO’s participating providers and its patients, and includes
a consumer advisory board and other processes for inviting and considering consumer
input.
(2) The ACO has established appropriate mechanisms and care models to provide, manage,
and coordinate high-quality health care services for its patients, including incorporating
the Blueprint for Health, coordinating services for complex high-need patients, and
providing access to health care providers who are not participants in the ACO. The
ACO ensures equal access to appropriate mental health care that meets standards of
quality, access, and affordability equivalent to other components of health care as
part of an integrated, holistic system of care.
(3) The ACO has established appropriate mechanisms to receive and distribute payments
to its participating health care providers in a fair and equitable manner. To the
extent that the ACO has the authority and ability to establish provider reimbursement
rates, the ACO shall minimize differentials in payment methodology and amounts among
comparable participating providers across all practice settings, as long as doing
so is not inconsistent with the ACO’s overall payment reform objectives.
(4) The ACO has established appropriate mechanisms and criteria for accepting health care
providers to participate in the ACO that prevent unreasonable discrimination and are
related to the needs of the ACO and the patient population served.
(5) The ACO has established mechanisms and care models to promote evidence-based health
care, patient engagement, coordination of care, use of electronic health records,
and other enabling technologies to promote integrated, efficient, seamless, and effective
health care services across the continuum of care, where feasible.
(6) The ACO’s participating providers have the capacity for meaningful participation in
health information exchanges.
(7) The ACO has performance standards and measures to evaluate the quality and utilization
of care delivered by its participating health care providers.
(8) The ACO does not place any restrictions on the information its participating health
care providers may provide to patients about their health or decisions regarding their
health.
(9) The ACO’s participating health care providers engage their patients in shared decision
making to inform them of their treatment options and the related risks and benefits
of each.
(10) The ACO offers assistance to health care consumers, including:
(A) maintaining a consumer telephone line for complaints and grievances from attributed
patients;
(B) responding and making best efforts to resolve complaints and grievances from attributed
patients, including providing assistance in identifying appropriate rights under a
patient’s health plan;
(C) providing an accessible mechanism for explaining how ACOs work;
(D) providing contact information for the Office of the Health Care Advocate; and
(E) sharing deidentified complaint and grievance information with the Office of the Health
Care Advocate at least twice annually.
(11) The ACO collaborates with providers not included in its financial model, including
home- and community-based providers and dental health providers.
(12) The ACO does not interfere with patients’ choice of their own health care providers
under their health plan, regardless of whether a provider is participating in the
ACO; does not reduce covered services; and does not increase patient cost sharing.
(13) The meetings of the ACO’s governing body comply with the provisions of section 9572 of this title.
(14) The impact of the ACO’s establishment and operation does not diminish access to any
health care or community-based service or increase delays in access to care for the
population and area it serves.
(15) The ACO has in place appropriate mechanisms to conduct ongoing assessments of its
legal and financial vulnerabilities.
(16) The ACO has in place a financial guarantee sufficient to cover its potential losses.
(17) The ACO provides connections and incentives to existing community services for preventing
and addressing the impact of childhood adversity. The ACO collaborates on the development
of quality-outcome measurements for use by primary care providers who work with children
and families and fosters collaboration among care coordinators, community service
providers, and families.
[Subsection (a) effective January 1, 2027; see also subsection (a) effective until
January 1, 2027, set out above.]
(a)(1) In order to be eligible to operate in Vermont, each accountable care organization
shall obtain and maintain certification from the Green Mountain Care Board. The Board
shall adopt rules pursuant to 3 V.S.A. chapter 25 to establish standards and processes for certifying accountable care organizations.
To the extent permitted under federal law, the Board shall ensure these rules anticipate
and accommodate a range of ACO models and sizes, balancing oversight with support
for innovation. In order to certify an ACO to operate in this State, the Board shall
ensure that the following criteria are met:
(A) The ACO’s mechanisms and care models, taken as a whole, support and do not hinder
the State’s principles for health care reform as set forth in section 9371 of this title.
(B) The ACO’s financial incentives for providers and patients are reasonably calculated
to improve, or at a minimum, maintain, the quality of, access to, and affordability
of care.
(C) The ACO has established appropriate mechanisms to receive and distribute payments
to its participating health care providers in a fair and equitable manner.
(D) The ACO has established appropriate mechanisms and criteria for accepting health care
providers to participate in the ACO that prevent unreasonable discrimination.
(E) The ACO has performance standards and measures to evaluate the quality and utilization
of care delivered by its participating health care providers.
(F) The ACO does not place any restrictions on the information its participating health
care providers may provide to patients about their health or decisions regarding their
health.
(G) The ACO offers assistance to health care consumers, including:
(i) maintaining a consumer telephone line for questions, complaints, and grievances from
attributed patients;
(ii) responding and making best efforts to resolve complaints and grievances from attributed
patients, including providing assistance in identifying appropriate rights under a
patient’s health plan;
(iii) providing an accessible mechanism for explaining how ACOs work;
(iv) providing contact information for the Office of the Health Care Advocate; and
(v) sharing deidentified complaint and grievance information with the Office of the Health
Care Advocate at least twice annually.
(H) The ACO has in place a financial guarantee sufficient to cover its potential losses.
(2) Notwithstanding subdivision (1) of this subsection, the Green Mountain Care Board
may adopt rules in accordance with 3 V.S.A. chapter 25 to establish a streamlined process for certification as a Medicare-only ACO for an
entity authorized by the Centers for Medicare and Medicaid Services to act as an accountable
care organization under the Medicare program. The streamlined process may require
a Medicare-only ACO to meet one or more of the criteria set forth in subdivision (1)
of this subsection. Certification obtained pursuant to the streamlined process shall
apply to the Medicare-only ACO’s actions only as they relate to Medicare beneficiaries
and only to the extent that the federal authorization allows.
[Subsections (b)–(e) effective until January 1, 2026; see also subsections (b)–(g)
effective January 1, 2026, set out below.]
(b)(1) The Green Mountain Care Board shall adopt rules pursuant to 3 V.S.A. chapter 25 to establish standards and processes for reviewing, modifying, and approving the
budgets of ACOs with 10,000 or more attributed lives in Vermont. To the extent permitted
under federal law, the Board shall ensure the rules anticipate and accommodate a range
of ACO models and sizes, balancing oversight with support for innovation. In its review,
the Board shall review and consider:
(A) information regarding utilization of the health care services delivered by health
care providers participating in the ACO and the effects of care models on appropriate
utilization, including the provision of innovative services;
(B) the Health Resource Allocation Plan identifying Vermont’s critical health needs, goods,
services, and resources as identified pursuant to section 9405 of this title;
(C) the expenditure analysis for the previous year and the proposed expenditure analysis
for the year under review by payer;
(D) the character, competence, fiscal responsibility, and soundness of the ACO and its
principals;
(E) any reports from professional review organizations;
(F) the ACO’s efforts to prevent duplication of high-quality services being provided efficiently
and effectively by existing community-based providers in the same geographic area,
as well as its integration of efforts with the Blueprint for Health and its regional
care collaboratives;
(G) the extent to which the ACO provides incentives for systemic health care investments
to strengthen primary care, including strategies for recruiting additional primary
care providers, providing resources to expand capacity in existing primary care practices,
and reducing the administrative burden of reporting requirements for providers while
balancing the need to have sufficient measures to evaluate adequately the quality
of and access to care;
(H) the extent to which the ACO provides incentives for systemic integration of community-based
providers in its care model or investments to expand capacity in existing community-based
providers, in order to promote seamless coordination of care across the care continuum;
(I) the extent to which the ACO provides incentives for systemic health care investments
in social determinants of health, such as developing support capacities that prevent
hospital admissions and readmissions, reduce length of hospital stays, improve population
health outcomes, reward healthy lifestyle choices, and improve the solvency of and
address the financial risk to community-based providers that are participating providers
of an accountable care organization;
(J) the extent to which the ACO provides incentives for preventing and addressing the
impacts of adverse childhood experiences (ACEs) and other traumas, such as developing
quality outcome measures for use by primary care providers working with children and
families, developing partnerships between nurses and families, providing opportunities
for home visits, and including parent-child centers and designated agencies as participating
providers in the ACO;
(K) public comment on all aspects of the ACO’s costs and use and on the ACO’s proposed
budget;
(L) information gathered from meetings with the ACO to review and discuss its proposed
budget for the forthcoming fiscal year;
(M) information on the ACO’s administrative costs, as defined by the Board;
(N) the effect, if any, of Medicaid reimbursement rates on the rates for other payers;
(O) the extent to which the ACO makes its costs transparent and easy to understand so
that patients are aware of the costs of the health care services they receive; and
(P) the extent to which the ACO provides resources to primary care practices to ensure
that care coordination and community services, such as mental health and substance
use disorder counseling that are provided by community health teams, are available
to patients without imposing unreasonable burdens on primary care providers or on
ACO member organizations.
(2) The Green Mountain Care Board shall adopt rules pursuant to 3 V.S.A. chapter 25 to establish standards and processes for reviewing, modifying, and approving the
budgets of ACOs with fewer than 10,000 attributed lives in Vermont. In its review,
the Board may consider as many of the factors described in subdivision (1) of this
subsection as the Board deems appropriate to a specific ACO’s size and scope.
(3)(A) The Office of the Health Care Advocate shall have the right to receive copies of all
materials related to any ACO budget review and may:
(i) ask questions of employees of the Green Mountain Care Board related to the Board’s
ACO budget review;
(ii) submit written questions to the Board that the Board will ask of the ACO in advance
of any hearing held in conjunction with the Board’s ACO review;
(iii) submit written comments for the Board’s consideration; and
(iv) ask questions and provide testimony in any hearing held in conjunction with the Board’s
ACO budget review.
(B) The Office of the Health Care Advocate shall not disclose further any confidential
or proprietary information provided to the Office pursuant to this subdivision (3).
(c) The Board’s rules shall include requirements for submission of information and data
by ACOs and their participating providers as needed to evaluate an ACO’s success.
They may also establish standards as appropriate to promote an ACO’s ability to participate
in applicable federal programs for ACOs.
(d) All information required to be filed by an ACO pursuant to this section or to rules
adopted pursuant to this section shall be made available to the public upon request,
provided that individual patients or health care providers shall not be directly or
indirectly identifiable.
(e) To the extent required to avoid federal antitrust violations, the Board shall supervise
the participation of health care professionals, health care facilities, and other
persons operating or participating in an accountable care organization. The Board
shall ensure that its certification and oversight processes constitute sufficient
State supervision over these entities to comply with federal antitrust provisions
and shall refer to the Attorney General for appropriate action the activities of any
individual or entity that the Board determines, after notice and an opportunity to
be heard, may be in violation of State or federal antitrust laws without a countervailing
benefit of improving patient care, improving access to health care, increasing efficiency,
or reducing costs by modifying payment methods.
[Subsections (b)–(g) effective January 1, 2026; see also subsections (b)–(e) effective
until January 1, 2026, set out above.]
(b) The Green Mountain Care Board shall adopt rules in accordance with 3 V.S.A. chapter 25 to establish standards and processes for reviewing, modifying, and approving the
budgets of ACOs that receive payments from Medicaid or commercial insurers, or both,
on behalf of attributed lives in Vermont. To the extent permitted under federal law,
the Board shall ensure the rules anticipate and accommodate a range of ACO models
and sizes, balancing oversight with support for innovation. In its review, the Board
shall review and consider:
(1) information gathered from meetings with the ACO to review and discuss its proposed
budget for the forthcoming fiscal year;
(2) the efficacy with which the ACO uses funds from Medicaid and commercial insurers,
as applicable, to enhance and expedite the State’s health care system transformation
efforts;
(3) the ACO’s reasonable use of State and commercial insurance funds for its own administrative
costs, as defined by the Board;
(4) the ACO’s collaboration with a range of provider types, such as home- and community-based
providers, dental health providers, and mental health and substance use disorder treatment
providers;
(5) the ACO’s use of a consumer advisory board and other mechanisms for inviting and considering
consumer input; and
(6) public comment on all aspects of the ACO’s costs, operations, and proposed budget.
(c)(1) The Office of the Health Care Advocate shall have the right to receive copies of all
materials related to any ACO certification or budget review and may:
(A) ask questions of employees of the Green Mountain Care Board related to the Board’s
ACO budget review;
(B) submit written questions to the Board that the Board will ask of the ACO in advance
of any hearing held in conjunction with the Board’s ACO review;
(C) submit written comments for the Board’s consideration; and
(D) ask questions and provide testimony in any hearing held in conjunction with the Board’s
ACO budget review.
(2) The Office of the Health Care Advocate shall not disclose further any confidential
or proprietary information provided to the Office pursuant to this subsection.
(d) The Board’s rules shall include requirements for submission of information and data
by ACOs and their participating providers as needed to evaluate an ACO’s success.
The rules may also establish standards as appropriate to promote an ACO’s ability
to participate in applicable federal programs for ACOs.
(e) All information required to be filed by an ACO pursuant to this section or to rules
adopted pursuant to this section shall be made available to the public in accordance
with 1 V.S.A. chapter 5, subchapter 3 (Public Records Act), provided that individual patients or health care
providers shall not be directly or indirectly identifiable.
(f) To the extent required to avoid federal antitrust violations, the Board shall supervise
the participation of health care professionals, health care facilities, and other
persons operating or participating in an accountable care organization. The Board
shall ensure that its certification and oversight processes constitute sufficient
State supervision over these entities to comply with federal antitrust provisions
and shall refer to the Attorney General for appropriate action the activities of any
individual or entity that the Board determines, after notice and an opportunity to
be heard, may be in violation of State or federal antitrust laws without a countervailing
benefit of improving patient care, improving access to health care, increasing efficiency,
or reducing costs by modifying payment methods.
(g) The Board shall collect the following amounts from an accountable care organization:
(1) $10,000.00 for initial certification in accordance with subsection (a) of this section;
(2) $2,000.00 annually following initial certification to maintain certification; and
(3) $125,000.00 for each review of the accountable care organization’s budget in accordance
with subsection (b) of this section. (Added 2015, No. 113 (Adj. Sess.), § 5, eff. Jan. 1, 2018; amended 2017, No. 59, § 1; 2017, No. 167 (Adj. Sess.), §§ 2, 13a, eff. May 22, 2018; 2017, No. 200 (Adj. Sess.), § 15; 2017, No. 204 (Adj. Sess.), § 7; 2019, No. 14, § 54, eff. April 30, 2019; 2019, No. 52, § 2a; 2025, No. 62, § 5.)