§ 9414. Quality assurance for managed care
(a) The Commissioner shall have the power and responsibility to ensure that each managed
care organization provides quality health care to its members, in accordance with
the provisions of this section.
(1) In determining whether a managed care organization meets the requirements of this
section, the Commissioner may review and examine, in accordance with subsection (e)
of this section, the organization’s administrative policies and procedures, quality
management and improvement procedures, utilization management, credentialing practices,
members’ rights and responsibilities, preventive health services, medical records
practices, grievance and appeal procedures, member services, financial incentives
or disincentives, disenrollment, provider contracting, and systems and data reporting
capacities. The Commissioner shall establish, by rule, specific criteria to be considered
under this section.
(2) A managed care organization shall, in plain language, disclose to its members:
(A) any provision of its enrollment plan or provider contracts that may restrict referral
or treatment options or that may require prior authorization or utilization review
or that may limit in any manner the services covered under the members’ enrollment
plan;
(B) the criteria used for credentialing or selecting health care providers with whom the
organization contracts;
(C) the financial inducements offered to any health care provider or health care facility
for the reduction or limitation of health care services;
(D) the utilization review procedures of the organization, including the credentials and
training of utilization review personnel;
(E) whether the organization’s health care providers are contractually prohibited from
participating in other managed care organizations or from performing services for
persons who are not members of the managed care organization;
(F) upon request, health care providers available to members under the enrollment plan.
(3) A managed care organization shall not include any provision in a contract with a health
care provider that prohibits the health care provider from disclosing to members information
about the contract or the members’ enrollment plan that may affect their health or
any decision regarding health care treatment.
(4) The Commissioner or designee may resolve any consumer or provider complaint arising
out of this subsection as though the managed care organization were an insurer licensed
pursuant to Title 8. As used in this section, “complaint” means a report of a violation
or suspected violation of the standards set forth in this section or adopted by rule
pursuant to this section and made by or on behalf of a consumer or provider.
(5) The Commissioner shall prepare an annual report on or before July 1 of each year providing
the number of complaints received during the previous calendar year regarding violations
or suspected violations of the standards set forth in this section or adopted by rule
pursuant to this section. The report shall specify the aggregate number of complaints
related to each standard and shall be posted on the Department’s website.
(b)(1) A managed care organization shall ensure that the health care services provided to
members are consistent with prevailing professionally recognized standards of medical
practice.
(2) A managed care organization shall participate in the Blueprint for Health established
in chapter 13 of this title. If needed to implement the Blueprint, a managed care
organization shall establish a chronic care program, which shall include:
(A) appropriate benefit plan design;
(B) informational materials, training, and follow-up necessary to support members and
providers; and
(C) payment reform methodologies.
(3) Each managed care organization shall have procedures to ensure availability, accessibility,
and continuity of care, and ongoing procedures for the identification, evaluation,
resolution, and follow-up of potential and actual problems in its health care administration
and delivery.
(4) Each managed care organization shall be accredited by a national independent accreditation
organization approved by the Commissioner.
(c) Consistent with participation in the Blueprint for Health pursuant to subdivision
(b)(2) of this section and the accreditation required by subdivision (b)(4) of this
section, the managed care organization shall have an internal quality assurance program
to monitor and evaluate its health care services, including primary and specialist
physician services, and ancillary and preventive health care services, across all
institutional and noninstitutional settings. The internal quality assurance program
shall be fully described in written form; provided to all managers, providers, and
staff; and made available to members of the organization. The components of the internal
quality assurance program shall include the following:
(1) a peer review committee or comparable designated committee responsible for quality
assurance activities;
(2) accountability of the committee to the board of directors or other governing authority
of the organization;
(3) participation by an appropriate base of providers and support staff;
(4) supervision by the medical director of the organization;
(5) regularly scheduled meetings; and
(6) minutes or records of the meetings that describe in detail the actions of the committee,
including problems discussed, charts reviewed, recommendations made, and any other
pertinent information.
(d), (e) [Repealed.]
(f)(1) For the purpose of evaluating a managed care organization’s performance under the
provisions of this section, the Commissioner may examine and review information protected
by the provisions of the patient’s privilege under 12 V.S.A. § 1612(a) or otherwise required by law to be held confidential.
(2) [Repealed.]
(3) Any information made available under this section shall be furnished in a manner that
does not disclose the identity of the protected person. The Commissioner shall adopt
a confidentiality code to ensure that information obtained under this section is handled
in an ethical manner. Information disclosed to the Commissioner under this section
shall be confidential and privileged and shall not be subject to subpoena or available
for public disclosure, except that the Commissioner is authorized to use such information
during the course of any legal or regulatory action under this title against a managed
care organization.
(g)(1) In addition to any other remedy or sanction provided by law, after notice and an opportunity
to be heard, if the Commissioner determines that a managed care organization has violated
or failed to comply with any of the provisions of this section or any rule adopted
pursuant to this section, the Commissioner may:
(A) sanction the violation or failure to comply as provided in Title 8, including sanctions
provided by or incorporated in 8 V.S.A. §§ 4726, 5108, and 5109, and may use any information obtained during the course of any legal or regulatory
action against a managed care organization;
(B) order the managed care organization to cease and desist in further violations; and
(C) order the managed care organization to remediate the violation, including issuing
an order to the managed care organization to terminate its contract with any person
or entity that administers claims or the coverage of benefits on behalf of the managed
care organization.
(2) A managed care organization that contracts with a person or entity to administer claims
or provide coverage of health benefits is fully responsible for the acts and omissions
of such person or entity. Such person or entity shall comply with all obligations,
under this title and Title 8, of the health insurance plan and the health insurer
on behalf of which such person or entity is providing or administering coverage.
(3) A violation of any provision of this section or a rule adopted pursuant to this section
shall constitute an unfair act or practice in the business of insurance in violation
of 8 V.S.A. § 4723.
(h) Each managed care organization subject to examination, investigation, or review by
the Commissioner under this section shall pay the Commissioner the reasonable costs
of such examination, investigation, or review conducted or caused to be conducted
by the Commissioner, at a rate to be determined by the Commissioner. All examinations
conducted under this section shall be pursuant to and in conformity with 8 V.S.A. §§ 3573, 3574, 3575, and 3576, except that the Commissioner may modify or adapt those examination guidelines,
principles, and procedures to be more appropriate or useful to the examination of
managed care organizations.
(i) [Repealed.] (Added 1993, No. 30, § 19; amended 1995, No. 180 (Adj. Sess.), §§ 21, 38(a), (b); 1999, No. 38, § 22, eff. May 20, 1999; 2007, No. 142 (Adj. Sess.), §§ 2, 3, eff. May 14, 2008; 2007, No. 204 (Adj. Sess.), § 1; 2015, No. 54, § 36; 2015, No. 152 (Adj. Sess.), § 7; 2023, No. 6, § 229, eff. July 1, 2023.)