The Vermont Statutes Online

Title 18 : Health

Chapter 221 : Health Care Administration

Subchapter 002 : Claims Processing and Contract Standards

• § 9418d. Contract amendments

  (a) A health care contract may be amended by mutual agreement of the parties.

  (b) Absent mutual agreement of the parties, a health care contract may be amended only as follows:

  (1) The contracting entity shall provide to the participating provider notice of the amendment and the amendment in writing not later than 60 days prior to the effective date of the amendment. The notice shall be conspicuously entitled “Notice of Amendment to Contract” and shall include a summary of the amendment as described in subdivision (4) of this subsection. The notice period may be extended by mutual agreement of the parties.

  (2) The participating provider shall have 60 days after receiving the amendment, notice, and summary pursuant to subdivision (1) of this subsection to object, in writing, to the proposed amendment. If the participating provider objects to the amendment and there is no resolution of the objection within 60 days following the contracting entity’s receipt of the written objection, either party may terminate the contract upon written notice of termination provided to the other party. Termination shall become effective in the time period specified in the health care contract. If no termination period is specified in the health care contract, the termination shall become effective 90 days after the notice of termination is provided. The terms of the underlying contract shall remain in effect through the termination period and shall be unaffected by the proposed amendment.

  (3) If the participating provider does not object to the amendment in the manner specified in subdivision (2) of this subsection, the amendment shall be effective as specified in the notice described in subdivision (1) of this subsection.

  (4) The notice of amendment shall include a summary cover sheet that shall include the following information:

  (A) a brief explanation of the amendment;

  (B) the date the amendment will become effective;

  (C) a notice of right to object in writing to the amendment;

  (D) the time frame for objection;

  (E) the address to send an objection;

  (F) contact information for the person to call to discuss the amendment for further information or to resolve an objection;

  (G) the effect of an objection;

  (H) the right to terminate the contract if the objection is not resolved;

  (I) the time period for the effective date of any such termination; and

  (J) the address to send a notice of termination.

  (c) Subsection (b) of this section shall not apply in the following circumstances:

  (1) The delay caused by compliance with the 60-day notice period in subdivision (b)(1) of this section could result in imminent harm to an insured.

  (2) The amendment of a health care contract is required by a State or federal law, rule, or regulation that includes an effective date for the amendment.

  (3) The provider affirmatively accepts the amendment in writing and agrees to an earlier effective date than that specified in the notice required by subdivision (b)(1) of this section.

  (4) The participating provider’s payment or compensation is based on the current Medicaid or Medicare physician reimbursement schedule, and the amendment reflects a change in payment or compensation resulting solely from a change in that physician reimbursement schedule.

  (5) The amendment is a routine change or update of the health care contract made in response to any addition, deletion, or revision of any service code, procedure code, or reporting code, or a pricing change is made by a third party source. For purposes of this subdivision:

  (A) “Service code, procedure code, or reporting code” means the American Medical Association’s Current Procedural Terminology, the American Dental Association’s Current Dental Terminology, the Centers for Medicare and Medicaid Services’ Healthcare Common Procedure Coding System, the World Health Organization’s International Classification of Diseases, or the Drug Topics Red Book average wholesale price; and

  (B) “Third party source” means the American Medical Association, the American Society of Anesthesiologists, the American Dental Association, the Centers for Medicare and Medicaid Services, the National Center for Health Statistics, the U.S. Department of Health and Human Services Office of the Inspector General, the Vermont Department of Financial Regulation, or the Vermont Agency of Human Services.

  (d) Notwithstanding subsections (a), (b), and (c) of this section, a health care contract may be amended by operation of law as required by any applicable state or federal law, rule, or regulation.

  (e) Subsection (b) of this section shall not apply to amendments of health care contracts with hospitals. (Added 2009, No. 61, § 33.)