An act relating to reform for primary care

The enacted version directly establishes a new 18 V.S.A. section 721 creating a capitated per-member-per-month primary care payment program with specific statutory parameters. The House-passed version takes a more report-based approach, requiring the agency to develop and recommend program details rather than codifying them in statute.

The enacted version sets a specific target of 15 percent of total Vermont health care spending directed to primary care by January 1, 2029, with a transitional schedule. The House-passed version references a spending target section (710) but does not specify the 15 percent figure in the operative text.

The enacted version makes program participation mandatory for all primary care practices by January 1, 2028. The House-passed version's report-based approach leaves the timeline and mandate structure to be determined through agency recommendations and potential future legislation.

The enacted version caps quality measures at no more than 12 total, with any given practice required to adopt no more than 6. It also sets a specific goal of reducing practitioner administrative time from an average of 50 percent to 10 percent. These specific limits do not appear in the House-passed version.

The enacted version includes a bill-back provision allowing the Vermont Program for Quality in Health Care (VPQHC) to recover its expenses from hospitals and health insurers under 18 V.S.A. section 9416(c). This enforcement mechanism is absent from the House-passed version.

Several report deadlines differ between versions. The enacted version uses January 1, 2027 for some reports while the House-passed version uses January 15, 2027. The enacted version requires program operation to begin by July 1, 2027.

The enacted version references the 2020 Green Mountain Care Board report and NESCSO definitions for primary care services. The House-passed version additionally references the Advancing Healthcare Efficiency through Accountable Design (AHEAD) Model as an alternative definitional source.

The entire standalone Primary Care Payment Reform Program (18 V.S.A. Section 721) was removed. This included the capitated per-member-per-month payment pool, the requirement that all primary care practices participate by January 1, 2028, the specific 15 percent primary care spending target to be met by January 1, 2029, quality measure limits (max 12 measures, practices adopt max 6), and the risk-adjusted allocation model.

The bill now amends the existing Blueprint for Health subchapter (18 V.S.A. chapter 13, subchapter 1) rather than creating a new standalone program. It adds definitions for 'Blueprint for Health,' 'health insurance plan,' and 'health insurer' to Section 701, and expands Section 706 to require per-person-per-month payments tied to NCQA Patient Centered Medical Home scores, with health insurers paying at least equal to Medicaid amounts beginning in 2027.

The legislative intent was expanded from establishing 'a streamlined primary care payment system' to establishing 'a program of universal primary care' that is accessible and affordable for all Vermonters, with explicit purposes including improving patient experience, population health, reducing costs, and improving clinician well-being.

The Senate version's Section 4 requiring the Green Mountain Care Board to report on the Vermont Clinician Landscape Study and site-neutral reimbursements was removed from the enacted bill.

New Section 3a requires the Agency of Human Services to recommend by January 15, 2027 a process for transitioning Blueprint for Health funding from existing statutory mechanisms to the health care claims tax (32 V.S.A. chapter 243), including any necessary modifications to tax rates in 32 V.S.A. Section 10402.

The specific 15 percent primary care spending target (to be met by January 1, 2029) was removed. The enacted version instead requires the Agency of Human Services to 'establish a target' for per-person-per-month primary care spending and develop a transitional schedule, with a report due January 1, 2028, without specifying a numerical target or deadline.

New Section 6 requires the Agency of Human Services, Green Mountain Care Board, and Department of Financial Regulation to evaluate how their respective roles in health care regulation and reform should be distributed, with a report due January 15, 2027 identifying areas of agreement, disagreement, gaps, overlaps, and needed legislative changes.

The enacted version removes the specific implementation date of July 1, 2027 and the mandatory participation deadline of January 1, 2028. Instead, it requires a detailed report by January 15, 2027 on how to transition Blueprint payments to cover routine primary care needs, with an operational plan and proposed timeline for implementation.

The sunset provision repealing 18 V.S.A. Section 33 (primary care physician scholarship program) on July 1, 2027 was removed from the enacted version.

Throughout the bill, references to the 'Department of Vermont Health Access' and 'Commissioner of Vermont Health Access' were changed to 'Agency of Human Services' and 'Secretary of Human Services,' reflecting a reorganization of state health agencies. Several report deadlines shifted from January 1, 2027 to January 15, 2027.

New standalone primary care payment reform program (18 V.S.A. section 721) replaces the previous approach of amending existing Blueprint for Health sections (706 and 710). The new program is a capitated payment system that covers all routine primary care needs of attributed patients without any patient cost-sharing requirements.

New section (Sec. 6) requires the Green Mountain Care Board to consider existing regulatory structures for access to VHCURES and VUHDDS data, recommend improvements for quality improvement while preserving privacy, and recommend statutory modifications to enable VPQHC's expenses to be billed back to hospitals and health insurers.

The unofficial version included a section (Sec. 10) amending 8 V.S.A. section 4092(i) to require health insurers to notify enrollees of pharmaceutical coverage changes annually and provide 60 days notice before removing a drug from a formulary. This provision is absent from the official version.

Participation in the program is initially voluntary for primary care practices but becomes mandatory for all primary care practices in Vermont no later than January 1, 2028. The program must begin operating on or before July 1, 2027.

The program is funded by allocating a portion of commercial health insurance premiums, premium equivalents from other participating payers, and public funds from Medicare and Medicaid (to the extent permitted by federal law). A payment pool is established to collect and distribute funds.

An initial primary care spending allocation target of 15 percent of total Vermont health care spending is set to be met no later than January 1, 2029. The Department must establish a transitional schedule increasing the proportion over time. Indirect primary care spending is limited as a percentage of total direct and indirect primary care spending. A higher target may be established after benchmarks are met.

Quality measures are capped at no more than 12 total, with practices required to adopt no more than 6. Each measure must be claims-derived, patient-centered, appropriate for primary care, and supported by peer-reviewed evidence. Goals include reducing practitioner administrative time from an average of 50 percent to 10 percent and reducing the ratio of administrative staff to clinical staff.

The Department must adopt by rule a risk-adjusted allocation model that may blend capitated payments with fee-for-service, accounts for closure of accountable care organizations, accurately attributes patients to practices, supports team-based primary care including mental health and social drivers of health, and does not require cost-sharing for routine primary care services.

A report is due to the legislature by December 15, 2026 on progress in establishing the program and options for expanding it by January 1, 2028 to any patient of a participating practice regardless of coverage type or status.

The legislative intent was changed from investing in primary care through streamlined payments that build on the Blueprint for Health to investing in primary care by establishing a streamlined primary care payment system, reflecting the shift away from the Blueprint framework as the organizing structure.

The bill was restructured from creating a new standalone program at 18 V.S.A. section 721 to amending the existing Blueprint for Health chapter (18 V.S.A. chapter 13, subchapter 1), embedding payment reform within the existing state health care integration framework.

Insurer participation changed from voluntary (with a mandate for all practices by January 2028) to mandatory as a condition of doing business in Vermont from the start. Practices must meet NCQA Physician Practice Connections-Patient Centered Medical Home certification or another quality standard set by the Blueprint Director.

The payment model changed from a capitated per-member per-month payment that replaces all routine primary care costs and eliminates patient cost-sharing, to a per-person per-month add-on payment provided in addition to normal fee-for-service payments. Payments must be at least equal to Medicaid rates beginning in 2027.

The specific 15 percent primary care spending target by January 2029 was removed and replaced with a requirement that the Agency of Human Services establish its own target with a transitional schedule. The introduced version's detailed risk-adjusted allocation model with eight specific criteria was simplified to give the Blueprint Director broad discretion to recommend changes.

A new section (Sec. 10) requires health insurers to notify all covered individuals of changes in pharmaceutical coverage and to provide at least 60 days advance notice before removing a prescription drug from its formulary or a pharmacy benefit manager's formulary.

The introduced version's specific administrative burden reduction goals (reducing practitioner admin time from 50 percent to 10 percent and reducing the ratio of administrative staff to clinical staff) were removed in the Senate version.

A new appeal process was added allowing health insurers to challenge payment methodology decisions before the Commissioner of Vermont Health Access or Secretary of Human Services, with further appeal to Superior Court within 30 days.

The introduced version required the program to begin operating by July 1, 2027 with a report due December 15, 2026. The Senate version has no explicit program start date but requires multiple reports by January 1, 2027 (baseline spending, payment methodology transition plan) and January 1, 2028 (spending targets and operational plan).

If the Secretary of Human Services is denied permission from CMS to include Medicare financial participation, health insurers are not required to cover costs for individuals covered by Medicare. This creates a carve-out that was not present in the introduced version.