S 197

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No. 173. An act relating to reform for primary care.
                                     (S.197)
It is hereby enacted by the General Assembly of the State of Vermont:
Sec. 1. LEGISLATIVE INTENT; PURPOSES
   (a) It is the intent of the General Assembly to invest in primary care and to
establish a program of universal primary care that:
      (1) is accessible to and affordable for all Vermonters; and
      (2) will promote the public good by:
          (A) improving the patient experience of care;
          (B) improving population health;
          (C) reducing costs; and
          (D) improving the well-being of clinicians and staff.
   (b) The purposes of this bill are to:
      (1) obtain the information necessary to develop a framework for
implementation of universal primary care;
      (2) optimize the Blueprint for Health;
      (3) determine whether the Blueprint is an appropriate mechanism
through which to provide universal primary care; and
      (4) explore other approaches to universal primary care and whether they
may be more suitable than the Blueprint in meeting Vermont’s needs.
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Sec. 2. 18 V.S.A. chapter 13, subchapter 1 is amended to read:
                        Subchapter 1. Blueprint for Health
§ 701. DEFINITIONS
   As used in this chapter:
         (1) “Blueprint for Health” or “Blueprint” means the State’s program for
integrating a system of health care for patients, improving the health of the
overall population, and improving control over health care costs by promoting
health maintenance, prevention, and care coordination and management.
                                       ***
         (8) “Health insurance plan” has the same meaning as means a major
medical insurance plan as defined in 8 V.S.A. § 4011.
         (9) “Health insurer” shall have the same meaning as in section 9402 of
this title means any person that offers, issues, renews, or administers a health
insurance plan or other health benefit plan in this State and includes, to the
extent permitted under federal law, third-party administrators that administer a
health benefit plan offering coverage in this State or that provide
administrative services only for a health benefit plan offering coverage in this
State.
                                       ***
§ 706. HEALTH INSURER PARTICIPATION; PAYMENTS TO
          PRACTICES
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   (a) As set forth in 8 V.S.A. § 4025, health insurance plans shall be
consistent with the Blueprint for Health as determined by the Commissioner of
Financial Regulation.
   (b)(1) Health insurers shall participate in the Blueprint for Health as a
condition of doing business in this State as provided for in this section and in
8 V.S.A. § 4025.
      (2) In order to facilitate development of the sustainable payment models
necessary for the Blueprint’s success, health insurers shall submit to the
Agency of Human Services at least quarterly, or more frequently upon the
Agency’s request, all information that the Director of the Blueprint deems
necessary to perform a comprehensive fiscal analysis of the total cost of care
within Vermont and to implement one or more payment models that address
health care capacity, volume, quality, and clinical outcomes.
   (c)(1) The Blueprint payment reform methodologies shall include per-
person per-month payments to medical home participating practices, including
medical homes and primary care providers, by each health insurer and
Medicaid for their attributed patients and for contributions to the shared costs
of operating Blueprint initiatives, including the community health teams. Per-
person per-month payments to practices shall be:
          (A) based on the official National Committee for Quality
Assurance’s Physician Practice Connections-Patient Centered Medical Home
(NCQA PPC-PCMH) score or another quality standard identified by the
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Director of the Blueprint in consultation with the Blueprint Payment
Implementation Workgroup, to the extent practicable and shall be;
          (B) provided in addition to their normal a practice’s typical fee-for-
service or other payments; and
          (C) from health insurers, in amounts at least equal to Medicaid
payments beginning in 2027.
      (2) Consistent with recommendations of the Blueprint Executive
Committee, the Director of the Blueprint may recommend to the
Commissioner of Vermont Health Access Secretary of Human Services
changes to the payment amounts or to the payment reform methodologies
described in subdivision (1) of this subsection, including by providing for
enhanced payment to health care professional practices that operate as a
medical home, including medical homes and primary care naturopathic
physicians’ practices; payment toward the shared costs for community health
teams; or other payment methodologies required by the Centers for Medicare
and Medicaid Services (CMS) for participation by Medicaid or Medicare. In
formulating recommendations, the Director shall strive to achieve or maintain
parity across payers and payment methodologies and to adjust payment
methodologies annually as needed to adequately support practices in
maintaining NCQA PCMH status or meeting other requirements for
participation in Blueprint programs.
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      (3) Health insurers shall modify payment methodologies and amounts to
health care professionals and providers as required for the establishment of the
model described in sections 703–705 of this title and this section, including
any requirements specified by the Centers for Medicare and Medicaid Services
(CMS) in approving federal participation in the model to ensure consistency of
payment methods in the model.
      (4) In the event that the Secretary of Human Services is denied
permission from the Centers for Medicare and Medicaid Services (CMS) to
include financial participation by Medicare, health insurers shall not be
required to cover the costs associated with individuals covered by Medicare.
   (d) An A health insurer may appeal a decision to require a particular
payment methodology or payment amount to the Commissioner of Vermont
Health Access Secretary of Human Services or designee, who shall provide a
hearing in accordance with 3 V.S.A. chapter 25. An A health insurer
aggrieved by the decision of the Commissioner Secretary or designee may
appeal to the Superior Court for the Washington District within 30 days after
the Commissioner issues his or her Secretary or designee issues a decision.
                                      ***
Sec. 3. BLUEPRINT PAYMENTS TO PRACTICES; PRIMARY CARE;
          REPORT
   (a) On or before January 15, 2027, the Director of the Blueprint for Health,
in consultation with the Blueprint Executive Committee and the Vermont
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Steering Committee for Comprehensive Primary Health Care, shall report to
the House Committee on Health Care and the Senate Committee on Health and
Welfare regarding changes to the payment amounts or payment methodologies,
or both, that would be necessary to transition the Blueprint’s per-person per-
month payments to primary care practices to include payment for the routine
primary care needs of attributed patients who are covered by participating
health plans. The report shall:
        (1) establish definitions of “primary care services” and “primary care
provider” and define which services should be considered routine primary
care;
        (2) address any differences in methodology for different practice types;
        (3) make recommendations regarding risk-adjustment and attribution
methodologies;
        (4) describe the ways in which the methodology will balance capacity,
volume, quality, and outcomes;
        (5) include mechanisms for ensuring that health plans make accurate
and appropriate payments to primary care practices in a timely manner;
        (6) make recommendations regarding participation or quality
measurement requirements, or both;
        (7) provide an analysis of including cost-sharing amounts for individuals
covered by participating health plans in the methodology, including the extent
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to which such inclusion would be permissible for a high-deductible health plan
without losing its eligibility to be paired with a health savings account;
      (8) provide an analysis of ways to incorporate a primary care spending
allocation target into the methodology;
      (9) provide an operational plan, a description of any additional
legislation needed in order to implement the methodology, and a proposed
timeline for implementation; and
      (10) provide a description of the ways in which the Blueprint can
optimize the delivery of the services within each of its current initiatives, the
costs associated with enhancing each initiative to its highest level, and the
amount of additional per-person per-month spending that would be needed to
support the enhanced delivery of these services across all Blueprint initiatives.
   (b) The Director of the Blueprint or designee shall be available upon
request from July through December 2026 to provide updates to the Health
Reform Oversight Committee on the development of the report required by
subsection (a) of this section.
Sec. 3a. FUNDING FOR BLUEPRINT FOR HEALTH; HEALTH CARE
          CLAIMS TAX; REPORT
   On or before January 15, 2027, the Agency of Human Services, in
consultation with the Department of Taxes, shall recommend to the House
Committees on Health Care and on Ways and Means and the Senate
Committees on Health and Welfare and on Finance a process by which funding
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for the Blueprint for Health may be transitioned from the mechanisms
established in 18 V.S.A. chapter 13, subchapter 1 to the health care claims tax
established in 32 V.S.A. chapter 243, as identified in the report that the
Director of the Blueprint submitted to the General Assembly in accordance
with 2023 Acts and Resolves No. 51, Sec. 5. The Agency’s recommendations
shall include any modifications to the tax rates established in 32 V.S.A.
§ 10402 that would be necessary to fully support the operation of the
Blueprint, as amended by Sec. 2 of this act, and a potential timeline for
implementation.
Sec. 4. PRIMARY CARE SPENDING; AGENCY OF HUMAN SERVICES;
          REPORT
   On or before January 15, 2027, the Agency of Human Services, in
consultation with the Green Mountain Care Board, shall report to the House
Committee on Health Care and the Senate Committee on Health and Welfare
the baseline per-person per-month spending on primary care services for
Vermont residents overall and by each health insurer, third-party administrator
administering a health plan or providing administrative services only for a
health plan, Medicaid, and Medicare. The Agency shall use the definitions of
primary care providers and services established pursuant to Sec. 3(a) of this
act.
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Sec. 5. PRIMARY CARE SPENDING TARGETS; REPORT
   The Agency of Human Services shall establish a target for the amount of
per-person per-month spending on Vermont residents that should be for
primary care services and shall develop a transitional schedule that increases
the target over time. On or before January 1, 2028, the Agency of Human
Services shall provide the spending targets and transitional schedule, as well as
any recommendations for adjustments to the targets that are needed to reflect
payer-specific differences, such as age and health status, to the House
Committee on Health Care and the Senate Committee on Health and Welfare.
Sec. 6. DISTRIBUTION OF DUTIES FOR HEALTH CARE
          REGULATION AND HEALTH CARE REFORM; REPORT
   (a) The Agency of Human Services, Green Mountain Care Board, and
Department of Financial Regulation, in collaboration with the Office of the
Health Care Advocate, shall evaluate the roles their respective organizations
play in health care regulation and health care reform in this State, including
with respect to hospital transformation efforts, health insurance rate review,
management of the Office of Health Care Reform, operation of the Blueprint
for Health, and administration of other programs and initiatives. The Agency,
Board, and Department shall identify where each health care regulation and
health care reform function should be most appropriately located in order to
optimize collaboration, information sharing, and efficient operations in
furtherance of attaining the principles for health care reform set forth in 2011
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Acts and Resolves No. 48 and as codified at 18 V.S.A. § 9371; improving
access to high-quality, affordable health care services; accomplishing health
care transformation; and safeguarding hospital sustainability and insurer
solvency.
   (b) On or before January 15, 2027, the Agency, Board, and Department
shall each provide specific recommendations on the distribution of
responsibilities resulting from their efforts pursuant to subsection (a) of this
section, including areas of agreement and disagreement, gaps and overlaps
identified, and any legislative changes needed to achieve their preferred
organizational structures, to the House Committee on Health Care and the
Senate Committees on Health and Welfare and on Finance. The Agency,
Board, and Department shall also be available upon request from July through
December 2026 to provide updates to the Health Reform Oversight Committee
on their efforts and the development of the report required by subsection (a) of
this section.
Sec. 7. TRANSITIONING CARE TO COMMUNITY SETTINGS; REPORT
   On or before January 15, 2027, the Agency of Human Services, in
consultation with the Vermont Steering Committee for Comprehensive
Primary Health Care, the Blueprint for Health, the Vermont Association of
Hospitals and Health Systems, the Vermont Medical Society, Bi-State Primary
Care Association, and other interested stakeholders, shall report to the House
Committee on Health Care and the Senate Committee on Health and Welfare
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with recommendations for ways to accelerate the appropriate transition of
patients from hospital care to care delivered in a community setting, including
ways to reduce the extent to which primary care services are delivered to
patients in an inpatient hospital setting following surgery or other acute care,
when care delivered by a primary care provider in the community would be as
or more effective and less costly. The recommendations shall include
opportunities to use community health teams through the Blueprint for Health
to coordinate patients’ care transitions. The Agency shall incorporate the
recommendations into the Statewide Health Care Delivery Strategic Plan as
appropriate.
Sec. 8. REGIONAL UNIVERSAL PRIMARY CARE PROGRAM; REPORT
   The Office of the State Treasurer, in consultation with the Agency of
Human Services, shall collaborate with other northeastern states to explore the
potential to establish a regional universal primary care program that would be
available to all residents of the member states. On or before January 15, 2027,
the State Treasurer shall report to the House Committee on Health Care and the
Senate Committee on Health and Welfare regarding the Office’s outreach
efforts, interest from other northeastern states, any legal or regulatory obstacles
identified, and recommendations for next steps.
Sec. 9. 8 V.S.A. § 4092(i) is amended to read:
   (i)(1) On a periodic basis but not less than once per calendar year, each
health insurer shall notify all individuals covered under its health insurance
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plans of any changes in pharmaceutical coverage and provide access to the
preferred drug list maintained by the health insurer or its pharmacy benefit
manager.
      (2) Not less than 60 days prior to removing a prescription drug from its
formulary or from the formulary maintained by a pharmacy benefit manager on
its behalf, a health insurer shall notify all individuals covered under its health
insurance plans who filled a prescription for that prescription drug within the
previous 12-month period that coverage for the drug will be discontinued and
of the date on which the coverage will end.
Sec. 10. EFFECTIVE DATE
   This act shall take effect on passage.
Date Governor signed bill: June 18, 2026
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