H 680

 BILL AS INTRODUCED  H.680
 2026  Page 1 of 15
1H.680
2 Introduced by Representatives Olson of Starksboro, Cole of Hartford,
3Garofano of Essex, Greer of Bennington, Keyser of Rutland
4City, Labor of Morgan, Masland of Thetford, McCann of
5Montpelier, and Yacovone of Morristown
6 Referred to Committee on
7 Date:
8 Subject: Health; health care professionals; primary care; Agency of Human
9Services; Green Mountain Care Board
10 Statement of purpose of bill as introduced: This bill proposes to establish a
11 primary care access reform program in which participating primary care
12 providers would receive a monthly payment from the patient’s health insurer or
13 other payer for each participating patient that would cover the patient’s routine
14 primary care services for the month without any cost-sharing requirements.
15 The bill would require reports from the Agency of Human Services on
16 expanding the program and from the Green Mountain Care Board on site-
17 neutral reimbursements. The bill would also invest funds in primary care
18 workforce development programs for fiscal year 2027 and eliminate the 2027
19 sunset on a primary care physician scholarship program.
20    An act relating to a primary care access reform program
                                                                   VT LEG #386171 v.1
 BILL AS INTRODUCED  H.680
 2026  Page 2 of 15
1 It is hereby enacted by the General Assembly of the State of Vermont:
2 Sec. 1. FINDINGS; LEGISLATIVE INTENT
3    (a) The General Assembly finds that:
4(1) Good access to primary care is essential for the health of Vermonters
5 and for reducing the need for more costly services, but Vermont’s health care
6 system currently does not provide access to primary care with the timeliness
7 and scope that Vermonters need. This lack of access pushes patients to seek
8 traditional primary care services from specialists, urgent care clinics,
9 emergency departments, pharmacies, out-of-state telehealth platforms, and
10 other sources, further fragmenting care, reducing the professional satisfaction
11 of primary care clinicians, and undermining patient trust in the primary care
12 medical system.
13(2) Primary care clinicians and patients face significant system-imposed
14 administrative and cost burdens that delay or restrict provision of and access to
15 high-value primary care. In addition, primary care clinicians are not
16 compensated commensurate with their value to the health care system. As a
17 result, many primary care clinicians are leaving their Vermont practices, and
18 too few new clinicians are replacing them. Other clinicians are choosing a
19 concierge or direct-care practice model in an effort to restore the focus on the
20 patient-provider relationship and to avoid some of the cumbersome barriers in
21 the health care system. While these models offer significant benefits to both
                                                                    VT LEG #386171 v.1
 BILL AS INTRODUCED  H.680
 2026  Page 3 of 15
1 patients and providers, the patient panel sizes are generally much smaller than
2 in traditional practice models, so more such practices are needed to meet the
3 State’s overall primary care needs.
4(3) Vermont’s health care system is in a state of crisis. Premiums in the
5 commercial health insurance markets are increasingly out of reach for
6 individual Vermonters, their families, private employers, and public employers
7 such as schools and State and local governments. Increasing support for our
8 primary care system in service of improving access to primary and preventive
9 services is Vermont’s best opportunity for short- and long-term improvements
10 to Vermont’s health care system and to the health of Vermonters.
11(4) Access reform for primary care must support the four key functions
12 of primary care—first-contact access, comprehensiveness, coordination, and
13 continuity—which are essential to meeting the goals of improved quality and
14 reduced spending. The success of access reform is highly dependent on
15 alignment across payers and is unlikely to work if only a small subset of a
16 practice’s patient population is included. Increased investment in primary care
17 across public and private payers using value-based care models designed for
18 primary care will contribute significantly to improving health, reducing
19 inequities, reducing the per capita cost of care over time, and improving the
20 well-being of the primary care team.
                                                                   VT LEG #386171 v.1
 BILL AS INTRODUCED  H.680
 2026  Page 4 of 15
1(5) A national time study revealed that during the office day, physicians
2 spent 27.0 percent of their total time on direct clinical face time with patients
3 and 49.2 percent of their time on electronic health records and desk work. A
4 2022 study found that primary care clinicians would need to work 26.7 hours
5 per day to provide guideline-recommended primary care to the typical patient
6 panel, including documentation and message management.
7    (6) In 2020, the Green Mountain Care Board and the Department of
8 Vermont Health Access submitted a report to the General Assembly that
9 calculated primary care spending, both across all payers and by payer type, as a
10 proportion of health care spending. The report found that 10.2 percent of all
11 health care spending was allocated to primary care, though investment varied
12 by payer, with Medicare at 6.5 percent, Medicaid at 24.3 percent, and
13 commercial health insurance at 9.2 percent.
14    (7) The Green Mountain Care Board and the Agency of Human Services
15 already have experience calculating primary care spending using both a State-
16 specific definition of primary care and the New England States Consortium
17 Systems Organization’s (NESCSO) definition. Vermont is required to set a
18 primary care spending target for purposes of the federal AHEAD model and
19 has already proposed using the NESCSO definition of primary care.
20    (b) By enacting this act, it is the intent of the General Assembly to invest in
21 primary care by establishing a streamlined primary care payment system that
                                                                     VT LEG #386171 v.1
 BILL AS INTRODUCED  H.680
 2026  Page 5 of 15
1 will promote the public good by increasing access to primary care in order to
2 improve the health of Vermonters and reduce health care system costs.
3 Sec. 2. 18 V.S.A. § 721 is added to read:
4 § 721. PRIMARY CARE ACCESS REFORM PROGRAM
5    (a)(1) The Agency of Human Services, in coordination with the Green
6 Mountain Care Board, the Blueprint for Health, and the Vermont Steering
7 Committee for Comprehensive Primary Health Care, and in consultation with
8 other interested stakeholders, shall develop and implement a primary care
9 access reform program that will promote the public good by investing in
10 primary care and reducing administrative burdens in order to increase access to
11 care and reduce health system costs.
12(2) The primary care access reform program shall be voluntary for
13 primary care practices and shall be funded by allocating a portion of
14 commercial health insurance premiums; a portion of premium equivalents from
15 other participating payers; and, to the extent permitted by federal law, waivers
16 of federal law, and federal initiatives, public funds from Medicare and
17 Medicaid.
18(3) The program shall collect and aggregate payments from participating
19 payers in order to provide a capitated, per-member per-month payment to each
20 participating primary care practice to cover all of the routine primary care
                                                                   VT LEG #386171 v.1
 BILL AS INTRODUCED  H.680
 2026  Page 6 of 15
1 needs of attributed patients who are covered by participating plans, without
2 any patient cost-sharing requirements.
3    (b)(1) To the extent that the program includes any practice participation
4 requirements, administrative or documentation requirements, or quality
5 measurements, the Agency shall establish them in a manner that streamlines
6 and reduces the administrative burdens on primary care practices imposed by
7 the program and by public and private payers, including aligning with and
8 incorporating necessary Blueprint for Health requirements.
9(2) The program shall establish not more than 12 quality measures and
10 may require a primary care practice to adopt not more than six of them. Each
11 quality measure shall be claims-derived, patient-centered, appropriate for a
12 primary care setting, and supported by peer-reviewed, evidence-based research
13 indicating that the measure is actionable and that its use will lead to
14 improvements in patient health.
15(3) The program shall identify and reform administrative burdens and
16 requirements imposed on primary care providers, including data collection
17 requirements, data system coordination, increased uniformity of requirements
18 across networks and payers, and electronic health records requirements.
19(4) Practice participation requirements shall include reasonable access
20 improvement standards, the goals of which are to make meaningful progress
21 toward reducing the percentage of primary care practices that are not accepting
                                                                     VT LEG #386171 v.1
 BILL AS INTRODUCED  H.680
 2026  Page 7 of 15
1 new patients and toward reducing the average wait times for appointments.
2 The standards shall incorporate metrics for measuring progress in achieving
3 these goals. Initiatives that practices may implement to meet the access
4 improvement standards may include accepting walk-in patients, increasing the
5 number of same-day appointments, adopting extended hours, and undertaking
6 other appropriate access improvement efforts.
7    (c) The Agency shall adopt by rule a risk-adjusted allocation model for
8 primary care practices participating in the access reform program that may be
9 informed by previous accountable care organization payment methodologies
10 and may blend base per-member per-month capitated payments with fee-for-
11 service payments as needed for specific primary care services. The allocation
12 shall include a reimbursement model and level that:
13(1) accomplishes Vermont’s primary care spending target as set forth in
14 subsection (h) of this section;
15(2) supports sufficient access to and sustainability of primary care
16 services in Vermont;
17(3) incorporates different methodologies as needed to address the unique
18 needs of all practice types, including independent practices, federally qualified
19 health centers and rural health centers, and hospital-based primary care
20 practices;
                                                                   VT LEG #386171 v.1
 BILL AS INTRODUCED  H.680
 2026  Page 8 of 15
1(4) incorporates a methodology with the flexibility necessary to support
2 and adjust for the different scope of services delivered by different practices;
3(5) accounts for the closure of accountable care organizations;
4(6) accurately attributes patients to primary care practices;
5(7) is sufficient to support practices in offering comprehensive, team-
6 based primary care that includes supports for mental health and social drivers
7 of health; and
8(8) to the extent permitted under federal law, does not require
9 individuals covered by participating health plans to pay cost-sharing amounts
10 when receiving routine primary care services from participating primary care
11 providers and practices.
12    (d) The Agency shall operate a payment pool to:
13(1) collect the primary care allocation of premiums, premium
14 equivalents, and public program funds due from each payer; and
15(2) determine the per capita payments or other payment mechanism to
16 distribute the funds to participating primary care practices.
17    (e) The Agency of Human Services shall adopt rules in accordance with 3
18 V.S.A. chapter 25 to implement the primary care access reform program,
19 including:
                                                                       VT LEG #386171 v.1
 BILL AS INTRODUCED  H.680
 2026  Page 9 of 15
1(1) determining the scope of the primary care services to be included in
2 the capitated rate and the primary care practices that are eligible for
3 participation in the program;
4(2) if using, practice participation requirements, administrative and
5 documentation requirements, and quality measurements, in accordance with
6 subsection (b) of this section;
7(3) the risk-adjusted allocation model, in accordance with subsection (c)
8 of this section;
9(4) operation of the payment pool, in accordance with subsection (d) of
10 this section;
11(5) program parameters that address and mitigate against practices
12 avoiding high-risk patients or otherwise engaging in adverse selection, while
13 also striving to maximize practice eligibility and participation;
14(6) definitions of direct and indirect primary care spending and
15 appropriate limits on indirect primary care spending as a percentage of health
16 care spending, as set forth in subdivision (g)(2) of this section; and
17(7) benchmarks for determining the program’s performance, as set forth
18 in subdivision (g)(3) of this section.
19    (f) The Agency of Human Services or the Green Mountain Care Board, or
20 both, shall enter into negotiations with the Centers for Medicare and Medicaid
21 Services in order to secure Medicare participation in the primary care access
                                                                     VT LEG #386171 v.1
 BILL AS INTRODUCED  H.680
 2026  Page 10 of 15
1 reform program. The Agency or Board, or both, shall also conduct outreach to
2 self-funded, nongovernmental employer-sponsored plans regarding
3 opportunities for their voluntary participation in the program and to discuss
4 with interested plans the appropriate allocation of premium equivalents to be
5 paid into the payment pool, which amounts should not unfairly disadvantage
6 individuals covered by fully insured plans, self-funded governmental plans, or
7 public benefit programs.
8    (g)(1) Implementation of the primary care access reform program shall
9 increase the proportion of total annual health care spending on behalf of
10 Vermont residents that is spent on primary care, with an initial primary care
11 spending allocation target of 15 percent of the total amount spent for all health
12 care services delivered to Vermont residents both within and outside Vermont,
13 to be met not later than January 1, 2029. The Agency shall establish a
14 transitional schedule that increases the proportion of primary care spending
15 over time in order to achieve the primary care spending target. The increased
16 spending for primary care shall not result in an increase in the overall amount
17 of health care spending for Vermont residents’ care.
18(2) The Agency shall limit indirect primary care spending, as defined by
19 rule, as a percentage of total primary care spending for purposes of the primary
20 care spending target.
                                                                   VT LEG #386171 v.1
 BILL AS INTRODUCED  H.680
 2026  Page 11 of 15
1(3) The Agency may establish a new, higher primary care spending
2 target after the initial target has been achieved if the Agency’s analysis
3 determines that the primary care access reform program has met specific
4 benchmarks established by the Agency by rule, in areas including access to
5 primary care, quality of primary care services delivered, impact on health
6 outcomes, and containment of overall health care costs.
7(4) For purposes of the primary care spending allocation target, the
8 Agency shall use a definition of primary care services that aligns with the
9 definition used in the 2020 report determining the proportion of health care
10 spending in Vermont that is allocated to primary care, which was submitted to
11 the General Assembly by the Green Mountain Care Board and the Department
12 of Vermont Health Access in accordance with 2019 Acts and Resolves No. 17,
13 Sec. 2, and with the definition of primary care services used by the New
14 England States Consortium Systems Organization (NESCSO).
15(5)(A) Each health insurer with at least 5,000 covered lives under a
16 health insurance plan issued, delivered, or issued for delivery in Vermont shall
17 comply with the requirements of this subsection (g), including meeting or
18 exceeding the annual primary care spending targets established pursuant to this
19 subsection (g).
20(B) In meeting its annual primary care spending obligations, each
21 health insurer shall:
                                                                    VT LEG #386171 v.1
 BILL AS INTRODUCED  H.680
 2026  Page 12 of 15
1(i) ensure that the individuals covered by its fully insured plans do
2 not bear a greater financial burden than their fair share of the expenses related
3 to the insurer’s compliance with its obligations under this subsection (g), with
4 a proportional amount borne by individuals covered by noninsured plans
5 administered by the insurer, if any; and
6(ii) for nonprimary care services, adjust reimbursement rates,
7 implement utilization management tools, and take other steps as needed to
8 avoid increasing the health insurer’s total health care spending, to the extent
9 feasible and in accordance with rules and guidance adopted by the program.
10(C) As used in this subdivision (5), “health insurer” has the same
11 meaning as in section 9402 of this title.
12(D) The Agency, in consultation with the Department of Financial
13 Regulation and the Green Mountain Care Board, may adopt rules as
14 appropriate to carry out the purposes of this subdivision (5).
15 Sec. 3. PRIMARY CARE ACCESS REFORM PROGRAM;
16IMPLEMENTATION DATE; REPORTS
17    (a) The Agency of Human Services shall begin operating the primary care
18 access reform program established in Sec. 2 of this act on or before July 1,
19 2027.
20    (b) On or before December 15, 2026, the Agency of Human Services, in
21 coordination with the Green Mountain Care Board, shall report to the House
                                                                    VT LEG #386171 v.1
 BILL AS INTRODUCED  H.680
 2026  Page 13 of 15
1 Committee on Health Care, the Senate Committee on Health and Welfare, and
2 the Health Reform Oversight Committee regarding:
3(1) progress in establishing the primary care access reform program and
4 a timeline for its implementation; and
5(2) options for revenue sources and mechanisms, along with an
6 operational and financial plan, for expanding the program not later than
7 January 1, 2028, to any patient of a participating practice, regardless of type of
8 the individual’s health coverage or coverage status.
9 Sec. 4. VERMONT CLINICIAN LANDSCAPE; SITE-NEUTRAL
10REIMBURSEMENTS; REPORTS
11    On or before January 1, 2027, the Green Mountain Care Board shall report
12 to the House Committee on Health Care and the Senate Committee on Health
13 and Welfare with:
14(1) an updated version of the Board’s 2017 Vermont Clinician
15 Landscape Study report that reflects the current climate among practicing
16 clinicians in Vermont; and
17(2) an updated version of the Board’s previous reporting regarding site-
18 neutral reimbursements pursuant to 2015 Acts and Resolves No. 54, Sec. 23;
19 2016 Acts and Resolves No. 143, Sec. 5; and 2017 Acts and Resolves No. 85,
20 Sec. E.345.1, including the current state of reimbursement differentials based
21 on practice setting and ownership type, along with a description of any
                                                                    VT LEG #386171 v.1
 BILL AS INTRODUCED  H.680
 2026  Page 14 of 15
1 significant efforts that have been implemented since 2017 toward achieving
2 site-neutral reimbursements.
3 Sec. 5. INVESTMENTS IN PRIMARY CARE WORKFORCE
4    The sum of $6,750,000.00 is appropriated from the General Fund to the
5 Department of Health in fiscal year 2027 for investments in the primary care
6 workforce as follows:
7(1) $1,250,000.00 for the first year of implementation of the Maple
8 Mountain Family Medicine Residency Program, a new Teaching Health Center
9 Graduate Medical Education Program that will increase the number of family
10 medicine residents practicing in rural regions of Vermont. It is the intent of the
11 General Assembly to appropriate funds in future fiscal years to allow for full
12 implementation of the Program.
13(2) $500,000.00 for the Medical Student Incentive Scholarship Program
14 at the University of Vermont College of Medicine established pursuant to 18
15 V.S.A. § 33.
16(3) $5,000,000.00 for the Vermont Educational Loan Repayment
17 Program established pursuant to 18 V.S.A. § 32, to be used for loan repayment
18 for physicians licensed pursuant to 26 V.S.A. chapter 23 or 33; naturopathic
19 physicians licensed pursuant to 26 V.S.A. chapter 81; advanced practice
20 registered nurses licensed pursuant to 26 V.S.A. chapter 28, subchapter 2; and
21 physician assistants licensed pursuant to 26 V.S.A. chapter 31, who practice in
                                                                   VT LEG #386171 v.1
 BILL AS INTRODUCED  H.680
 2026  Page 15 of 15
1 primary care, in order to fully fund existing demand for the Program using the
2 number of applicants and the needs demonstrated when additional funding was
3 made available through the American Rescue Plan Act, P. L. No. 117-2. It is
4 the intent of the General Assembly to continue this investment annually until
5 Vermont reaches an adequate supply of primary care clinicians relative to
6 benchmarks.
7 Sec. 6. 2020 Acts and Resolves No. 155, Sec. 7a, as amended by 2021 Acts
8and Resolves No. 74, Sec. E.311.2, is further amended to read:
9    Sec. 7a. SUNSET
10    18 V.S.A. § 33 (medical students; primary care) is repealed on July 1, 2027.
11 [Deleted.]
12 Sec. 7. EFFECTIVE DATES
13    This act shall take effect on passage, except that Sec. 5 (investments in
14 primary care workforce) shall take effect on July 1, 2026.
                                                                   VT LEG #386171 v.1