§ 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 which 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.)