Vermont Statutes Title 18 Sec. 9418g
Terms Used In Vermont Statutes Title 18 Sec. 9418g
- Commissioner: means the Commissioner of Financial Regulation or the Commissioner's designee. See
- Contracting entity: means any entity that contracts directly or indirectly with a health care provider for either the delivery of health care services or the selling, leasing, renting, assigning, or granting of access to a contract or terms of a contract. See
- Covered entity: means an organization that enters into a contract with a contracting entity to gain access to a provider network contract. See
- following: when used by way of reference to a section of the law shall mean the next preceding or following section. See
- Health care facility: means all institutions, whether public or private, proprietary or nonprofit, which offer diagnosis, treatment, inpatient, or ambulatory care to two or more unrelated persons, and the buildings in which those services are offered. See
- Health care provider: means a person, partnership, or corporation, other than a facility or institution, licensed or certified or authorized by law to provide professional health care service in this State to an individual during that individual's medical care, treatment, or confinement. See
- Health plan: means a health insurer, disability insurer, health maintenance organization, medical or hospital service corporation, and, to the extent permitted under federal law, any administrator of an insured or self-insured plan. See
- Jurisdiction: (1) The legal authority of a court to hear and decide a case. Concurrent jurisdiction exists when two courts have simultaneous responsibility for the same case. (2) The geographic area over which the court has authority to decide cases.
- Payer: means any person or entity that assumes the financial risk for the payment of claims under a health care contract or the reimbursement for health care services rendered to an insured by a participating provider under the health care contract. See
- State: when applied to the different parts of the United States may apply to the District of Columbia and any territory and the Commonwealth of Puerto Rico. See
§ 9418g. Enforcement
In addition to any other remedy provided by law, the Commissioner may, in the Commissioner’s sole discretion, enforce the provisions of this subchapter as specified in this section. In determining whether to undertake an enforcement action, the Commissioner may consider the relative resources of the complaining party and the alleged noncompliant party, the Commissioner’s other enforcement responsibilities, and such other factors as the Commissioner deems appropriate.
(1) The Commissioner shall have the power to examine and investigate any health plan, contracting entity, covered entity, or payer to determine if the health plan, contracting entity, covered entity, or payer has violated the provisions of this subchapter, or any rules or order of the Commissioner adopted or issued pursuant to this subchapter.
(2) If the Commissioner finds that a health plan, contracting entity, covered entity, or payer has violated this subchapter, or any rules or order of the Commissioner adopted or issued pursuant to this subchapter, the Commissioner may order the health plan, contracting entity, covered entity, or payer to cease and desist from further violations and may order the health plan, contracting entity, covered entity, or payer to remediate the violation.
(3) If the Commissioner finds that a health plan, contracting entity, covered entity, or payer has violated this subchapter or any rules or order of the Commissioner adopted or issued pursuant to this subchapter, the Commissioner may impose an administrative penalty against the health plan, contracting entity, covered entity, or payer of not more than $1,000.00 for each violation and not more than $10,000.00 for each willful violation. In determining the amount of the penalty to be assessed, the Commissioner shall consider the following factors:
(A) the appropriateness of the penalty with respect to the financial resources and good faith of the health plan, contracting entity, covered entity, or payer;
(B) the gravity of the violation or practice;
(C) the history of previous violations or practices of a similar nature;
(D) the economic benefit derived by the health plan, contracting entity, covered entity, or payer and the economic impact on the health care facility or health care provider resulting from the violation; and
(E) any other relevant factors.
(4) Any dispute arising out of or relating to the provisions of this subchapter shall, at the option of either party, be settled by arbitration in accordance with the commercial rules of the American Arbitration Association or the rules or procedures of another mutually agreed upon alternative dispute resolution forum, such as the American Health Lawyers Association. Judgment upon the arbitrator’s award may be entered in any court having jurisdiction, and the arbitrator’s award shall be binding on both parties.
(5) Nothing in this subchapter shall be construed to prohibit a health plan, contracting entity, covered entity, or payer from applying payment policies that are consistent with applicable federal or State laws and regulations, or to relieve a health plan, contracting entity, covered entity, or payer from complying with payment standards established by federal or State laws and regulations, including rules adopted by the Commissioner. (Added 2009, No. 61, § 36; amended 2023, No. 6, § 236, eff. July 1, 2023.)