Vermont Statutes Title 18 Sec. 9418d
Terms Used In Vermont Statutes Title 18 Sec. 9418d
- Amendment: A proposal to alter the text of a pending bill or other measure by striking out some of it, by inserting new language, or both. Before an amendment becomes part of the measure, thelegislature must agree to it.
- contract: means a contract entered into, amended, or renewed between a contracting entity or health plan and a health care provider specifying the rights and responsibilities of the contracting entity and provider for the delivery of health care services to insureds, including primary care health services, preventive health services, chronic care services, and specialty health care services. See
- Contract: A legal written agreement that becomes binding when signed.
- 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
- Department: means the Department of Financial Regulation. See
- following: when used by way of reference to a section of the law shall mean the next preceding or following section. See
- Insured: means any person eligible for health care benefits under a health benefit plan, and includes all of the following terms: enrollee, subscriber, member, insured, dependent, covered individual, and beneficiary. See
- Participating provider: means a health care provider that has a health care contract with a contracting entity and is entitled to reimbursement for health care services rendered to an insured under the health care contract. See
- Person: means any individual, company, corporation, association, partnership, the U. See
- provider: means a person, partnership, or corporation licensed, certified, or otherwise authorized by law to provide professional health care services in this State and shall include a health care provider group, network, independent practice association, or physician hospital organization that is acting exclusively as an administrator on behalf of a health care provider to facilitate the provider's participation in health care contracts. 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
§ 9418d. Contract amendments
(a) A health care contract may be amended by mutual agreement of the parties.
(b) Absent mutual agreement of the parties, a health care contract may be amended only as follows:
(1) The contracting entity shall provide to the participating provider notice of the amendment and the amendment in writing not later than 60 days prior to the effective date of the amendment. The notice shall be conspicuously entitled “Notice of Amendment to Contract” and shall include a summary of the amendment as described in subdivision (4) of this subsection. The notice period may be extended by mutual agreement of the parties.
(2) The participating provider shall have 60 days after receiving the amendment, notice, and summary pursuant to subdivision (1) of this subsection to object, in writing, to the proposed amendment. If the participating provider objects to the amendment and there is no resolution of the objection within 60 days following the contracting entity’s receipt of the written objection, either party may terminate the contract upon written notice of termination provided to the other party. Termination shall become effective in the time period specified in the health care contract. If no termination period is specified in the health care contract, the termination shall become effective 90 days after the notice of termination is provided. The terms of the underlying contract shall remain in effect through the termination period and shall be unaffected by the proposed amendment.
(3) If the participating provider does not object to the amendment in the manner specified in subdivision (2) of this subsection, the amendment shall be effective as specified in the notice described in subdivision (1) of this subsection.
(4) The notice of amendment shall include a summary cover sheet that shall include the following information:
(A) a brief explanation of the amendment;
(B) the date the amendment will become effective;
(C) a notice of right to object in writing to the amendment;
(D) the time frame for objection;
(E) the address to send an objection;
(F) contact information for the person to call to discuss the amendment for further information, or to resolve an objection;
(G) the effect of an objection;
(H) the right to terminate the contract if the objection is not resolved;
(I) the time period for the effective date of any such termination; and
(J) the address to send a notice of termination.
(c) Subsection (b) of this section shall not apply in the following circumstances:
(1) The delay caused by compliance with the 60-day notice period in subdivision (b)(1) of this section could result in imminent harm to an insured.
(2) The amendment of a health care contract is required by a State or federal law, rule, or regulation that includes an effective date for the amendment.
(3) The provider affirmatively accepts the amendment in writing and agrees to an earlier effective date than that specified in the notice required by subdivision (b)(1) of this section.
(4) The participating provider’s payment or compensation is based on the current Medicaid or Medicare physician reimbursement schedule, and the amendment reflects a change in payment or compensation resulting solely from a change in that physician reimbursement schedule.
(5) The amendment is a routine change or update of the health care contract made in response to any addition, deletion, or revision of any service code, procedure code, or reporting code, or a pricing change is made by a third party source. For purposes of this subdivision:
(A) “Service code, procedure code, or reporting code” means the American Medical Association’s Current Procedural Terminology, the American Dental Association’s Current Dental Terminology, the Centers for Medicare and Medicaid Services’ Healthcare Common Procedure Coding System, the World Health Organization’s International Classification of Diseases, or the Drug Topics Red Book average wholesale price; and
(B) “Third party source” means the American Medical Association; the American Society of Anesthesiologists; the American Dental Association; the Centers for Medicare and Medicaid Services; the National Center for Health Statistics; the U.S. Department of Health and Human Services Office of the Inspector General; the Vermont Department of Financial Regulation; or the Vermont Agency of Human Services.
(d) Notwithstanding subsections (a), (b), and (c) of this section, a health care contract may be amended by operation of law as required by any applicable state or federal law, rule, or regulation.
(e) Subsection (b) of this section shall not apply to amendments of health care contracts with hospitals. (Added 2009, No. 61, § 33.)