Vermont S 190: An act relating to reference-based pricing and the Green Mountain Care Board

Bill Text

BILLAS INTRODUCED AND PASSED BY SENATE AND HOUSE S.190
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S.190
Introduced by Senator Lyons
Referred to Committee on Health and Welfare
Date: January 6, 2026
Subject: Health; health care reform; Green Mountain Care Board; hospitals;
health insurance; reference-based pricing; provider taxes
Statement of purpose of bill as introduced: This bill proposes to set certain
requirements for hospitals and health insurers to meet in order to facilitate the
Green Mountain Care Board’s implementation of reference-based pricing. The
bill would establish regulatory oversight of hospitals’ use of outsourcing
contracts for clinical services. The bill would repeal authorizing language for
health care provider bargaining groups, clarify procedures for appealing Green
Mountain Care Board decisions and orders, and allow the Board to conduct
examinations and investigations of hospitals, including audits, as part of its
hospital budget reviews. The bill would also direct the Green Mountain Care
Board to develop an interactive health system performance tool if the State
receives the funding necessary to support the project.
An act relating to the Green Mountain Care Board, reference-based pricing,
and hospital outsourcing of clinical care
An act relating to the Green Mountain Care Board, reference-based pricing,
and studying the creation of a Public Employee Health Benefit Authority
An act relating to reference-based pricing and the Green Mountain Care
Board
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BILLAS INTRODUCED AND PASSED BY SENATE AND HOUSE S.190
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It is hereby enacted by the General Assembly of the State of Vermont:
* * * Reference-Based Pricing * * *
Sec. 1. 18 V.S.A. § 9376(e) is amended to read:
(e) Reference-based pricing.
* * *
(3)(A) The Board shall begin implementing reference-based pricing as
soon as practicable but not later than hospital fiscal year 2027 by establishing
the maximum amounts that Vermont hospitals shall accept as payment in full
for items provided and services delivered. After initial implementation, the
Board shall review the reference-based prices for each hospital annually as part
of the hospital budget review process set forth in chapter 221, subchapter 7 of
this title.
(B) The Board, in collaboration with the Department of Financial
Regulation, shall monitor the implementation of reference-based pricing to
ensure that any decreases in amounts paid to hospitals also result in decreases
in health insurance premiums. The Board shall post its findings regarding the
alignment between price decreases and premium decreases annually on its
website.
(C) For provider contracts entered into on or after October 1, 2026,
each hospital and health insurer shall express the rates for all items and
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BILLAS INTRODUCED AND PASSED BY SENATE AND HOUSE S.190
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services as a percentage of Medicare or of another benchmark, if another
benchmark is deemed appropriate by the Green Mountain Care Board.
(D)(i) Each hospital shall apply for, obtain, and use a unique
National Provider Identifier (NPI) on all claims filed after October 1, 2026, for
reimbursement or payment of items provided and services delivered at an off-
campus department of the hospital that is distinct from the NPI used for
services delivered at the main hospital campus or at any other off-campus
hospital department.
(ii) As used in this subdivision (D):
(I) “Campus” has the same meaning as in 42 C.F.R. § 413.65.
(II) “Off-campus” means a facility located more than 250 yards
from the main hospital campus.
(E) When making public the charges for items and services pursuant
to 45 C.F.R. Part 180, each hospital shall include in its machine-readable files
pricing information shown as a percentage of Medicare rates, as well as in
dollars and cents, disaggregated by payer and by plan.
(F) The Board shall establish a default percentage of Medicare above
which a hospital shall not accept payment for an item or service under any
newly established Current Procedural Terminology (CPT) code unless and
until the Board establishes a specific reference-based price for the item or
service pursuant to this chapter.
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(G) The Board shall establish a default maximum percentage of
Medicare above which a hospital shall not accept payment for any individual
inpatient or outpatient item or service.
* * *
* * * Hospital Outsourcing * * *
Sec. 2. HOSPITALOUTSOURCING; FINDINGS; PURPOSE
(a) The General Assembly finds that:
(1) Hospitals are increasingly outsourcing their clinical services, such as
emergency medicine, anesthesiology, radiology, laboratory services, and other
specialized care, to outside entities.
(2) Revenue from outsourced clinical services is not consistently
reported in the hospital budget process and has been excluded from the Green