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NEED TO KNOW
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Vermont Legislature Returns to Montpelier Tomorrow – VMS Advocacy Webinar this Thurs 7:30am
The VMS Policy team is excited for the start of the new legislative session, which starts on Wednesday January 8th. The 2024 election brought turnover to both the House and the Senate, with roughly 45 new House members and 7 new Senators and all new Committees and new leadership in both chambers. The majority leader in the House is Lori Houghton, former chair of the House Health Care Committee, and the majority leader in the Senate is Kesha Ram Hinsdale, former chair of the Senate Economic Development Committee. Tomorrow will begin with a fractious vote on the House Speaker's race, in which Rep. Laura Sibilia, I-Dover is challenging longtime House Speaker Jill Krowinski, D-Burlington. There is also a late-breaking challenge for the Senate President role as Sen. Randy Brock, R-Franklin, will go up against the incumbent Senator Phil Baruth, D-Chittenden North. After that the Senate will vote to confirm former Senator John Rodgers as the new Lt. Governor. We are looking forward to a lot of changes and are asking lawmakers to support the VMS 2025 Policy Priorities.
Please join us in 2025 to meet your lawmakers during the VMS Advocacy Breakfasts. These breakfasts, which will be held in the cafeteria at the Vermont Statehouse in Montpelier are an informal opportunity to educate lawmakers on ways to improve Vermont's practice environment and health care system. You don’t need any prior advocacy experience to join! Each breakfast starts on specific Wednesday at 8-9:30AM. The first all specialty/VMS breakfast kicks off on January 15th. Register here.
We will also be hosting an Intro to Advocacy and legislative breakfast logistics webinar Thursday, January 9th from 7:30-8am. The webinar will also be recorded for those who can’t join live. Join the Zoom link on the 9th here.
Please reach out to Jill Sudhoff-Guerin at jsudhoffguerin@vtmd.org if you have any questions and be sure to register to receive important logistics and policy updates before your breakfast. |
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Act 111 Prior Authorization Reductions Effective 1/1/25
Many crucial provisions of Act 111 that reduce prior authorization went into effect on January 1st. In summary, as of January 1, 2025, the new law requires that state-regulated commercial health plans:
- Waive prior authorization for Blueprint for Health-participating primary care providers;
- Provide additional notice of policy changes;
- Put in place an exception process for step therapy protocols;
- Approve urgent prior authorization requests within 24 hours; and
- Honor approved prior authorizations for at least one year; or for a treatment, service, or course of medication that continues for more than one year, the plan cannot require renewal of prior authorization approval more often than once every five years.
The Vermont Department of Financial Regulation (DFR) posted an FAQ guidance document regarding the new law on December 20th. The guidance clarifies topics like who qualifies for the prior authorization waiver; how clinicians will know that the Act 111 prior authorization waives apply to a patient’s health plan; how billing providers should bill claims exempt from prior authorization; and what supporting documentation is needed for a step therapy protocol override determination. Health plans are also posting guidance for providers – information from BCBSVT can be found here and here.
As the provisions go into effect and practices incorporate the changes into workflows, please reach out to Jessa Barnard at VMS at jbarnard@vtmd.org with questions or concerns. VMS continues to meet regularly with payers, provider organizations and DFR regarding implementation and we want to know how it’s working for your practice. VMS also continues to work with lawmakers regarding expanding the prior authorization exemption to all primary care providers, not just those who participate in the Blueprint for Health. |
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State Approaching Decision Point on Joining AHEAD Model – VMS Submits Comments
The few weeks before the holidays were a busy time for the Agency of Human Services and Green Mountain Care Board in negotiating details of Vermont’s participation with Medicare in the AHEAD payment reform model. As reported in the December 24th Rounds, the State has now released a 2-page summary term sheet as well as a full draft agreement with CMS. The following slides from the AHS Health Care Reform Workgroup also provide important summary information about what it would mean for the State to participate in the Model. If Vermont is able to keep to negotiated Medicare cost trends, it could bring in an additional $138.9 million in Medicare dollars to the state in 2026 to reinvest in broader population health goals such as access to primary care and availability of services across the continuum of care. In addition, Medicare will continue to contribute $10.9 million to Blueprint Community Health Team Payments and the Supports and Services at Home program. Under new Enhanced Primary Care Payments, primary care practices could receive approximately $17 per Medicare beneficiary per month. A major component of the model is hospital global budgets. At first the state would use a federal hospital global budget methodology, potentially transitioning to a state-based methodology going forward. Open questions include how hospitals will fare under the global budget methodology and the state resources necessary to implement hospital global budgets.
The Agreement must be signed by the Governor, AHS and the Green Mountain Care Board. The Green Mountain Care Board was seeking public comments on joining the model by January 3rd and plans to make a decision regarding signing the agreement next week. They have public meetings scheduled starting at 1pm on Wednesday, January 8th and January 15th. Comments submitted by VMS on January 3rd can be found here. |
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Compliance Reminder: Reproductive Health Care Data Sharing Rules Took Effect December 23rd
In the last year, there have been important changes to how reproductive and gender affirming care data can be used, designed to protect patient privacy and preserve the ability of providers to deliver care. The compliance date for one of these changes, the HIPAA Privacy Rule Final Rule to Support Reproductive Health Care Privacy, was December 23rd. VITL offers resources to help your organization navigate these changes, including a recorded webinar and guidance documents produced by John Wallace at Primmer Piper Eggleston & Cramer.
- Watch the webinar here
- View the webinar slides
- Read a comparison of the Vermont Shield Law and the HIPAA Final Rule here
- Read guidance for responding to requests for records potentially related to reproductive health care here
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MISC.
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Reminder: Telehealth Coding Changes for 2025
VMS has received a number of questions about telehealth coverage for 2025.
Some things are not changing:
- Vermont’s coverage and payment parity laws (8 V.S.A. § 4100k; 8 V.S.A. § 4100l) that require state-regulated commercial plans to cover and provide reimbursement at parity for telehealth and audio-only services are still in place – BCBSVT and MVP are still paying for telehealth and audio-only services.
- Medicaid coverage for audio-only and audio-visual telehealth services is ongoing and will not be changing for 2025.
- Medicare coverage is continuing at least through March 31, 2025 . Absent action from Congress, Medicare’s telehealth coverage flexibilities were scheduled to end on January 1, 2025, ending most coverage for audio-only services and the ability to provide telehealth when a patient is located in their home vs a medical facility. Just before the holidays, Congress passed continuing funding through March 31, 2025, which included extending Medicare telehealth flexibilities for 90 days. See further description here.
What is changing:
- The AMA has created new codes for telehealth services – this means that many plans (commercial and Medicaid) are changing coding – while coverage is not ending.
- In particular, the 2025 Medicare physician fee schedule approved using new telehealth-specific E/M codes (CPT codes 98000-98016) to replace telephone only codes 99441-99443 and in-person E/M codes used with modifiers. See additional details here regarding how Vermont Medicaid, BlueCross BlueShield Vermont and MVP are adopting these changes.
- Adding to the confusion, even though these new codes are described in the Medicare fee schedule, Medicare itself has not adopted these new codes and will continue to utilize existing office/outpatient E/M codes (99202-99215) with appropriate POS code to identify the location of the beneficiary and, when applicable, the appropriate modifier to identify the service as being furnished via audio-only communication technology. Medicare will pay separately for new CPT code 98016 in lieu of HCPCS G2012 (Brief communication technology-based service/virtual check-in). They have promised additional educational materials on Medicare coding in 2025.
Contact jbarnard@vtmd.org for more information. |
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New in 2025: $2,000 Out-of-Pocket Prescription Drug Cost Cap in Medicare Part D
This year, people with Original Medicare Part D prescription drug coverage will benefit from a new $2,000 out-of-pocket cap on prescription drug costs. The new out-of-pocket cap was passed in the Inflation Reduction Act, along with a number of other ways to reduce prescription drug costs for those on Medicare, including:
- Beginning in 2025, the option to pay out-of-pocket prescription drug costs in monthly installment payments instead of all at once, allowing for smaller, more predictable payments for high cost drugs;
- Enrollees pay no more than $35 for a month’s supply of each covered insulin product, beginning in 2023; and
- Lower prices in 2026 for 10 selected drugs through Medicare negotiations with participating drug companies.
With the $2,000 cap in effect this year, 19 million seniors, and others on Medicare, are expected to save an additional $7.4 billion in out-of-pocket costs. Learn more about the Inflation Reduction Act provisions to improve drug coverage for those on Medicare at: https://www.hhs.gov/inflation-reduction-act/index.html. |
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Health Care Providers for Blue Plan Patients Eligible for Share of $2.8 Billion Settlement
A landmark $2.8 billion settlement was reached in December with the Blue Cross Blue Shield Association (“BCBSA”) and participating Individual Blue Plans, including Blue Cross Blue Shield of Vermont (“Settling Defendants”). The settlement resolves claims brought by healthcare providers alleging anti-competitive practices, including agreements to divide geographic service areas and price-fixing for healthcare services. The Settling Defendants deny these allegations but have agreed to the settlement to avoid prolonged litigation.
Who Is Included in the Settlement Class?
The Settlement Class includes healthcare providers across the United States who, between July 24, 2008, and October 4, 2024, provided services, equipment, or supplies to patients insured by, or beneficiaries of, any plan administered by a Settling Individual Blue Plan. Certain providers are excluded; details on exclusions are available at the website below.
Settlement Highlights
- $2.8 Billion Settlement Fund: A fund will be established, with $100 million allocated for notice and administration costs.
- Business Practice Reforms: The settlement includes commitments to changes that will:
- Increase competition in the healthcare marketplace.
- Transform the BlueCard program.
- Improve provider interactions with Settling Individual Blue Plans.
Important Deadlines for Eligible Providers
- Claim Submission Deadline: Submit a claim form online or by mail no later than July 29, 2025.
- Exclusion Deadline: Eligible providers that want to sue the Settling Defendants must exclude themselves from the Class by March 4, 2025.
- Objection Deadline: File objections to the settlement by March 4, 2025.
- Fairness Hearing: The Court will decide whether to approve the Settlement at a hearing on July 29, 2025, at 9:30 a.m. The hearing will also address attorneys’ fees (up to 25% of the Settlement Fund) and expense reimbursements of approximately $100 million.
Where to Get More Information
For further details about the Settlement, deadlines, and eligibility, visit the settlement website: www.BCBSprovidersettlement.com, law firm updates at https://whatleykallas.com/bcbs-settlement/ or join upcoming webinars:
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New Clinician Wellbeing Workshops Available at No Cost for 2025
VMS is pleased to continue our partnership with Doug Wysockey-Johnson of Lumunos Clinician Well-Being Services to provide up to 9 practices/medical staffs no-cost clinician wellbeing workshops over 2025.
Lumunos Clinician Well-Being Workshops are designed to support clinicians in meeting the demands of modern health care. Workshops are built around Lumunos’ daily experience working with physicians, nurses, APPs and clinical leaders across the country. These meetings are designed to be efficient, effective and interactive, with topics that directly address the biggest challenges clinicians face daily. Workshops are led by Doug Wysockey-Johnson, Workplace Program Facilitator of Lumunos, a seasoned facilitator with 20 years of experience leading clinician groups
New topics available for 2025 include: Creating a Positive Team Culture; Work/Home Boundaries; Hope; and Compassion (Fatigue). Click here for more details and to see the full list of available topics. Contact Jessa at jbarnard@vtmd.org or Doug at doug@lumunos.org with additional questions or to book a workshop. |
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Change to Vermont Medicaid/Gainwell Provider Relations Representatives Coverage
Effective January 1, 2025, the assignment of Vermont Medicaid/Gainwell Provider Relations Representatives will transition from being based on county to being based on provider type. This adjustment will align Provider Representatives with specific provider types, ensuring that all active providers within a given type are supported by a designated representative.
Physicians, PAs and hospitals are all now represented by Emma Rapp, available at emma.rapp@gainwelltechnologies.com or 802-800-2527.
For more information, view the Provider Representative Map located at https://vtmedicaid.com/assets/resources/ProviderRepMap.pdf or email vtproviderreps@gainwelltechnologies.com. |
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2025 Loan Repayment Program Application Open
The 2025 Vermont Educational Loan Repayment (Recruitment/Retention) Program for Physicians, Nurse Practitioners, & Physician Assistants application is now available.
Application and corresponding documents can be found here.
The 2025 application deadline is Tuesday, February 4, 2025. |
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Vermont Health Connect Open Enrollment Ends Jan 15
January 15 is the last day for Vermonters to enroll or make changes to get health coverage. What does this mean? [1] Any eligible Vermonter can enroll with Vermont Health Connect for the coming year, or [2] Any existing Vermont Health Connect customer can change plans if they find a new plan that better fits their needs. Vermonters should use the Plan Comparison Tool to shop and compare plans, as well as see what amount of financial help they are eligible for.
Vermonters can get more financial help in 2025 and can apply it to any plan. This year Gold plans will cost less than Silver plans through Vermont Health Connect. Depending on a household’s budget, individuals and families may find more value with a Gold plan, such as lower out-of-pocket expenses.
Key links:
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Federal Health Care Advocacy in 2025 – AMA Webinar Jan. 22
Change is once again in the air for Washington with the 2024 elections marking the sixth consecutive "change election." Both the US Senate and White House will flip to Republican control in 2025. Democrats had a net gain of 1 seat in the House, but that wasn't enough for them to retake the majority in that chamber.
Please join the AMA at 8pm ET on January 22
These changes in party control aren't the only aspects of the 119th Congress that are noteworthy. Within each chamber of Congress, additional seeds of change have been planted, with more to come. Could other changes jolt the makeup of Congress in 2025? Who will wield more influence in the 119th Congress? And what does this all mean for health policy?
This AMA educational session will explore the fluid Congressional landscape, the effect it will have on health care policy in the new Congress, and how you can be an effective advocate in 2025 and beyond. Register now to reserve your spot. |
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Next Commissioner Call, February 6, 2025
The Commissioner of Health, Mark Levine, MD, will hold his next Public Health Update with VMS Members this Thursday, February 6th at 12:30 pm. You can join the zoom meetings here.
He held his most recent VMS member call on January 2nd. Notes from the call are here. |
EVENTS
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Contemporary Issues in Health Care Ethics: A 4 Part Series
January 2025, 12pm - 1:15pm
AI in Healthcare: Legal and Ethical Challenges January 9th - Register here.
How Health Care Can Outgrow Bias January 14th - Register here
Critical Issues in the Care of Older Adults with Cognitive Impairment January 21st - Register here
Incapacitated Refusals & Vermont's Ulysses Clause January 30th - Register here
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42nd PAAV Annual Winter CME Conference
January 30th - February 2nd, 2025
The annual winter PA Academy of Vermont Conference is at Stoweflake in Stowe, VT 1/30/25 -2/2/25
Please come join the fun and get CME too!
VMS President, Dr. Katie Marvin speaking on Saturday!
The early bird rate is extended through 12/13/24. (save $100)
Learn more and register here.
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Learning Collaboratives on In-Basket Reduction and Reducing Regulatory Burden
October 2024 – March 2025
AMA STEPS Forward® Innovation Academy is launching two new, six-month learning collaboratives on optimizing the in-basket to reduce work burden and rethinking how organizations apply regulatory rules to clinical practice. Each collaborative will convene dyads or triads of leadership representatives from multiple organizations to engage in a longitudinal shared learning experience. Limited space available. Learn more.
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For more information about offerings from UVM
CMIE, visit here. |
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Vermont Medical Society 134 Main Street Montpelier, VT 05602 -- Unsubscribe -- |
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