§ 1825. Health benefits
(a)(1) Green Mountain Care shall include primary care, preventive care, chronic care, acute
episodic care, and hospital services and shall include at least the same covered services
as those included in the benefit package in effect for the lowest cost Catamount Health
plan offered on January 1, 2011.
(2) It is the intent of the General Assembly that Green Mountain Care provide a level
of coverage that includes benefits that are actuarially equivalent to at least 87
percent of the full actuarial value of the covered health services.
(3) The Green Mountain Care Board shall consider whether to impose cost-sharing requirements;
if so, whether to make the cost-sharing requirements income-sensitized; and the impact
of any cost-sharing requirements on an individual’s ability to access care. The Board
shall consider waiving any cost-sharing requirement for evidence-based primary and
preventive care; for palliative care; and for chronic care for individuals participating
in chronic care management and, where circumstances warrant, for individuals with
chronic conditions who are not participating in a chronic care management program.
(4)(A) The Green Mountain Care Board established in 18 V.S.A. chapter 220 shall consider
whether to include dental, vision, and hearing benefits in the Green Mountain Care
benefit package.
(B) The Green Mountain Care Board shall consider whether to include long-term care benefits
in the Green Mountain Care benefit package.
(5) Green Mountain Care shall not limit coverage of preexisting conditions.
(6) The Green Mountain Care Board shall approve the benefit package and present it to
the General Assembly as part of its recommendations for the Green Mountain Care budget.
(b)(1)(A) For individuals eligible for Medicaid or CHIP, the benefit package shall include the
benefits required by federal law, as well as any additional benefits provided as part
of the Green Mountain Care benefit package.
(B) Upon implementation of Green Mountain Care, the benefit package for individuals eligible
for Medicaid or CHIP shall also include any optional Medicaid benefits pursuant to
42 U.S.C. § 1396d or services covered under the State plan for CHIP as provided in 42 U.S.C. § 1397cc for which these individuals are eligible on January 1, 2014. Beginning with the second
year of Green Mountain Care and going forward, the Green Mountain Care Board may,
consistent with federal law, modify these optional benefits, as long as at all times
the benefit package for these individuals contains at least the benefits described
in subdivision (A) of this subdivision (b)(1).
(2) For children eligible for benefits paid for with Medicaid funds, the benefit package
shall include early and periodic screening, diagnosis, and treatment services as defined
under federal law.
(3) For individuals eligible for Medicare, the benefit package shall include the benefits
provided to these individuals under federal law, as well as any additional benefits
provided as part of the Green Mountain Care benefit package. (Added 2011, No. 48, § 4.)