Act No. 150 (S.200). Health; health insurers; reporting requirements; pharmacies; pharmacy audits; ambulance services

An act relating to pharmacy audits, reimbursement for ambulance services, and the reporting requirements of health insurers

Health insurer reporting requirements

This act requires each health insurer covering at least 2,000 Vermont lives or offering insurance through the Vermont Health Benefit Exchange (Exchange) to report the information described below to the commissioner of financial regulation annually as an addendum to the insurer's annual statement:

· State of domicile and number of states in which the insurer operates

· Number of Vermont lives covered by the insurer

· Number of claims submitted to the insurer

· Number of claims denied by the insurer

· Number of denials of service by the insurer at the preauthorization level and number of adverse benefit determinations made by the insurer, including for each:

o Number appealed and overturned at the first-level grievance

o Number appealed and overturned at any second-level grievance

o Number appealed and overturned where an external review was sought

· Number of claims denied by the insurer because the service was experimental or investigational, was subject to preexisting condition exclusions, involved an off-label use of a drug, or was not medically necessary, or because access to a provider was inconsistent with the plan's limitations

· Number of claims denied by the insurer as duplicate claims, coding errors, or for services or providers not covered

· Titles and salaries, bonuses, and compensatory benefits of all corporate officers or board members

· Insurer's marketing and advertising expenses

· Insurer's federal and Vermont-specific lobbying expenses

· Amount and recipient of the insurer's political contributions

· Amount and recipient of dues paid by the insurer to trade groups involved in lobbying efforts or that make political contributions

· Insurer's legal expenses related to denials for claims or services

· Amount and recipient of the insurer's charitable contributions

The act requires the department of financial regulation (DFR) to create a standardized form for the reporting of the information described above. Insurers must report Vermont-specific information on the form and indicate if any reported information is not specific to Vermont. The act requires DFR to post insurers' completed forms on its website and the department of Vermont health access to post a links to the forms on the Exchange website.

The act requires DFR to convene a working group to study the accessibility and comprehensibility of the health insurers' filings. It directs the working group to make recommendations for improving the format, content, accessibility, and delivery of filings required of health insurers in a manner that enhances informed consumer decision-making. The working group must submit its finding and recommendations, including suggested administrative and legislative actions, to the committees of jurisdiction by January 15, 2014.

Pharmacy audits

The act enumerates the rights of pharmacies when their claims are audited by a pharmacy benefit manager or a health insurer other than Medicaid or other public health care assistance program, including the right to:

· Have an audit involving clinical or professional judgment be conducted by a licensed pharmacist who has familiarity with Vermont's pharmacy laws

· Receive at least 14 days' written notice before an on-site audit and to receive a list of the prescriptions to be audited

· Not be audited on Mondays or on weeks containing a federal holiday

· Not be audited on claims more than 18 months old or on more than 200 selected prescription claims

· Not have clerical or recordkeeping errors deemed fraudulent in the absence of financial harm or other evidence

· Use any prescription that meets the requirements of Vermont law, including those with prescriber notations such as "as directed" and "as needed," to validate claims

· Dispense and be reimbursed for the full quantity of the smallest available commercially packaged product containing the amount necessary to meet the prescriber's orders, even if the amount in the packaged product exceeds the maximum days' supply allowed

· Have recoupment limited to amounts paid in excess of amounts payable under a corrected claim

· Not have demands for recoupment or repayment include the dispensing fee unless the prescription was not actually dispensed, was not valid, was fraudulent, or was outside the provisions of the contract

· Not have demands for recoupment or repayment made due to information missing from a prescription or not in the right location if the information or location is not required by state or federal law

· Not have the accounting practice of extrapolation used in calculating recoupments or penalties

· Have preliminary and final reports delivered within specified time lines

· Not be subject to more than one audit per calendar year, except in certain circumstances

The act provides pharmacies with appeal rights and places limitations on the amounts pharmacies must repay except in cases of fraud or misrepresentation. It specifies that the pharmacy audit provisions do not apply to audits conducted by state agencies or to any audit or investigation involving Medicaid fraud, waste, or abuse; insurance fraud; or criminal fraud or misrepresentation.

Reimbursement for ambulance service providers

The act requires health insurers to reimburse ambulance service providers directly for emergency medical treatment provided to a person insured under the insurer's plan. It specifies that the direct reimbursement requirement is not intended to interfere with coordination of benefits or to require a health insurer to provide coverage for services not otherwise included under the plan, and that it does not preclude an insurer from entering into a contract with a nonparticipating ambulance service to establish reimbursement rates for emergency medical treatment.

Multiple effective dates, beginning on July 1, 2012