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Subchapter 001: GENERAL PROVISIONS
§ 4011. Definitions
As used in this chapter:
(1) “Covered individual” means an individual who is covered by a health insurance plan,
whether as the primary subscriber or policyholder or as a dependent, employee, or
employee’s dependent under the plan.
(2) “Health care services” means services for the diagnosis, prevention, treatment, cure,
or relief of a health condition, illness, injury, or disease.
(3) “Health insurance plan” means a policy or contract issued by a health insurer, including
the health benefit plan or plans offered by the State of Vermont to its employees
and any health benefit plan offered by any agency or instrumentality of the State
to its employees. Unless otherwise specified, “health insurance” does not include
Vermont Medicaid.
(4) “Health insurer” means an insurance company that provides health insurance as defined
in subdivision 3301(a)(2) of this title, a nonprofit hospital or medical service corporation, a managed care organization,
a health maintenance organization, and, to the extent permitted under federal law,
any administrator of an insured, self-insured, or publicly funded health care benefit
plan offered by a public or private entity.
(5) “Major medical insurance” means a comprehensive health insurance plan that is not
specific disease, accident, hospital indemnity, dental care, vision care, disability
income, long-term care, Medicare supplement insurance, or other limited-benefit coverage.
The term does not include short-term, limited-duration health insurance coverage or
a plan under which benefits are paid directly to a covered individual or the individual’s
assigns and for which the amount of the benefit is not based on potential medical
costs or on actual costs incurred. (Recodified and amended 2025, No. 11, § 2, eff. September 1, 2025.)
§ 4012. Compliance with federal law
(a) Except as otherwise provided in this title, health insurers, hospital and medical
service corporations, and health maintenance organizations that issue, sell, renew,
or offer health insurance plans in Vermont shall comply with the requirements of the
Health Insurance Portability and Accountability Act of 1996, as amended from time
to time (42 U.S.C. Chapter 6A, Subchapter XXV), and the Patient Protection and Affordable
Care Act of 2010, Pub. L. No. 111-148, as amended by the Health Care and Education Reconciliation Act of 2010, Pub. L. No. 111-152. The Commissioner shall enforce such requirements pursuant to the Commissioner’s
authority under this title.
(b)(1) Health insurers, hospital and medical service corporations, health maintenance organizations,
and health care providers, as that term is defined in 18 V.S.A. § 9432, shall comply with the requirements of the No Surprises Act, Pub. L. No. 116-260, Division BB, Title I, as amended from time to time.
(2) The Commissioner shall enforce the requirements of the No Surprises Act as they apply
to health insurers, hospital and medical service corporations, health maintenance
organizations, and health care providers, to the extent permitted under federal law,
pursuant to the Commissioner’s authority under this title. The Commissioner may also
refer cases of noncompliance to the U.S. Department of Health and Human Services under
the terms of a collaborative enforcement agreement, or to the Office of the Vermont
Attorney General. (Recodified and amended 2025, No. 11, § 2, eff. September 1, 2025.)
§ 4013. Discrimination prohibited
No health insurer shall make or permit any unfair discrimination between individuals
of substantially the same hazard in the amount of premium rates charged for any health
insurance plan or in the benefits payable under the plan; provided, however, that
this section shall not be construed to prohibit different premium rates, different
benefits, or different underwriting procedure for individuals insured under group,
family expense, or blanket plans of insurance. (Recodified and amended 2025, No. 11, § 2, eff. September 1, 2025.)
§ 4014. Advertising practices
(a) No company doing business in this State, and no insurance agent or broker, shall use
in connection with the solicitation of health insurance or pharmacy benefit management
any advertising copy or advertising practice or any plan of solicitation that is materially
misleading or deceptive. An advertising copy or advertising practice or plan of solicitation
shall be considered to be materially misleading or deceptive if by implication or
otherwise it transmits information in such manner or of such substance that a prospective
applicant for health insurance may be misled by it to the applicant’s material damage.
(b)(1) If the Commissioner finds that any such advertising copy or advertising practice or
plan of solicitation is materially misleading or deceptive, the Commissioner shall
order the company or the agent or broker using such copy or practice or plan to cease
and desist from such use.
(2) Before making any such finding and order, the Commissioner shall give notice, not
less than 10 days in advance, and a hearing to the company, agent, or broker affected.
(3) If the Commissioner finds, after due notice and hearing, that any authorized insurer,
licensed pharmacy benefit manager, licensed insurance agent, or licensed insurance
broker has intentionally violated any such order to cease and desist, the Commissioner
may suspend or revoke the license of such insurer, pharmacy benefit manager, agent,
or broker. (Recodified 2025, No. 11, § 2, eff. September 1, 2025.)
§ 4015. Penalties for violations
The Commissioner may impose an administrative penalty of up to $750.00 on any person
who intentionally violates any provision of this chapter or any order of the Commissioner
made in accordance with this chapter. The Commissioner may also suspend or revoke
the license of a health insurer or agent for any such intentional violation. (Recodified and amended 2025, No. 11, § 2, eff. September 1, 2025.)
§ 4016. Appeal
(a) Any person aggrieved by any action of the Commissioner may obtain a review by appeal
to the Superior Court of Washington County. The appeal shall be based on the record
of the proceedings before the Commissioner and shall not be limited to questions of
law. If the appeal is from an order of the Commissioner, the order shall not take
effect during the pendency of the appeal unless the court determines otherwise.
(b) The court may review all the facts and in disposing of any issue before it may modify,
affirm, or reverse any order of the Commissioner in whole or in part.
(c) Either party may appeal from the decision of the Superior Court to the Supreme Court
in the manner provided by law. (Recodified and amended 2025, No. 11, § 2, eff. September 1, 2025.)
§ 4017. Exemption from attachment and trustee process
So much of any benefits under all policies of health insurance as does not exceed
$200.00 for each month during any period of disability covered by the policy shall
not be liable to attachment, trustee process, or other process, or to be seized, taken,
appropriated, or applied by any legal or equitable process or by operation of law,
either before or after payment of such benefits, to pay any debt or liabilities of
the person insured under the policy. However, this exemption shall not apply where
an action is brought to recover for necessaries contracted for during the period of
disability and the writ or bill of complaint contains a statement to that effect.
When a policy provides for a lump sum payment because of a dismemberment or other
loss insured, the payment shall be exempt from execution of the covered individual’s
creditors. (Recodified and amended 2025, No. 11, § 2, eff. September 1, 2025.)
§ 4018. Third-party ownership
Nothing in this chapter shall be construed as preventing a person other than the covered
individual with proper insurable interest from making application for and owning a
policy covering the covered individual or from being entitled under such a policy
to any indemnities, benefits, and rights provided in the policy. (Recodified and amended 2025, No. 11, § 2, eff. September 1, 2025.)
§ 4019. Notice as waiver
A health insurer shall not be deemed to have waived any rights to defend a claim under
a health insurance plan based solely on the health insurer’s acknowledgement of receipt
of notice under the plan, furnishing or accepting forms for filing proof of loss under
the plan, or investigating any claim of loss under the plan. (Recodified and amended 2025, No. 11, § 2, eff. September 1, 2025.)
§ 4020. Age limits
(a) If a health insurance plan contains a provision establishing, as an age limit or otherwise,
a date after which the coverage provided by the plan will not be effective, and if
that date falls within a period for which the health insurer has accepted a premium
or if the health insurer accepts a premium after that date, the coverage provided
by the plan shall continue in force subject to any right of cancellation until the
end of the period for which a premium has been accepted.
(b) Notwithstanding any provision of subsection (a) of this section to the contrary, if
the age of the covered individual has been misstated and if, according to the correct
age of the covered individual, the coverage provided by the policy would not have
become effective or would have ceased prior to the health insurer’s acceptance of
the premium or premiums, then the health insurer’s liability shall be limited to the
refund, upon request, of all premiums paid for the period not covered by the plan. (Recodified and amended 2025, No. 11, § 2, eff. September 1, 2025.)
§ 4021. Termination of coverage
(a)(1) A major medical insurance policy issued by a health insurer that insures employees,
members, or subscribers for hospital and medical insurance on an expense-incurred,
service, or prepaid basis shall:
(A) provide notice to the policyholder or other responsible party of any premium payment
due on a policy at least 21 days before the due date; and
(B) provide a grace period of at least one month for the payment of each premium falling
due after the first premium, during which grace period the plan shall continue in
force and the issuer of the plan shall be liable for valid claims for covered losses
incurred prior to the end of the grace period.
(2) If the issuer of a plan described subdivision (1) of this subsection does not receive
payment by the due date, the issuer shall send a termination notice to the policyholder
at least 21 days prior to termination notifying the policyholder that the issuer may
terminate the plan if payment is not received by the termination date.
(3) The termination date of a plan described in subdivision (1) of this subsection shall
not be earlier than the day following the last day of the grace period set forth in
subdivision (1)(B) of this subsection.
(b) For all health insurance policies other than major medical insurance policies, a health
insurer shall notify a policyholder of any premium payment due on a policy at least
21 days before the due date. If a health insurer does not receive payment by the due
date, the health insurer shall send a termination notice to the policyholder notifying
the policyholder that the health insurer will terminate the policy effective on the
due date if payment is not received within 14 days from the date of mailing of the
termination notice. If a health insurer does not receive payment within 14 days from
the date of mailing of the termination notice, the health insurer may cancel coverage
effective on the due date. (Recodified and amended 2025, No. 11, § 2, eff. September 1, 2025.)
§ 4022. Rebates and commissions prohibited for nongroup and small group policies and plans
offered through the Vermont Health Benefit Exchange
(a) No health insurer doing business in this State and no insurance agent or broker shall:
(1) offer, promise, allow, give, set off, or pay, directly or indirectly:
(A) any rebate of or part of the premium payable on a health insurance plan issued pursuant
to 33 V.S.A. § 1811 or earnings, profits, dividends, or other benefits founded, arising, accruing, or
to accrue on or from the premium;
(B) any special advantage in date of policy or age of issue;
(C) any paid employment or contract for services of any kind; or
(D) any other valuable consideration or inducement to or for insurance on any risk in
this State, or for or upon any renewal of any such insurance, that is not specified
in the health insurance plan; or
(2) offer, promise, give, option, sell, or purchase any stocks, bonds, securities, or
property, or any dividends or profits accruing or to accrue on them, or other thing
of value as inducement to insurance or in connection with insurance, or any renewal
thereof, that is not specified in the health insurance plan.
(b) No person insured under a health insurance plan issued pursuant to 33 V.S.A. § 1811 or party or applicant for such plan shall directly or indirectly receive or accept
or agree to receive or accept any rebate of premium or of any part of the premium,
or any favor or advantage, or share in any benefit to accrue under any health insurance
plan issued pursuant to 33 V.S.A. § 1811, or any valuable consideration or inducement, that is not specified in the health
insurance plan.
(c) Nothing in this section shall be construed as prohibiting any health insurer from:
(1) allowing or returning to its participating policyholders dividends, savings, or unused
premium deposits;
(2) returning or otherwise abating, in full or in part, the premiums of its policyholders
out of surplus accumulated from nonparticipating insurance; or
(3) taking a bona fide obligation, with interest not exceeding six percent per annum,
in payment of any premium.
(d)(1) No insurer shall pay any commission, fee, or other compensation, directly or indirectly,
to a licensed or unlicensed agent, broker, or other individual in connection with
the sale of a health insurance plan issued pursuant to 33 V.S.A. § 1811, nor shall a health insurer include in an insurance rate for a health insurance plan
issued pursuant to 33 V.S.A. § 1811 any sums related to services provided by an agent, broker, or other individual. A
health insurer may provide to its employees wages, salary, and other employment-related
compensation in connection with the sale of health insurance plans but shall not structure
any such compensation in a manner that promotes the sale of particular health insurance
plans over other plans offered by that insurer.
(2) Nothing in this subsection shall be construed to prohibit the Vermont Health Benefit
Exchange established in 33 V.S.A. chapter 18, subchapter 1 from structuring compensation for agents or brokers in the form of
an additional commission, fee, or other compensation outside insurance rates or from
compensating agents, brokers, or other individuals through the procedures and payment
mechanisms established pursuant to 33 V.S.A. § 1805(17). (Recodified and amended 2025, No. 11, § 2, eff. September 1, 2025.)
§ 4022a. Rebates prohibited for group insurance policies
(a) As used in this section, “group insurance” means any policy described in section 4041 of this title, except that it shall not include any small group policy issued pursuant to 33 V.S.A. § 1811.
(b) No health insurer doing business in this State and no insurance agent or broker shall:
(1) offer, promise, allow, give, set off, or pay, directly or indirectly:
(A) any rebate of or part of the premium payable on a group insurance policy, or on any
group insurance policy or agent’s commission on the premium or earnings, profits,
dividends, or other benefits founded, arising, accruing, or to accrue on or from the
premium;
(B) any special advantage in date of policy or age of issue;
(C) any paid employment or contract for services of any kind; or
(D) any other valuable consideration or inducement to or for insurance on any risk in
this State, or for or upon any renewal of any such insurance, that is not specified
in the health insurance plan; or
(2) offer, promise, give, option, sell, or purchase any stocks, bonds, securities, or
property, or any dividends or profits accruing or to accrue on them, or other thing
of value as inducement to insurance or in connection with insurance, or any renewal
thereof, that is not specified in the health insurance plan.
(c) No person insured under a group insurance policy or party or applicant for group insurance
shall directly or indirectly receive or accept or agree to receive or accept any rebate
of premium or of any part of the premium, or all or any part of any agent’s or broker’s
commission on the premium, or any favor or advantage, or share in any benefit to accrue
under any health insurance plan, or any valuable consideration or inducement, that
is not specified in the health insurance plan.
(d) Nothing in this section shall be construed as prohibiting:
(1) the payment of commission or other compensation to any duly licensed agent or broker;
(2) any health insurer from allowing or returning to its participating policyholders dividends,
savings, or unused premium deposits;
(3) any health insurer from returning or otherwise abating, in full or in part, the premiums
of its policyholders out of surplus accumulated from nonparticipating insurance; or
(4) the health insurer from taking a bona fide obligation, with interest not exceeding
six percent per annum, in payment of any premium.
(e) A health insurer that pays a commission, fee, or other compensation, directly or indirectly,
to a licensed or unlicensed agent, broker, or other individual other than a bona fide
employee of the health insurer in connection with the sale of a group insurance policy
shall clearly disclose to the purchaser of the policy the amount of any such commission,
fee, or compensation paid or to be paid. (Recodified and amended 2025, No. 11, § 2, eff. September 1, 2025.)
§ 4023. Provisions applying to policies delivered in another state
If any policy is issued by a health insurer domiciled in this State for delivery to
a person residing in another state, and if the official having responsibility for
the administration of the insurance laws of the other state informs the Commissioner
that the policy is not subject to approval or disapproval by the official, the Commissioner
may issue an order requiring that the policy meet the standards set forth in sections 4029, 4030, and 4031 of this title. (Recodified and amended 2025, No. 11, § 2, eff. September 1, 2025.)
§ 4024. Coordination of insurance coverage with Medicaid and compliance with Medicaid recovery
provisions
(a) No health insurer shall consider the availability of or eligibility for medical assistance
in this or any other state under Title XIX of the Social Security Act (Medicaid) when
considering eligibility for coverage or making payments under its plan for eligible
enrollees, subscribers, policyholders, or certificate holders.
(b) A health insurer that issues, sells, renews, or offers health insurance coverage in
Vermont or who is required to be licensed or registered with the Department shall
comply with the requirements of 33 V.S.A. §§ 1907, 1908, 1909, and 1910. The Commissioner shall enforce such requirements pursuant to the Commissioner’s
authority under this title. (Recodified and amended 2025, No. 11, § 2, eff. September 1, 2025.)
§ 4025. Health insurance and the Blueprint for Health
(a) All major medical insurance plans shall be offered, issued, and administered consistent
with the Blueprint for Health established in 18 V.S.A. chapter 13.
(b) Health insurers offering major medical insurance plans shall participate in the Blueprint
for Health as specified in 18 V.S.A. § 706. (Recodified and amended 2025, No. 11, § 2, eff. September 1, 2025.)
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Subchapter 002: POLICY FORMS AND FILING REQUIREMENTS
§ 4026. Filing and approval of policy forms and premiums
(a)(1) No policy of health insurance or certificate under a policy filed by a health insurer
and not exempted by subdivision 3368(a)(4) of this title shall be delivered or issued for delivery in this State, nor shall any endorsement,
rider, or application that becomes a part of any such policy be used, until a copy
of the form and of the rules for the classification of risks has been filed with the
Department of Financial Regulation and a copy of the premium rates has been filed
with the Green Mountain Care Board, and the Green Mountain Care Board has issued a
decision approving, modifying, or disapproving the proposed rate.
(2)(A) The Green Mountain Care Board shall review rate requests and shall approve, modify,
or disapprove a rate request within 90 calendar days after receipt of an initial rate
filing from a health insurer. If a health insurer fails to provide necessary materials
or other information to the Board in a timely manner, the Board may extend its review
for a reasonable additional period of time, not to exceed 30 calendar days.
(B) Prior to the Board’s decision on a rate request, the Department of Financial Regulation
shall provide the Board with an analysis and opinion on the impact of the proposed
rate on the insurer’s solvency and reserves.
(3) The Board shall determine whether a rate is affordable; promotes quality care; promotes
access to health care; protects insurer solvency; and is not unjust, unfair, inequitable,
misleading, or contrary to the laws of this State. In making this determination, the
Board shall consider the analysis and opinion provided by the Department of Financial
Regulation pursuant to subdivision (2)(B) of this subsection.
(b)(1) In conjunction with a rate filing required by subsection (a) of this section, a health
insurer shall file a plain language summary of the proposed rate. All summaries shall
include a brief justification of any rate increase requested, the information that
the Secretary of the U.S. Department of Health and Human Services (HHS) requires for
rate increases over 10 percent, and any other information required by the Board. The
plain language summary shall be in the format required by the Secretary of HHS pursuant
to the Patient Protection and Affordable Care Act of 2010, Pub. L. No. 111-148, as amended by the Health Care and Education Reconciliation Act of 2010, Pub. L. No. 111-152, and shall include notification of the public comment period established in subsection
(c) of this section. In addition, the insurer shall post the summaries on its website.
(2)(A) In conjunction with a rate filing required by subsection (a) of this section, a health
insurer shall disclose to the Board:
(i) for all covered prescription drugs, including generic drugs, brand-name drugs excluding
specialty drugs, and specialty drugs dispensed at a pharmacy, network pharmacy, or
mail-order pharmacy for outpatient use:
(I) the percentage of the premium rate attributable to prescription drug costs for the
prior year for each category of prescription drugs;
(II) the year-over-year increase or decrease, expressed as a percentage, in per-member,
per-month total health plan spending on each category of prescription drugs; and
(III) the year-over-year increase or decrease in per-member, per-month costs for prescription
drugs compared to other components of the premium rate; and
(ii) the specialty tier formulary list.
(B) The insurer shall provide, if available, the percentage of the premium rate attributable
to prescription drugs administered by a health care provider in an outpatient setting
that are part of the medical benefit as separate from the pharmacy benefit.
(C) The insurer shall include information on its use of a pharmacy benefit manager, if
any, including which components of the prescription drug coverage described in subdivisions
(A) and (B) of this subdivision (2) are managed by the pharmacy benefit manager, as
well as the name of the pharmacy benefit manager or managers used.
(3)(A) Upon request, in conjunction with a rate filing required by subsection (a) of this
section, a health insurer shall provide to the Board detailed information about the
insurer’s payments to specific providers, which may include fee schedules, payment
methodologies, and other payment information specified by the Board.
(B) Confidential business information and trade secrets received from a health insurer
pursuant to subdivision (A) of this subdivision (3) shall be exempt from public inspection
and copying under 1 V.S.A. § 317(c)(9) and shall be kept confidential, except that the Board may disclose or release information
publicly in summary or aggregate form if doing so would not disclose confidential
business information or trade secrets.
(C) Notwithstanding 1 V.S.A. chapter 5, subchapter 2 (Vermont Open Meeting Law), the Board may examine and discuss confidential
information outside a public hearing or meeting.
(c)(1) The Board shall provide information to the public on the Board’s website about the
public availability of the filings and summaries required under this section.
(2)(A) The Board shall post the rate filings pursuant to subsection (a) of this section and
summaries pursuant to subsection (b) of this section on the Board’s website within
five calendar days following filing. The Board shall also establish a mechanism by
which members of the public may request to be notified automatically each time a proposed
rate is filed with the Board.
(B) The Board shall provide an electronic mechanism for the public to comment on all rate
filings. The Board shall accept public comment on each rate filing from the date on
which the Board posts the rate filing on its website pursuant to subdivision (A) of
this subdivision (2) until 15 calendar days after the Board posts on its website the
analyses and opinions of the Department of Financial Regulation and of the Board’s
consulting actuary, if any, as required by subsection (d) of this section. The Board
shall review and consider the public comments prior to issuing its decision.
(3)(A) In addition to the public comment provisions set forth in this subsection (c), the
Office of the Health Care Advocate established in 18 V.S.A. chapter 229, acting on behalf of health insurance consumers in this State, may, within 30 calendar
days after the Board receives a health insurer’s rate request pursuant to this section,
submit to the Board, in writing, questions with a substantial relationship to the
rate filing and review criteria that the Board shall ask the insurer, either directly
or through its contracting actuary, if any.
(B) The Office of the Health Care Advocate may also submit to the Board written comments
on a health insurer’s rate request. The Board shall post the comments on its website
and shall consider the comments prior to issuing its decision.
(d) The Green Mountain Care Board shall post on its website or otherwise make available
to the public through a file-sharing platform all materials in the record of a rate
review proceeding after redacting any information or other material that the Board
determines to be confidential or otherwise subject to protection from disclosure by
law.
(e) Within the time period set forth in subdivision (a)(2)(A) of this section, the Board
shall:
(1) conduct a public hearing, at which the Board shall:
(A) call as witnesses the Commissioner of Financial Regulation or designee and the Board’s
contracting actuary, if any, unless all parties agree to waive such testimony; and
(B) provide an opportunity for testimony from the insurer, the Office of the Health Care
Advocate, and members of the public;
(2) at a public hearing, announce the Board’s decision of whether to approve, modify,
or disapprove the proposed rate; and
(3) issue its decision in writing.
(f)(1) The insurer shall notify its policyholders of the Board’s decision in a timely manner,
as defined by the Board by rule.
(2) Rates shall take effect on the date specified in the insurer’s rate filing.
(3) If the Board has not issued its decision by the effective date specified in the insurer’s
rate filing, the insurer shall notify its policyholders of its pending rate request
and of the effective date proposed by the insurer in its rate filing.
(g) A health insurer, the Office of the Health Care Advocate, and any member of the public
with party status, as defined by the Board by rule, may appeal a decision of the Board
approving, modifying, or disapproving the insurer’s proposed rate to the Vermont Supreme
Court.
(h)(1) The authority of the Board under this section shall apply only to the rate review
process for policies for major medical insurance coverage and shall not apply to the
policy forms for major medical insurance coverage or to the rate and policy form review
process for policies for specific disease, accident, injury, hospital indemnity, dental
care, vision care, disability income, long-term care, student health insurance coverage,
Medicare supplement insurance coverage, or other limited benefit coverage; to short-term,
limited-duration health insurance coverage; or to benefit plans that are paid directly
to an individual insured or to the individual’s assigns and for which the amount of
the benefit is not based on potential medical costs or actual costs incurred. Premium
rates and rules for the classification of risk for Medicare supplement insurance policies
shall be governed by section 4051 of this title.
(2) The policy forms for major medical insurance coverage, as well as the policy forms,
premium rates, and rules for the classification of risk for the other lines of insurance
described in subdivision (1) of this subsection shall be reviewed and approved or
disapproved by the Commissioner. In making a determination, the Commissioner shall
consider whether a policy form, premium rate, or rule is affordable and is not unjust,
unfair, inequitable, misleading, or contrary to the laws of this State; and, for a
policy form for major medical insurance coverage, whether it ensures equal access
to appropriate mental health care in a manner equivalent to other aspects of health
care as part of an integrated, holistic system of care. The Commissioner shall make
a determination within 30 days after the date the insurer filed the policy form, premium
rate, or rule with the Department. At the expiration of the 30-day period, the form,
premium rate, or rule shall be deemed approved unless prior to then it has been affirmatively
approved or disapproved by the Commissioner or found to be incomplete. The Commissioner
shall notify a health insurer in writing if the insurer files any form, premium rate,
or rule containing a provision that does not meet the standards expressed in this
subsection. In such notice, the Commissioner shall state that a hearing will be granted
within 20 days upon the insurer’s written request.
(i) Notwithstanding the procedures and timelines set forth in subsections (a) through
(e) of this section, the Board may establish, by rule, a streamlined rate review process
for certain rate decisions, including proposed rates affecting fewer than a minimum
number of covered lives and proposed rates for which a de minimis increase, as defined
by the Board by rule, is sought. (Recodified and amended 2025, No. 11, § 2, eff. September 1, 2025; amended 2025, No. 6, § 1.)
§ 4027. Filing fees
Each filing of a policy, contract, or document form or premium rates or rules, submitted
pursuant to section 4026 of this title, shall be accompanied by payment to the Commissioner or the Green Mountain Care Board,
as appropriate, of a nonrefundable fee of $150.00. (Recodified and amended 2025, No. 11, § 2, eff. September 1, 2025.)
§ 4028. Form and contents of policy
No policy of individual health insurance shall be delivered or issued for delivery
to any person in this State unless all of the following conditions are met:
(1) The policy sets forth all of the monetary and other considerations for the policy.
(2) The policy sets forth the time at which the insurance takes effect and terminates.
(3) The policy purports to insure only one person, except that a policy may insure, originally
or by subsequent amendment, upon the application of an adult member of a family who
shall be deemed the policyholder, any two or more eligible members of that family,
including a spouse or civil union partner, dependent children or any children under
a specified age that shall not exceed 26 years of age, and any other person dependent
upon the policyholder.
(4) The style, arrangement, and overall appearance of the policy give no undue prominence
to any portion of the text, and every printed portion of the text of the policy and
of any endorsements or attached papers is plainly printed in light-faced type of a
style in general use, the size of which shall be uniform and not less than 10-point
with a lowercase unspaced alphabet length not less than 120-point. As used in this
subdivision, the “text” includes all printed matter except the name and address of
the insurer; the name or title of the policy; the brief description, if any; and the
captions and subcaptions.
(5) The exceptions and reductions of indemnity are set forth in the policy and, except
those that are set forth in sections 4029 and 4030 of this title, are printed, at the insurer’s option, either with the benefit provision to which
they apply or under an appropriate caption such as “EXCEPTIONS” or “EXCEPTIONS AND
REDUCTIONS”; provided, however, that if an exception or reduction specifically applies
only to a particular benefit of the policy, the statement of the exception or reduction
shall be included with the benefit provision to which it applies.
(6) Each policy form, including riders and endorsements, is identified by a form number
in the lower left-hand corner of the first page of the form.
(7) The policy does not contain any provision purporting to make any portion of the charter,
rules, constitution, or bylaws of the health insurer a part of the policy unless that
portion is set forth in full in the policy, except in the case of the incorporation
of, or reference to, a statement of rates or classification of risks or a short-rate
table filed with the Commissioner.
(8) Either prominently printed on or attached to the first page of the policy is a notice
to the effect that during a period of 30 days following the date the policy is delivered
to persons eligible for Medicare by reason of age, and 10 days following the date
of delivery to all other persons, the policy may be surrendered to the insurer together
with a written request for cancellation of the policy, and that in such event, the
insurer will refund any premium paid, including any policy fees or other charges;
provided, however, that this subdivision shall not apply to single premium nonrenewable
policies insuring against accident only or medical costs or accidental bodily injury
only. (Recodified and amended 2025, No. 11, § 2, eff. September 1, 2025.)
§ 4029. Required standard policy provisions
Except as provided in section 4031 of this title, each health insurance policy delivered or issued for delivery to any person in this
State shall contain the provisions specified in this section using the language set
forth in this section; provided, however, that a health insurer may, at its option,
substitute different language approved by the Commissioner for one or more provisions,
provided the substituted language is not less favorable in any respect to the insured
or covered individual than the language used in this section. The provisions specified
in this section shall be preceded individually by the caption appearing in this section
or, at the option of the health insurer, by such appropriate captions or subcaptions
as the Commissioner may approve:
(1) ENTIRE CONTRACT; CHANGES: This policy, including the endorsements and the attached
papers, if any, constitutes the entire contract of insurance. No change in this policy
shall be valid until approved by an executive officer of the insurer and unless such
approval be endorsed hereon or attached hereto. No agent has authority to change this
policy or to waive any of its provisions.
(2) TIME LIMIT ON CERTAIN DEFENSES:
(a) After three years from the date of issue of this policy no misstatements, except fraudulent
misstatements, made by the applicant in the application for such policy, shall be
used to void the policy or to deny a claim for loss incurred or disability (as defined
in the policy) commencing after the expiration of such three-year period.
(The foregoing policy provision shall not be so construed as to affect any legal requirement for avoidance of a policy or denial of a claim during such initial three-year period, nor to limit the application of subdivisions 4030(1)–(5) of this title in the event of misstatement with respect to age or occupation or other insurance.) (A policy which the insured has the right to continue in force subject to its terms by the timely payment of premium (1) until at least age 50, or (2) in the case of a policy issued after age 44, for at least five years from its date of issue, may contain in lieu of the foregoing the following provision (from which the clause in parentheses may be omitted at the insurer’s option) under the caption “INCONTESTABLE”:
After this policy has been in force for a period of three years during the lifetime of the insured (excluding any period during which the insured is disabled), it shall become incontestable as to the statements contained in the application.)
(b) No claim for loss incurred or disability (as defined in the policy) commencing after
three years from the date of issue of this policy shall be reduced or denied on the
ground that a disease or physical condition not excluded from coverage by name or
specific description effective on the date of loss had existed prior to the effective
date of coverage of this policy.
(3) GRACE PERIOD: A grace period of . . . . (insert a number not less than “7” for weekly
premium policies, “10” for monthly premium policies and “31” for all other policies)
days will be granted for the payment of each premium falling due after the first premium,
during which grace period the policy shall continue in force.
(A policy which contains a cancellation provision may add, at the end of the above provision,
subject to the right of the insurer to cancel in accordance with the cancellation provision hereof,
A policy in which the insurer reserves the right to refuse any renewal shall have, at the beginning of the above provision,
Unless not less than five days prior to the premium due date the insurer has delivered to the insured or has mailed to his or her last address as shown by the records of the insurer written notice of its intention not to renew this policy beyond the period for which the premium has been accepted.)
(4) REINSTATEMENT: If any renewal premium be not paid within the time granted the insured
for payment, a subsequent acceptance of premium by the insurer or by any agent duly
authorized by the insurer to accept such premium, without requiring in connection
therewith an application for reinstatement, shall reinstate the policy; provided,
however, that if the insurer or such agent requires an application for reinstatement
and issues a conditional receipt for the premium tendered, the policy will be reinstated
upon approval of such application by the insurer or, lacking such approval, upon the
45th day following the date of such conditional receipt unless the insurer has previously
notified the insured in writing of its disapproval of such application. The reinstated
policy shall cover only loss resulting from such accidental injury as may be sustained
after the date of reinstatement and loss due to such sickness as may begin more than
ten days after such date. In all other respects the insured and insurer shall have
the same rights thereunder as they had under the policy immediately before the due
date of the defaulted premium, subject to any provisions endorsed hereon or attached
hereto in connection with the reinstatement. Any premium accepted in connection with
a reinstatement shall be applied to a period for which premium has not been previously
paid, but not to any period more than sixty days prior to the date of reinstatement.
(The last sentence of the above provision may be omitted from any policy which the insured has the right to continue in force subject to its terms by the timely payment of premiums (1) until at least age 50, or (2) in the case of a policy issued after age 44, for at least five years from its date of issue.)
(5) NOTICE OF CLAIM: Written notice of claim must be given to the insurer within 20 days
after the occurrence or commencement of any loss covered by the policy, or as soon
thereafter as is reasonably possible. Notice given by or on behalf of the insured
or the beneficiary to the insurer at . . . . (insert the location of such office as
the insurer may designate for the purpose), or to any authorized agent of the insurer,
with information sufficient to identify the insured, shall be deemed notice to the
insurer.
(In a policy providing a loss-of-time benefit which may be payable for at least two
years, an insurer may at its option insert the following between the first and second
sentences of the above provision:
Subject to the qualifications set forth below, if the insured suffers loss of time on account of disability for which indemnity may be payable for at least two years, he or she shall, at least once in every six months after having given notice of claim, give to the insurer notice of continuance of said disability, except in the event of legal incapacity. The period of six months following any filing of proof by the insured or any payment by the insurer on account of such claim or any denial of liability in whole or in part by the insurer shall be excluded in applying this provision. Delay in the giving of such notice shall not impair the insured’s right to any indemnity which would otherwise have accrued during the period of six months preceding the date on which such notice is actually given.)
(6) CLAIM FORMS: The insurer, upon receipt of a notice of claim, will furnish to the claimant
such forms as are usually furnished by it for filing proofs of loss. If such forms
are not furnished within 15 days after the giving of such notice the claimant shall
be deemed to have complied with the requirements of this policy as to proof of loss
upon submitting, within the time fixed in the policy for filing proofs of loss, written
proof covering the occurrence, the character and the extent of the loss for which
claim is made.
(7) PROOFS OF LOSS: Written proof of loss must be furnished to the insurer at its said
office in case of claim for loss for which this policy provides any periodic payment
contingent upon continuing loss within 90 days after the termination of the period
for which the insurer is liable and in case of claim for any other loss within 90
days after the date of such loss. Failure to furnish such proof within the time required
shall not invalidate nor reduce any claim if it was not reasonably possible to give
proof within such time, provided such proof is furnished as soon as reasonably possible
and in no event, except in the absence of legal capacity, later than one year from
the time proof is otherwise required.
(8) TIME OF PAYMENT OF CLAIMS: Indemnities payable under this policy for any loss other
than loss for which this policy provides any periodic payment will be paid immediately
upon receipt of due written proof of such loss. Subject to due written proof of loss,
all accrued indemnities for loss for which this policy provides periodic payment will
be paid . . . . (insert period for payment which must not be less frequently than
monthly) and any balance remaining unpaid upon the termination of liability will be
paid immediately upon receipt of due written proof.
(9) PAYMENT OF CLAIMS: Indemnity for loss of life will be payable in accordance with the
beneficiary designation and the provisions respecting such payment which may be prescribed
herein and effective at the time of payment. If no such designation or provision is
then effective, such indemnity shall be payable to the estate of the insured. Any
other accrued indemnities unpaid at the insured’s death may, at the option of the
insurer, be paid either to such beneficiary or to such estate. All other indemnities
will be payable to the insured.
(The following provisions, or either of them, may be included with the foregoing provision
at the option of the insurer:
If any indemnity of this policy shall be payable to the estate of the insured, or to an insured or beneficiary who is a minor or otherwise not competent to give a valid release, the insurer may pay such indemnity, up to an amount not exceeding $. . . . . . (insert an amount which shall not exceed $1,000.00), to any relative by blood or connection by civil marriage of the insured or beneficiary who is deemed by the insurer to be equitably entitled thereto. Any payment made by the insurer in good faith pursuant to this provision shall fully discharge the insurer to the extent of such payment.
Subject to any written direction of the insured in the application or otherwise all or a portion of any indemnities provided by this policy on account of hospital, nursing, medical, or surgical services may, at the insurer’s option and unless the insured requests otherwise in writing not later than the time of filing proofs of such loss, be paid directly to the hospital or person rendering such services; but it is not required that the service be rendered by a particular hospital or person.)
(10) PHYSICAL EXAMINATIONS AND AUTOPSY: The insurer at its own expense shall have the right
and the opportunity to examine the person of the insured when and as often as it may
reasonably require during the pendency of a claim hereunder and to make an autopsy
in case of death where it is not forbidden by law.
(11) LEGAL ACTIONS: No action at law or in equity shall be brought to recover on this policy
prior to the expiration of 60 days after written proof of loss has been furnished
in accordance with the requirements of this policy. No such action shall be brought
after the expiration of three years after the time written proof of loss is required
to be furnished.
(12) CHANGE OF BENEFICIARY: Unless the insured makes an irrevocable designation of beneficiary,
the right to change of beneficiary is reserved to the insured and the consent of the
beneficiary or beneficiaries shall not be requisite to surrender or assignment of
this policy or to any change of beneficiary or beneficiaries, or to any other changes
in this policy.
(The first clause of this provision, relative to the irrevocable designation of beneficiary, may be omitted at the insurer’s option.) (Recodified and amended 2025, No. 11, § 2, eff. September 1, 2025.)
§ 4030. Optional standard policy provisions
Except as provided in section 4031 of this title, no health insurance policy delivered or issued for delivery to any person in this
State shall contain provisions respecting the matters set forth in this section unless
the provisions use the language set forth in this section; provided, however, that
a health insurer may, at its option, substitute different language approved by the
Commissioner for one or more provisions, provided the substituted language is not
less favorable in any respect to the insured or covered individual than the language
used in this section. Any provision set forth in this section that is contained in
the policy shall be preceded individually by the appropriate caption appearing in
this section or, at the option of the health insurer, by such appropriate captions
or subcaptions as the Commissioner may approve:
(1) CHANGE OF OCCUPATION: If the insured be injured or contract sickness after having
changed his or her occupation to one classified by the insurer as more hazardous than
that stated in this policy or while doing for compensation anything pertaining to
an occupation so classified, the insurer will pay only such portion of the indemnities
provided in this policy as the premium paid would have purchased at the rates and
within the limits fixed by the insurer for such more hazardous occupation. If the
insured changes his or her occupation to one classified by the insurer as less hazardous
than that stated in this policy, the insurer, upon receipt of proof of such change
of occupation, will reduce the premium rate accordingly, and will return the excess
pro rata unearned premium from the date of change of occupation or from the policy
anniversary date immediately preceding receipt of such proof, whichever is the more
recent. In applying this provision, the classification of occupational risk and the
premium rates shall be such as have been last filed by the insurer prior to the occurrence
of the loss for which the insurer is liable or prior to date of proof of change in
occupation with the state official having supervision of insurance in the state where
the insured resided at the time this policy was issued; but if such filing was not
required, then the classification of occupational risk and the premium rates shall
be those last made effective by the insurer in such state prior to the occurrence
of the loss or prior to the date of proof of change in occupation.
(2) MISSTATEMENT OF AGE: If the age of the insured has been misstated, all amounts payable
under this policy shall be such as the premium paid would have purchased at the correct
age.
(3) OTHER INSURANCE IN THIS INSURER: If an accident or sickness or accident and sickness
policy or policies previously issued by the insurer to the insured be in force concurrently
herewith, making the aggregate indemnity for .... (insert type of coverage or coverages)
in excess of $.................... (insert maximum limit of indemnity or indemnities)
the excess insurance shall be void and all premiums paid for such excess shall be
returned to the insured or to his or her estate.
or, in lieu thereof:
Insurance effective at any one time on the insured under a like policy or policies
in this insurer is limited to the one such policy elected by the insured, his or her
beneficiary or his or her estate, as the case may be, and the insurer will return
all premiums paid for all other such policies.
(4) INSURANCE WITH OTHER INSURERS: If there be other valid coverage, not with this insurer,
providing benefits for the same loss on a provision of service basis or on an expense
incurred basis and of which this insurer has not been given written notice prior to
the occurrence or commencement of loss, the only liability under any expense incurred
coverage of this policy shall be for such proportion of the loss as the amount which
would otherwise have been payable hereunder plus the total of the like amounts under
all such other valid coverages for the same loss of which this insurer had notice
bears to the total like amounts under all valid coverages for such loss, and for the
return of such portion of the premiums paid as shall exceed the pro rata portion for
the amount so determined. For the purpose of applying this provision when other coverage
is on a provision of service basis, the “like amount” of such other coverage shall
be taken as the amount which the services rendered would have cost in the absence
of such coverage.
(If the foregoing policy provision is included in a policy which also contains the next following policy provision there shall be added to the caption of the foregoing provision the phrase “—EXPENSE INCURRED BENEFITS.” The insurer may, at its option, include in this provision a definition of “other valid coverage,” approved as to form by the Commissioner, which definition shall be limited in subject matter to coverage provided by organizations subject to regulation by insurance law or by insurance authorities of this or any other state of the United States or any province of Canada, and by hospital or medical service organizations, and to any other coverage the inclusion of which may be approved by the Commissioner. In the absence of such definition such term shall not include group insurance, automobile medical payments insurance, or coverage provided by hospital or medical service organizations or by union welfare plans or employer or employee benefit organizations. For the purpose of applying the foregoing policy provision with respect to any insured, any amount of benefit provided for such insured pursuant to any compulsory benefit statute (including any workers’ compensation or employer’s liability statute) whether provided by a governmental agency or otherwise shall in all cases be deemed to be “other valid coverage” of which the insurer has had notice. In applying the foregoing policy provision no third party liability coverage shall be included as “other valid coverage.”)
(5) INSURANCE WITH OTHER INSURERS: If there be other valid coverage, not with this insurer,
providing benefits for the same loss on other than an expense incurred basis and of
which this insurer has not been given written notice prior to the occurrence or commencement
of loss, the only liability for such benefits under this policy shall be for such
proportion of the indemnities otherwise provided hereunder for such loss as the like
indemnities of which the insurer had notice (including the indemnities under this
policy) bear to the total amount of all like indemnities for such loss, and for the
return of such portion of the premium paid as shall exceed the pro rata portion for
the indemnities thus determined.
(If the foregoing policy provision is included in a policy which also contains the next preceding policy provision there shall be added to the caption of the foregoing provision the phrase “—OTHER BENEFITS.” The insurer may, at its option, include in this provision a definition of “other valid coverage,” approved as to form by the Commissioner, which definition shall be limited in subject matter to coverage provided by organizations subject to regulation by insurance law or by insurance authorities of this or any other state of the United States or any province of Canada, and to any other coverage the inclusion of which may be approved by the Commissioner. In the absence of such definition such term shall not include group insurance, or benefits provided by union welfare plans or by employer or employee benefit organizations. For the purpose of applying the foregoing policy provision with respect to any insured, any amount of benefit provided for such insured pursuant to any compulsory benefit statute (including any workers’ compensation or employer’s liability statute) whether provided by a governmental agency or otherwise shall in all cases be deemed to be “other valid coverage” of which the insurer has had notice. In applying the foregoing policy provision no third party liability coverage shall be included as “other valid coverage.”)
(6) RELATION OF EARNINGS TO INSURANCE: If the total monthly amount of loss of time benefits
promised for the same loss under all valid loss of time coverage upon the insured,
whether payable on a weekly or monthly basis, shall exceed the monthly earnings of
the insured at the time disability commenced or his or her average monthly earnings
for the period of two years immediately preceding a disability for which claim is
made, whichever is the greater, the insurer will be liable only for such proportionate
amount of such benefits under this policy as the amount of such monthly earnings or
such average monthly earnings of the insured bears to the total amount of monthly
benefits for the same loss under all such coverage upon the insured at the time such
disability commences and for the return of such part of the premiums paid during such
two years as shall exceed the pro rata amount of the premiums for the benefits actually
paid hereunder; but this shall not operate to reduce the total monthly amount of benefits
payable under all such coverage upon the insured below the sum of $200.00 or the sum
of the monthly benefits specified in such coverages, whichever is the lesser, nor
shall it operate to reduce benefits other than those payable for loss of time.
(The foregoing policy provision may be inserted only in a policy which the insured
has the right to continue in force subject to its terms by the timely payment of premiums
(1) until at least age 50; or (2) in the case of a policy issued after age 44, for
at least five years from its date of issue. The insurer may, at its option, include
in this provision a definition of “valid loss of time coverage,” approved as to form
by the Commissioner, which definition shall be limited in subject matter to coverage
provided by governmental agencies or by organizations subject to regulation by insurance
law or by insurance authorities of this or any other state of the United States or
any province of Canada, or to any other coverage the inclusion of which may be approved
by the Commissioner or any combination of such coverages. In the absence of such definition
such term shall not include any coverage provided for such insured pursuant to any
compulsory benefit statute (including any workers’ compensation or employer’s liability
statute), or benefits provided by union welfare plans or by employer or employee benefit
organizations.)
(7) UNPAID PREMIUM: Upon the payment of a claim under this policy, any premium then due
and unpaid or covered by any note or written order may be deducted therefrom.
(8) CANCELLATION: The insurer may cancel this policy at any time by written notice delivered
to the insured, or mailed to his or her last address as shown by the records of the
insurer, stating when, not less than five days thereafter, such cancellation shall
be effective; and after the policy has been continued beyond its original term the
insured may cancel this policy at any time by written notice delivered or mailed to
the insurer, effective upon receipt or on such later date as may be specified in such
notice. In the event of cancellation, the insurer will return promptly the unearned
portion of any premium paid. If the insured cancels, the earned premium shall be computed
by the use of the short-rate table last filed with the state official having supervision
of insurance in the state where the insured resided when the policy was issued. If
the insurer cancels, the earned premium shall be computed pro rata. Cancellation shall
be without prejudice to any claim originating prior to the effective date of cancellation.
(9) CONFORMITY WITH STATE STATUTES: Any provision of this policy which, on its effective
date, is in conflict with the statutes of the state in which the insured resides on
such date is hereby amended to conform to the minimum requirements of such statutes.
(10) ILLEGAL OCCUPATION: The insurer shall not be liable for any loss to which a contributing
cause was the insured’s commission of or attempt to commit a felony or to which a
contributing cause was the insured’s being engaged in an illegal occupation. (Recodified and amended 2025, No. 11, § 2, eff. September 1, 2025.)
§ 4031. Omission of inapplicable or inconsistent standard provisions
If any provision of sections 4029 and 4030 of this title is in whole or in part inapplicable to or inconsistent with the coverage provided
by a particular form of policy, the health insurer, with the approval of the Commissioner,
shall omit from such policy any inapplicable provision or part of a provision and
shall modify any inconsistent provision or part of the provision in such manner as
to make the provision as contained in the policy consistent with the coverage provided
by the policy. (Recodified and amended 2025, No. 11, § 2, eff. September 1, 2025.)
§ 4032. Order of standard policy provisions
The provisions specified in sections 4029 and 4030 of this title, or any corresponding provisions used in lieu of those provisions as permitted by
those sections, shall either be printed in the same order as the provisions are set
forth in those sections or, at the option of the health insurer, any such provision
may appear as a unit in any part of the policy, with other provisions to which it
may be logically related, provided the resulting policy shall not be in whole or in
part unintelligible, uncertain, ambiguous, abstruse, or likely to mislead a person
to whom the policy is offered, delivered, or issued. (Recodified and amended 2025, No. 11, § 2, eff. September 1, 2025.)
§ 4033. Discretionary clauses prohibited
(a) The purpose of this section is to ensure that health insurance benefits, disability
income protection coverage, and life insurance benefits are contractually guaranteed
and to avoid the conflict of interest that may occur when the carrier responsible
for providing benefits has discretionary authority to decide what benefits are due.
Nothing in this section shall be construed to impose any requirement or duty on any
person other than a health insurer or a health insurer offering disability income
protection coverage or life insurance.
(b) As used in this section:
(1) “Disability income protection coverage” means a policy, contract, certificate, or
agreement that provides for weekly, monthly, or other periodic payments for a specified
period during the continuance of disability resulting from illness, injury, or a combination
of illness and injury.
(2) “Health insurer” has the same meaning as in section 4011 of this chapter and, as used
in this section, also includes entities offering policies for specific disease, accident,
injury, hospital indemnity, dental care, disability income, long-term care, and other
limited benefit coverage.
(3) “Life insurance” means a policy, contract, certificate, or agreement that provides
life insurance as defined in subdivision 3301(a)(1) of this title.
(c) No policy, contract, certificate, or agreement offered or issued in this State by
a health insurer to provide, deliver, arrange for, pay for, or reimburse any of the
costs of health care services may contain a provision purporting to reserve discretion
to the health insurer to interpret the terms of the contract or to provide standards
of interpretation or review that are inconsistent with the laws of this State, and
any such provision in a policy, contract, certificate, or agreement shall be null
and void.
(d) No policy, contract, certificate, or agreement offered or issued in this State providing
for disability income protection coverage may contain a provision purporting to reserve
discretion to the insurer to interpret the terms of the contract or to provide standards
of interpretation or review that are inconsistent with the laws of this State, and
any such provision in a policy, contract, certificate, or agreement shall be null
and void.
(e) No policy, contract, certificate, or agreement of life insurance offered or issued
in this State shall contain a provision purporting to reserve discretion to the insurer
to interpret the terms of the contract or to provide standards of interpretation or
review that are inconsistent with the laws of this State, and any such provision in
a policy, contract, certificate, or agreement shall be null and void. (Recodified and amended 2025, No. 11, § 2, eff. September 1, 2025.)
§ 4034. Requirements of other jurisdictions
(a) Any policy of a foreign or alien insurer, when delivered or issued for delivery to
any person in this State, may contain any provision that is not less favorable to
the covered individual than the provisions of this chapter and that is prescribed
or required by the law of the state under which the insurer is organized.
(b) Any policy of a domestic health insurer, when issued for delivery in any other state
or country, may contain any provision permitted or required by the laws of such other
state or country. (Recodified and amended 2025, No. 11, § 2, eff. September 1, 2025.)
§ 4035. Policies not affected
Nothing in sections 4018–4020, 4023, 4028–4032, 4034, 4036, and 4037 of this title shall apply to or affect:
(1) any policy of workers’ compensation insurance or any policy of liability insurance,
with or without supplementary coverage;
(2) any policy or contract of reinsurance;
(3) any blanket or group policy of insurance enumerated in sections 4041–4043 and 4052 of this title, except as otherwise provided in those sections; or
(4) life insurance, endowment, or annuity contracts, or contracts supplemental to those
contracts, that contain only such provisions relating to accident and sickness insurance
as:
(A) provide additional benefits in case of death or dismemberment or loss of sight by
accident; or
(B) operate to safeguard the contracts against lapse or to give a special surrender value
or special benefit or an annuity in the event that the insured or annuitant becomes
totally and permanently disabled, as defined by the contract or supplemental contract. (Recodified and amended 2025, No. 11, § 2, eff. September 1, 2025.)
§ 4036. Nonconforming policies
(a) A health insurance policy shall not contain any provision that makes the policy or
any portion of the policy less favorable in any respect to the covered individual
than the provisions of the policy that are regulated by sections 4029 and 4030 of this title.
(b) A policy delivered or issued for delivery to any person in this State in violation
of sections 4029 and 4030 of this title shall be held valid but shall be construed as provided in this chapter. When any
provision in a policy regulated by sections 4029 and 4030 is in conflict with any
provision of those sections, the rights, duties, and obligations of the health insurer
and the covered individual shall be governed by the provisions of those sections. (Recodified and amended 2025, No. 11, § 2, eff. September 1, 2025.)
§ 4037. Applications for insurance
(a)(1) A covered individual shall not be bound by any statement made in an application for
a policy unless a copy of the application is attached to or endorsed on the policy
as a part of the policy when issued.
(2) If a policy delivered or issued for delivery to any person in this State is reinstated
or renewed and the covered individual or assignee of the policy makes a written request
to the health insurer for a copy of the application, if any, for such reinstatement
or renewal, the health insurer shall deliver or mail a copy of the application to
the individual making the request within 15 days after the receipt of the request.
If the health insurer does not deliver or mail the copy within 15 days, the health
insurer shall be precluded from introducing the application as evidence in any action
or proceeding based on or involving the policy or its reinstatement or renewal.
(b) No alteration of a written application for a policy shall be made by any person other
than the applicant without the applicant’s written consent, except that insertions
may be made by the health insurer, for administrative purposes only, in a manner that
indicates clearly that the insertions are not to be ascribed to the applicant.
(c) The falsity of any statement in an application for a policy shall not bar the right
to recovery under the policy unless the false statement materially affected either
the acceptance of the risk or the hazard assumed by the health insurer. (Recodified and amended 2025, No. 11, § 2, eff. September 1, 2025.)
§ 4038. Rulemaking on policy filings
The Commissioner may adopt such reasonable rules concerning the procedure for the
filing or submission of policies subject to sections 4023 and 4028–4030 of this title as are necessary, proper, or advisable for the administration of these sections.
This provision shall not abridge any other authority granted to the Commissioner by
law. (Recodified and amended 2025, No. 11, § 2, eff. September 1, 2025.)
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Subchapter 003: GROUP COVERAGE
§ 4041. Group health insurance policies; definitions
(a) As used in this section:
(1) “Employees” includes the officers, managers, and employees of the employer; the partners,
if the employer is a partnership; the officers, managers, and employees of subsidiary
or affiliated corporations of a corporation employer; and the individual proprietors,
partners, and employees of individuals and firms, the business of which is controlled
by the insured employer through stock ownership, contract, or otherwise.
(2) “Employer” may be deemed to include any municipal or governmental entity or officer,
or the appropriate officer for an unincorporated town or gore or for the Unified Towns
and Gores of Essex County, as well as private individuals, partnerships, and corporations.
(b) Group health insurance is a form of health insurance that covers one or more persons,
with or without their dependents, that is issued upon the following basis:
(1)(A) Under a policy issued to an employer, who is deemed the policyholder, insuring at
least one employee of the employer, for the benefit of persons other than the employer.
(B) In accordance with section 3368 of this title, an employer domiciled in a jurisdiction other than Vermont that has more than 25
certificate-holder employees whose principal worksite and domicile is in Vermont and
that is defined as a large group in its own jurisdiction and under the Patient Protection
and Affordable Care Act, Pub. L. No. 111-148, § 1304, as amended by the Health Care and Education Reconciliation Act of 2010, Pub. L. No. 111-152, may purchase insurance in the large group health insurance market for its Vermont-domiciled
certificate-holder employees.
(2)(A) Under a policy issued:
(i) to an association, a trust, or one or more trustees of a fund established by one or
more associations otherwise eligible for the issuance of a policy under this subdivision
(2) and maintained, directly or indirectly, by one or more associations for the benefit
of its members or a contract or plan issued by such an association or trust; or
(ii) by a multiple employer welfare arrangement as defined in the Employee Retirement Income
Security Act of 1974, as amended.
(B)(i) The association or associations shall have:
(I) a minimum of 100 persons at the time of incorporation or formation;
(II) been organized and maintained in good faith for purposes other than that of obtaining
insurance;
(III) been in active existence for at least one year; and
(IV) a constitution and bylaws that provide that:
(aa) the association or associations hold regular meetings not less than annually to further
purposes of the members;
(bb) except for credit unions, the association or associations collect dues or solicit
contributions from members; and
(cc) the members constitute a majority of the voting power of the association for all purposes
and have representation on the governing board and committees.
(ii)(I) The association or associations shall not be controlled by a health insurer, as evidenced
by the operation of the association or associations.
(II) The following factors may be used as evidence to determine whether an association
is a health insurer-operated association; provided, however, that the presence or
absence of one or more of these factors shall not serve to limit or be dispositive
of such a determination:
(aa) common board members, officers, executives, or employees;
(bb) common ownership of the health insurer and the association, or of the association
and another eligible group; and
(cc) common use of office space or equipment used by the health insurer to transact insurance.
(C) An association’s members shall have a shared or common purpose that is not primarily
a business or customer relationship.
(D)(i) A policy issued by an association shall not insure persons other than the members
or employees of the association or associations, or employees of members, or all of
any class or classes of employees of the association, associations, or members, together,
in each case, with the employees’ or members’ dependents, as applicable, for the benefit
of persons other than the employee’s employer.
(ii) A policy issued by an association shall insure all eligible persons, except those
who reject coverage in writing.
(E) An association shall not use the solicitation of insurance as the primary method of
obtaining new members.
(F) If a health insurer collects membership fees or dues on behalf of an association,
the health insurer shall disclose to the members of the association that the health
insurer is billing and collecting membership fees and dues on behalf of the association.
(3)(A) Under a policy issued to a trust, or to one or more trustees of a fund established
and maintained, directly or indirectly, by:
(i) two or more employers;
(ii) one or more labor unions or similar employee organizations; or
(iii) one or more employers and one or more labor unions or similar employee organizations.
(B)(i) A policy under this subdivision (3) must be issued to the trust or trustees for the
purpose of insuring all of the employees of the employers or all of the members of
the unions or organizations, or all of any class or classes of employees or members,
together, in each case, with the employees’ or members’ dependents, as applicable,
for the benefit of persons other than the employers or the unions or organizations.
(ii) A policy issued to a trust shall insure all eligible persons, except those who reject
coverage in writing.
(4) Under a policy issued to any other substantially similar group that, in the discretion
of the Commissioner, may be subject to the issuance of a group accident and sickness
policy or contract. (Recodified and amended 2025, No. 11, § 2, eff. September 1, 2025.)
§ 4042. Group insurance policies; required policy provisions
(a) Terms and conditions. No group health insurance policy shall contain any provision relating to notice of
claim, proofs of loss, time of payment of claims, or time within which legal action
must be brought upon the policy that, in the opinion of the Commissioner, is less
favorable to the persons insured than would be permitted by the provisions set forth
in section 4029 of this title. In addition, each such policy shall contain in substance the following provisions:
(1) A provision that the policy; the application of the policyholder, if an application
or copy is attached to the policy; and the individual applications, if any, submitted
by the employees or members in connection with the policy shall constitute the entire
contract between the parties, and that all statements, in the absence of fraud, made
by any applicant or applicants shall be deemed representations and not warranties,
and that no such statement shall avoid the insurance or reduce benefits under the
policy unless contained in a written application, of which a copy is attached to the
policy.
(2) A provision that the health insurer will furnish to the policyholder, for delivery
to each employee or member of the insured group, an individual certificate setting
forth in summary form a statement of the essential features of the insurance coverage
of the employee or member and to whom benefits are payable under the policy. If dependents
are included in the coverage, only one certificate need be issued for each family
unit.
(3) A provision that to the group originally insured may be added from time to time eligible
new employees or members or dependents, as the case may be, in accordance with the
terms of the policy.
(4) A provision that the health insurer shall not exclude part-time employees and shall
offer the same group health benefits to part-time employees as it offers to the employee
groups of which the part-time employees would be members if they were full-time employees.
The health insurer shall offer to include the part-time employees as part of the employer’s
employee group, at the full rate to be paid by the employer and the employee, at a
rate prorated between the employer and the employee, or at the employee’s expense.
As used in this subdivision, “part-time employee” means any employee who works a minimum
of at least 17.5 hours per week.
(b) Protections for covered individuals.
(1) Preexisting condition exclusions. A group insurance policy shall not contain any provision that excludes, restricts,
or otherwise limits coverage under the policy for one or more preexisting health conditions.
(2) Annual limitations on cost sharing.
(A)(i) The annual limitation on cost sharing for self-only coverage for any year shall be
the same as the dollar limit established by the federal government for self-only coverage
for that year in accordance with 45 C.F.R. § 156.130.
(ii) The annual limitation on cost sharing for other than self-only coverage for any year
shall be twice the dollar limit for self-only coverage described in subdivision (i)
of this subdivision (A).
(B)(i) In the event that the federal government does not establish an annual limitation on
cost sharing for any plan year, the annual limitation on cost sharing for self-only
coverage for that year shall be the dollar limit for self-only coverage in the preceding
calendar year, increased by any percentage by which the average per capita premium
for health insurance coverage in Vermont for the preceding calendar year exceeds the
average per capita premium for the year before that.
(ii) The annual limitation on cost sharing for other than self-only coverage for any year
in which the federal government does not establish an annual limitation on cost sharing
shall be twice the dollar limit for self-only coverage described in subdivision (i)
of this subdivision (B).
(3) Ban on annual and lifetime limits. A group insurance policy shall not establish any annual or lifetime limit on the
dollar amount of essential health benefits, as defined in Section 1302(b) of the Patient
Protection and Affordable Care Act of 2010, Pub. L. No. 111-148, as amended by the Health Care and Education Reconciliation Act of 2010, Pub. L. No. 111-152, and applicable regulations and federal guidance, for any individual insured under
the policy, regardless of whether the services are provided in-network or out-of-network.
(4) No cost sharing for preventive services.
(A) A group insurance policy shall not impose any co-payment, coinsurance, or deductible
requirements for:
(i) preventive services that have an “A” or “B” rating in the current recommendations
of the U.S. Preventive Services Task Force;
(ii) immunizations for routine use in children, adolescents, and adults that have in effect
a recommendation from the Advisory Committee on Immunization Practices of the Centers
for Disease Control and Prevention with respect to the individual involved;
(iii) with respect to infants, children, and adolescents, evidence-informed preventive care
and screenings as set forth in comprehensive guidelines supported by the federal Health
Resources and Services Administration; and
(iv) with respect to women, to the extent not included in subdivision (i) of this subdivision
(4)(A), evidence-informed preventive care and screenings set forth in binding comprehensive
health plan coverage guidelines supported by the federal Health Resources and Services
Administration.
(B) Subdivision (A) of this subdivision (4) shall apply to a high-deductible health plan
only to the extent that it would not disqualify the plan from eligibility for a health
savings account pursuant to 26 U.S.C. § 223.
(5) Definition of “group insurance policy.” As used in this subsection, “group insurance policy” has the same meaning as “group
health plan” and shall be subject to the same excepted benefits, in each case, as
set forth in 45 C.F.R. § 146.145, as in effect as of December 31, 2017. (Recodified and amended 2025, No. 11, § 2, eff. September 1, 2025.)
§ 4043. Association health plans
(a)(1) As used in this section, “association health plan” means a policy issued to an association;
to a trust; or to one or more trustees of a fund established, created, or maintained
for the benefit of the members of one or more associations or a contract or plan issued
by an association or trust or by a multiple employer welfare arrangement as defined
in the Employee Retirement Income Security Act of 1974, 29 U.S.C. § 1001 et seq.
(2) No association health plan shall be issued, offered, or renewed in this State to any
person other than an association that was formed or could have been formed under the
Employee Retirement Income Security Act of 1974, 29 U.S.C. § 1001 et seq., and accompanying U.S. Department of Labor regulations and guidance, in each
case, as in effect as of January 19, 2017.
(b) The Commissioner shall adopt rules pursuant to 3 V.S.A. chapter 25 regulating association health plans in order to protect Vermont consumers and promote
the stability of Vermont’s health insurance markets, to the extent permitted under
federal law, including rules regarding licensure, solvency and reserve requirements,
and rating requirements.
(c) The provisions of section 3661 of this title shall apply to association health plans. (Recodified and amended 2025, No. 11, § 2, eff. September 1, 2025.)
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Subchapter 006: OTHER FORMS OF HEALTH COVERAGE
§ 4051. Medicare supplement insurance policies [Effective until January 1, 2026; see also 8 V.S.A. § 4051 effective January 1, 2026 set out below]
(a) Community rating.
(1) A health insurer shall use a community rating method acceptable to the Commissioner
for determining premiums for Medicare supplement insurance policies.
(2) The Commissioner shall adopt rules for standards and procedure for permitting health
insurers that issue Medicare supplement insurance policies to use one or more risk
classifications in their community rating method. The premium charged shall not deviate
from the community rate and the rules shall not permit medical underwriting and screening,
except that a health insurer may set different community rates for persons eligible
for Medicare by reason of age and persons eligible for Medicare by reason of disability.
(b) Premium increases.
(1) Within five days after receiving a request for approval of any composite average rate
increase in excess of three percent, or any other coverage changes that the Commissioner
determines will have a comparable impact on cost or availability of coverage for a
Medicare supplement insurance policy issued by any health insurer with 5,000 or more
total lives in the Vermont Medicare supplement insurance market, the Commissioner
shall notify the Department of Disabilities, Aging, and Independent Living of the
proposed premium increase. A composite average rate is the enrollment-weighted average
rate increase of all plans offered by a health insurer.
(2) Within five days after receiving notification pursuant to subdivision (1) of this
subsection, the Department of Disabilities, Aging, and Independent Living shall inform
the members of the Advisory Board established pursuant to 33 V.S.A. § 505 of the proposed premium increase.
(3)(A) The Commissioner shall not approve any request to increase Medicare supplement insurance
premium rates unless the amount of the rate increase complies with the statutory standards
for approval under sections 4026, 4513, 4584, and 5104 of this title. Any approved rate increase shall not be based on an unreasonable change in loss
ratio from the previous year, unless the Commissioner makes written findings that
such change is necessary to prevent a substantial adverse impact on the financial
condition of the health insurer. In acting on such rate increase requests, the Commissioner
may deny the request, approve the rate increase as requested, or approve a rate increase
in an amount different from the increase requested. A decision by the Commissioner
other than an approval of the rate requested may be appealed by the health insurer,
provided that the burden of proof shall be on the health insurer to show that the
approved rate does not meet the statutory standards established under this subsection.
(B) Before acting on the rate increase requested, the Commissioner may make such examination
or investigation as the Commissioner deems necessary, including where applicable the
review process set forth in subdivision (C) of this subdivision (3).
(C)(i) In reviewing any Medicare supplement insurance rate increase for which an independent
analysis has been performed pursuant to 33 V.S.A. § 6706 and in which the health insurer’s requested composite average increase, the independent
expert’s recommended composite average rate increase, or the Department actuary’s
recommended composite average rate increase differ by two percentage points or more,
the Commissioner shall hold a public hearing at which the health insurer, the Department’s
actuary, the independent expert, any intervenor, and the public will have the opportunity
to present written and oral testimony and will be available to answer questions of
the Commissioner and those present.
(ii) The hearing shall be noticed and held at a time and place so as to facilitate public
participation and shall be recorded and become part of the record before the Commissioner.
At the Commissioner’s discretion, the hearing may be conducted remotely.
(iii) If the carrier’s requested composite average increase, the independent expert’s recommended
composite average increase, or the Department actuary’s recommended composite average
increase differs by less than two percentage points, the Department and the parties
shall confer by conference call, or by any other available media, to review the rate
requests and recommendations. However, a public hearing may be held at the Commissioner’s
discretion for good cause shown.
(D)(i) In any review held in accordance with this subdivision (3), the Commissioner shall
permit intervention by any person whom the Commissioner determines will materially
advance the interests of the covered individuals. The intervenor shall have access
to and may use the information of the independent expert appointed under 33 V.S.A. § 6706.
(ii) The reasonable and necessary cost of intervention as determined by the Commissioner
shall be paid by the affected policyholders or certificate holders. The maximum payment
shall be $2,500.00 except when waived by the Commissioner for good cause shown. The
$2,500.00 maximum amount may be adjusted to reflect, at the Commissioner’s discretion,
appropriate inflation factors.
(E) Nonproprietary, relevant information in any Medicare supplement insurance rate filing,
including any analysis by the Department’s actuary and the independent expert, shall
be made available to the public upon request.
(c) Disability.
(1) A health insurer that issues Medicare supplement insurance policies or certificates
to a person eligible for Medicare by reason of age shall make available, to persons
eligible for Medicare by reason of disability, the same policies or certificates that
are offered and sold to persons eligible for Medicare by reason of age. The initial
enrollment period for any such policies or certificates shall be at least six months
following the date the individual becomes eligible for Medicare by reason of disability.
Any additional enrollment periods as required by law and offered to individuals eligible
by reason of age shall be offered to individuals eligible by reason of disability.
(2) This subsection does not apply to persons eligible for Medicare by reason of end stage
renal disease.
(d) Outreach and education. The Department of Financial Regulation shall collaborate with health insurers, advocates
for older Vermonters and for other Medicare-eligible adults, and the Office of the
Health Care Advocate to educate the public about the benefits and limitations of Medicare
supplement insurance policies and Medicare Advantage plans, including information
to help the public understand issues relating to coverage, costs, and provider networks. (Recodified and amended 2025, No. 11, § 2, eff. September 1, 2025.)
§ 4051. Medicare supplement insurance policies [Effective January 1, 2026; see also 8 V.S.A. § 4051 effective until January 1, 2026 set out above]
(a) Community rating.
(1) A health insurer shall use a community rating method acceptable to the Commissioner
for determining premiums for Medicare supplement insurance policies.
(2) The Commissioner shall adopt rules for standards and procedure for permitting health
insurers that issue Medicare supplement insurance policies to use one or more risk
classifications in their community rating method. The premium charged shall not deviate
from the community rate and the rules shall not permit medical underwriting and screening,
except that a health insurer may set different community rates for persons eligible
for Medicare by reason of age and persons eligible for Medicare by reason of disability.
(b) Premium increases.
(1) Within five business days after receiving any request to increase the premium rate
for a Medicare supplement insurance policy from the health insurer issuing the policy,
the Department shall post information about the rate filing on the Department’s website,
including:
(A) the name of the health insurer requesting the rate increase;
(B) the overall composite average rate increase requested;
(C) the increase requested by plan type;
(D) the date on which the proposed increase would take effect;
(E) the System for Electronic Rate and Form Filing (SERFF) tracking number associated
with the filing and a web address for accessing the filing electronically; and
(F) instructions for submitting public comments and the deadline for doing so.
(2) Within five business days after receiving a request for approval of any composite
average rate increase in excess of 10 percent, or any other coverage changes that
the Commissioner determines will have a comparable impact on cost or availability
of coverage for a Medicare supplement insurance policy issued by any health insurer
with 5,000 or more total lives in the Vermont Medicare supplement insurance market,
the Commissioner shall notify the Department of Disabilities, Aging, and Independent
Living and the Office of the Health Care Advocate of the proposed premium increase.
A composite average rate is the enrollment-weighted average rate increase of all plans
offered by a health insurer.
(3) Within five business days after receiving notification pursuant to subdivision (2)
of this subsection, the Department of Disabilities, Aging, and Independent Living
shall inform the members of the Advisory Board established pursuant to 33 V.S.A. § 505 of the proposed premium increase.
(4)(A) The Commissioner shall not approve any request to increase Medicare supplement insurance
premium rates unless the amount of the rate increase complies with the statutory standards
for approval under sections 4026, 4513, 4584, and 5104 of this title. Any approved rate increase shall not be based on an unreasonable change in loss
ratio from the previous year, unless the Commissioner makes written findings that
such change is necessary to prevent a substantial adverse impact on the financial
condition of the health insurer. In acting on such rate increase requests, the Commissioner
may deny the request, approve the rate increase as requested, or approve a rate increase
in an amount different from the increase requested. A decision by the Commissioner
other than an approval of the rate requested may be appealed by the health insurer,
provided that the burden of proof shall be on the health insurer to show that the
approved rate does not meet the statutory standards established under this subdivision
(b)(4).
(B) Before acting on the rate increase requested, the Commissioner may make such examination
or investigation as the Commissioner deems necessary.
(C)(i) For any filing by a health insurer with 5,000 or more total lives in the Vermont Medicare
supplement insurance market in which the requested composite average rate increase
exceeds 10 percent, the Commissioner shall:
(I) solicit public comment; and
(II) hold a public hearing in accordance with the Department of Financial Regulation’s
applicable rules regarding administrative procedures if, not later than 30 days after
the rate filing information is posted on the Department’s website pursuant to subdivision
(1) of this subsection, a hearing is requested by the Department of Disabilities,
Aging, and Independent Living; by the Office of the Health Care Advocate; or by not
fewer than 25 policyholders whose premium rates would be affected by the requested
rate increase.
(ii) For any filing that does not meet the criteria specified in subdivision (i) of this
subdivision (C), a public hearing may be held in the Commissioner’s discretion.
(iii) In the Commissioner’s discretion, a hearing held pursuant to this subdivision (C)
may be conducted through a designated electronic meeting platform.
(D) In any review held in accordance with this section, the Commissioner shall permit
intervention by any person whom the Commissioner determines will materially advance
the interests of the individuals insured under the policy.
(E) Nonproprietary, relevant information in any Medicare supplement rate filing, including
any analysis by the Department’s actuary, shall be made available to the public upon
request.
(c) Disability.
(1) A health insurer that issues Medicare supplement insurance policies or certificates
to a person eligible for Medicare by reason of age shall make available, to persons
eligible for Medicare by reason of disability, the same policies or certificates that
are offered and sold to persons eligible for Medicare by reason of age. The initial
enrollment period for any such policies or certificates shall be at least six months
following the date the individual becomes eligible for Medicare by reason of disability.
Any additional enrollment periods as required by law and offered to individuals eligible
by reason of age shall be offered to individuals eligible by reason of disability.
(2) This subsection does not apply to persons eligible for Medicare by reason of end stage
renal disease.
(d) Premium rate filing deadlines. For a Medicare supplement insurance policy with an effective date of January 1, the
insurer shall file its premium rate request pursuant to this section not later than
July 1 of the preceding year. For a Medicare supplement insurance policy with an effective
date other than January 1, the insurer shall file its rate request pursuant to this
section not later than six months prior to the effective date of the policy.
(e) Outreach and education. The Department of Financial Regulation shall collaborate with health insurers, advocates
for older Vermonters and for other Medicare-eligible adults, and the Office of the
Health Care Advocate to educate the public about the benefits and limitations of Medicare
supplement insurance policies and Medicare Advantage plans, including information
to help the public understand issues relating to coverage, costs, and provider networks.
(Recodified and amended 2025, No. 11, § 2, eff. September 1, 2025; amended 2025, No. 23, § 20, eff. January 1, 2026.)
§ 4052. Blanket health insurance
(a) Blanket health insurance is a form of health insurance that, to the extent permitted
under federal law, is supplemental to major medical health insurance or provides coverage
other than the payment of all or a portion of the cost of health care services or
products, and that covers special groups of persons as follows:
(1) under a policy or contract issued to any common carrier, which shall be deemed the
policyholder, covering a group defined as all persons who may become passengers on
such common carrier;
(2) under a policy or contract issued to an employer, who shall be deemed the policyholder,
covering any group of employees defined by reference to exceptional hazards incident
to such employment;
(3) under a policy or contract issued to a public school, independent school, or approved
education program, as those terms are defined in 16 V.S.A. § 11; to a postsecondary school, as defined in 16 V.S.A. § 176(b)(1); or to a prequalified private prekindergarten provider, as defined in 16 V.S.A. § 829(a)(3), or to the head or principal of the school, program, or provider, who or which shall
be deemed the policyholder, covering students or teachers, or both;
(4) under a policy or contract issued in the name of any volunteer fire department, emergency
medical services provider, or other such volunteer group, which shall be deemed the
policyholder, covering all of the members of the department or group in connection
with their department or group activities; or
(5) under a policy or contract issued to any other substantially similar group that, in
the discretion of the Commissioner and after the prior approval by the Commissioner
of the group, may be subject to the issuance of a blanket health policy or contract.
(b)(1) No blanket health insurance policy shall contain any provision relating to notice
of claim, proofs of loss, time of payment of claims, or time within which legal action
must be brought upon the policy that, in the opinion of the Commissioner, is less
favorable to the persons insured than would be permitted by the provisions set forth
in section 4029 of this title.
(2) An individual application shall not be required from a person covered under a blanket
health policy or contract, nor shall it be necessary for the insurer to furnish each
person a certificate.
(3) All benefits under any blanket health policy shall, unless for hospital and physician
service or surgical benefits, be payable to the person insured, or to the person’s
designated beneficiary or beneficiaries, or to the person’s estate, except that if
the person insured is a minor, the benefits may be made payable to the minor’s parent,
guardian, or other person actually supporting the minor.
(4) Nothing in this section shall be deemed to affect the legal liability of policyholders
for the death of, or injury to, any members of the group.
(c) No blanket health insurance policy that provides coverage for the payment of all or
a portion of the cost of health care services or products shall contain any provision
that does not comply with a requirement of this title, or a rule adopted pursuant
to this title applicable to health insurance, other than those requirements applicable
to nongroup health insurance or small group health insurance. The Commissioner may
waive the application to a blanket insurance policy of one or more of the health insurance
requirements of this title, or a rule adopted pursuant to this title, if the requirement
is not relevant to the types of risks and duration of risks insured against in the
blanket insurance policy. (Recodified and amended 2025, No. 11, § 2, eff. September 1, 2025.)
§ 4053. Short-term, limited-duration health insurance
(a) As used in this section, “short-term, limited-duration health insurance” means health
insurance that provides medical, hospital, or major medical expense benefits coverage
pursuant to a policy or contract with a health insurer and that has an expiration
date specified in the policy or contract that is three months or less after the original
effective date of the policy or contract.
(b) No person shall provide short-term, limited-duration health insurance coverage without
a certificate of authority from the Commissioner to offer health insurance in this
State unless the person is exempted by subdivision 3368(a)(4) of this title.
(c) A short-term, limited-duration health insurance policy or contract shall be nonrenewable,
and a health insurer shall not issue a short-term, limited-duration health insurance
policy or contract to any person if the issuance would result in the person being
covered by short-term, limited-duration health insurance coverage for more than three
months in any 12-month period.
(d) A policy or contract for short-term, limited-duration health insurance coverage shall
display prominently in the policy or contract and in any application materials provided
in connection with enrollment in that coverage, in at least 14-point type, certain
disclosures regarding the scope of short-term, limited-duration health insurance coverage,
including the types of benefits and consumer protections that are and are not included.
The Commissioner shall determine the specific disclosure language that shall be used
in all short-term, limited-duration health insurance policies, contracts, and application
materials and shall provide the language to the health insurers offering that coverage.
(e) The Commissioner shall adopt rules pursuant to 3 V.S.A. chapter 25:
(1) establishing the minimum financial, marketing, service, and other requirements for
registration of a health insurer to provide short-term, limited-duration health insurance
coverage to individuals in this State;
(2) requiring a health insurer seeking to provide short-term, limited-duration health
insurance coverage to individuals in this State to file its rates and forms with the
Commissioner for the Commissioner’s approval;
(3) requiring a health insurer seeking to provide short-term, limited-duration health
insurance coverage to individuals in this State to file its advertising materials
with the Commissioner for the Commissioner’s approval; and
(4) establishing such other requirements as the Commissioner deems necessary to protect
Vermont consumers and promote the stability of Vermont’s health insurance markets.
(f) The provisions of section 4063 of this title, and any rules adopted under that section, shall apply to short-term, limited-duration
health insurance coverage. (Recodified and amended 2025, No. 11, § 2, eff. September 1, 2025.)
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Subchapter 007: CHILD AND DEPENDENT COVERAGE
§ 4057. Coverage of children
(a) Definition. “Health insurance plan” has the same meaning as in section 4011 of this chapter and
shall be subject to the same excepted benefits, in each case, as set forth in 45 C.F.R. § 146.145, as in effect as of December 31, 2017.
(b) Newborn coverage.
(1) A health insurance plan that provides dependent coverage of children shall also provide
that health insurance benefits applicable to children are payable with respect to
a newly born child of the insured or subscriber from the moment of birth. Coverage
for a newly born child shall include coverage of injury, sickness, and necessary care
and treatment of medically diagnosed congenital defect or birth abnormality.
(2) Coverage for a newly born child shall be provided without notice or additional premium
for not less than 60 days after the date of birth. If payment of a specific premium
or subscription fee is required in order to have the coverage continue beyond such
60-day period, the policy may require that notification of the birth of the newly
born child and payment of the required premium or fees be furnished to the health
insurer within a period of not less than 60 days after the date of birth.
(c) Adopted child coverage.
(1) As used in this section:
(A) “Child” means, in connection with any adoption or placement for adoption of the child,
an individual who has not attained 18 years of age as of the date of the adoption
or placement for adoption.
(B) “Placement for adoption” means the assumption and retention by a person of a legal
obligation for total or partial support of a child in anticipation of the adoption
of the child. The child’s placement with a person terminates upon the termination
of such legal obligations.
(2) In any case in which a health insurance plan provides coverage for dependent children
of covered individuals, the plan shall provide benefits to dependent children placed
with covered individuals for adoption under the same terms and conditions as apply
to the natural, dependent children of the covered individuals, irrespective of whether
the adoption has become final.
(3) A health insurance plan shall not restrict coverage under the plan of any dependent
child adopted by a covered individual, or placed with a covered individual for adoption,
solely on the basis of a preexisting condition of the child at the time that the child
would otherwise become eligible for coverage under the plan, if the adoption or placement
for adoption occurs while the covered individual is eligible for coverage under the
plan.
(d) Coverage required until 26 years of age. A health insurance plan that provides dependent coverage of children shall continue
to make that coverage available for an adult child until the child attains 26 years
of age, provided that this subsection shall not apply to a plan providing coverage
for a specified disease or other limited benefit coverage, and further provided that
nothing in this subsection shall require a plan to make coverage available for the
child of a child receiving dependent coverage.
(e) Coverage of adult child with a disability.
(1) A health insurance plan that provides for terminating the coverage of a dependent
child upon attainment of the limiting age for dependent children specified in the
policy shall not limit or restrict coverage with respect to an unmarried child who
meets all of the following criteria:
(A) is incapable of self-sustaining employment by reason of a mental or physical disability
that has been found to be a disability that qualifies or would qualify the child for
benefits using the definitions, standards, and methodology in 20 C.F.R. Part 404, Subpart P;
(B) became so incapable prior to attainment of the limiting age; and
(C) is chiefly dependent upon the employee, member, subscriber, or policyholder for support
and maintenance.
(2) Coverage under subdivision (1) of this subsection shall not be denied any person based
upon the existence of such a condition; provided, however, that a health insurance
plan may require reasonable periodic proof of a continuing condition not more frequently
than once every year.
(f) Coverage of leave of absence from college. A health insurance plan that covers dependent children who are full-time college students
beyond 18 years of age shall include coverage for a dependent’s medically necessary
leave of absence from school for a period not to exceed 24 months or the date on which
coverage would otherwise end pursuant to the terms and conditions of the policy or
coverage, whichever comes first, except that coverage may continue under subsection
(b) of this section as appropriate. To establish entitlement to coverage under this
subsection, documentation and certification by the student’s treating health care
professional of the medical necessity of a leave of absence shall be submitted to
the health insurer or, for self-insured plans, the health plan administrator. The
health insurance plan may require reasonable periodic proof from the student’s treating
health care professional that the leave of absence continues to be medically necessary.
(g) Parental rights. When a child has health coverage through the health insurer of a parent, the health
insurer shall:
(1) provide such information to either parent as may be necessary for the child to obtain
benefits through that coverage;
(2) permit either parent, a provider with parental authorization, the State Medicaid agency
as assignee, or any State agency administering health benefits or a health benefit
plan for which Medicaid is a source of funding to submit claims for covered services,
and to appeal the denial of any benefit, without the approval of the other parent;
and
(3) make payments on claims submitted in accordance with subdivision (2) of this subsection
directly to the parent who paid the provider, the provider as assignee, the State
Medicaid agency, or any State agency administering health benefits or a health benefit
plan for which Medicaid is a source of funding.
(h) Child vaccine coverage. No health insurer shall reduce its coverage for pediatric vaccines below the coverage
provided as of May 1, 1993. (Recodified and amended 2025, No. 11, § 2, eff. September 1, 2025.)
§ 4058. Medical support orders
(a) As used in this section:
(1) “Dependent coverage” means family coverage, or coverage for one or more persons as
long as the coverage for one or more persons is greater than or equal to the coverage
available under family coverage.
(2) “Health insurance plan” has the same meaning as in section 4011 of this chapter and
shall be subject to the same excepted benefits, in each case, as set forth in 45 C.F.R. § 146.145, as in effect as of December 31, 2017.
(b) A health insurer shall not deny enrollment of a child under the health insurance plan
of the child’s parent who is ordered to provide medical support on the grounds that:
(1) the child was born to unmarried parents;
(2) the child is not claimed as a dependent on the parent’s federal tax return; or
(3) the child does not reside with the parent or in the health insurer’s service area.
(c) When a parent is required by a court or administrative order to provide health coverage
for a child, and the parent is eligible for dependent health coverage, the health
insurer shall be required:
(1) To enroll, under the dependent coverage, a child who is otherwise eligible for the
coverage without regard to any enrollment season restrictions or any seasonal restrictions
on switching from one plan to another, upon application of either parent, the employer,
the State agency administering the Medicaid program, any State agency administering
health benefits or a health insurance plan for which Medicaid is a source of funding,
or the child support enforcement program.
(2) Not to disenroll or eliminate coverage of the child unless the health insurer is provided
satisfactory written evidence that:
(A) the court or administrative order is no longer in effect;
(B) the child is or will be enrolled in comparable health coverage through another health
insurer that will take effect not later than the effective date of disenrollment;
or
(C) the employer has eliminated dependent health coverage for all of its employees if
allowed by law.
(3) To provide enrollment under subdivision (1) of this subsection with coverage effective
three days after the mailing of notice of the court or administrative order to the
health insurer or upon actual receipt of notice by the health insurer, whichever is
sooner. The health insurer shall have 10 days from notice to process the enrollment
and shall be entitled to premiums from the effective date of enrollment.
(d) A health insurer shall not impose requirements on a State agency that has been assigned
the rights of an individual eligible for medical assistance under Medicaid and covered
for health benefits from the health insurer that are different from requirements applicable
to an agent or assignee of any other individual so covered.
(e) Any health insurer that fails to enroll a child after notice under 15 V.S.A. § 663(d) or 33 V.S.A. § 4110(a)(4) shall be directly liable for any medical expenses of the child that would have been
covered under the health insurance plan had the health insurer enrolled the child
upon receiving notice.
(f) Notice by first-class mail, postage prepaid, or by any other method showing actual
receipt shall be presumptive evidence of its receipt by the health insurer to whom
it is addressed. Any period of time that is determined under this section by the giving
of notice shall commence to run from the date of mailing, if the notice is mailed,
or the date of actual receipt if another method of transmitting the notice is used.
(g) A health insurer may cancel any health insurance plan that is the subject of a medical
support order for nonpayment of premium only if the health insurer mails or delivers
notice of cancellation to both parents and all other persons or agencies identified
in the medical support order. Any health insurer cancelling a health insurance plan
for nonpayment of premium shall reinstate the health insurance plan effective from
the date of cancellation if the nonpayment of premium is cured within 45 days of the
cancellation. (Recodified and amended 2025, No. 11, § 2, eff. September 1, 2025.)
§ 4059. Coverage for civil unions
(a) As used in this section:
(1) “Dependent coverage” means family coverage or coverage for one or more persons.
(2) “Party to a civil union” has the same meaning as in 15 V.S.A. § 1201.
(b) Notwithstanding any provision of law to the contrary, health insurers shall provide
dependent coverage to parties to a civil union that is equivalent to that provided
to covered individuals who are married. A health insurance policy that provides coverage
for a spouse or family member of the covered individual shall also provide the equivalent
coverage for a party to a civil union. (Recodified and amended 2025, No. 11, § 2, eff. September 1, 2025.)
§ 4060. Coverage for employees of an employer domiciled outside Vermont
(a) As used in this section:
(1) “Marriage” has the same meaning as in 15 V.S.A. § 8.
(2) “Party to a civil union” has the same meaning as in 15 V.S.A. § 1201.
(b) To the extent permitted under federal law, health insurance coverage provided to Vermont
residents who work for an employer domiciled outside Vermont shall not distinguish
between parties to a civil union, married same-sex couples, and married opposite-sex
couples. (Recodified and amended 2025, No. 11, § 2, eff. September 1, 2025.)
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Subchapter 008: INTERNAL AND EXTERNAL REVIEWS
§ 4063. Independent external review of health care service decisions
(a) As used in this section, “covered individual” includes a member of a health insurance
plan not otherwise subject to the Department’s jurisdiction that has voluntarily agreed
to use the external review process provided under this section.
(b) A covered individual who has exhausted all applicable internal review procedures provided
by the health insurance plan shall have the right to an independent external review
of a decision under a health insurance plan to deny, reduce, or terminate health care
coverage or to deny payment for a health care service. The independent review shall
be available when requested in writing by the affected covered individual, provided
the decision to be reviewed requires the plan to expend at least $100.00 for the service
and the decision by the plan is based on one of the following reasons:
(1) The health care service is a covered benefit that the health insurer has determined
to be not medically necessary.
(2) A limitation is placed on the selection of a health care provider that is claimed
by the covered individual to be inconsistent with limits imposed by the health insurance
plan and any applicable laws and rules.
(3) The health care treatment has been determined to be experimental or investigational
or is an off-label drug. A health insurance plan that denies use of a prescription
drug for the treatment of cancer as not medically necessary or as an experimental
or investigational use shall treat any internal appeal of such denial as an emergency
or urgent appeal and shall decide the appeal within the time frames applicable to
emergency and urgent internal appeals under rules adopted by the Commissioner.
(4) The health care service involves a medically based decision that a condition is preexisting.
(5) The decision involves an adverse determination related to surprise medical billing,
as established under Section 2799A-1 or 2799A-2 of the Public Health Service Act,
including with respect to whether an item or service that is the subject of the adverse
determination is an item or service to which Section 2799A-1 or 2799A-2 of the Public
Health Service Act, or both, applies.
(c) The right to review under this section shall not be construed to change the terms
of coverage under a health insurance plan.
(d) The Department shall adopt rules necessary to carry out the purposes of this section.
The rules shall ensure that the independent external reviews have the following characteristics:
(1) The independent external reviews shall be conducted:
(A) by independent review organizations pursuant to a contract with the Department, and
the reviewers shall include health care providers credentialed with respect to the
health care service under review and shall have no conflict of interest relating to
the performance of their duties under this section; and
(B) in accordance with standards of decision making based on objective clinical evidence,
shall resolve all issues in a timely manner, and shall provide expedited resolution
when the decision relates to emergency or urgent health care services.
(2) A covered individual shall:
(A) Be provided with adequate notice of the covered individual’s review rights under this
section.
(B) Have the right to use outside assistance during the review process and to submit evidence
relating to the health care service.
(C) Pay an application fee of $25.00 for each request for an independent external review
of an appealable decision not to exceed a total of $75.00 annually. The application
fee may be waived or reduced based on a determination by the Commissioner that the
financial circumstances of the covered individual warrant a waiver or reduction. The
application fee shall be paid by the health insurer, not the covered individual, if
the independent review organization reverses the health insurer’s decision to deny
payment for a health care service.
(D) Be protected from retaliation for exercising the covered individual’s right to an
independent external review under this section.
(3) Other costs of the independent review shall be paid by the health insurance plan.
(4) The independent review organization shall issue to both parties a written review decision
that is evidence-based. The decision shall be binding on the health insurance plan.
(5) The confidentiality of any health care information acquired or provided to the independent
review organization shall be maintained in compliance with any applicable State or
federal laws.
(6) The records of, and internal materials prepared for, specific reviews by any independent
review organization under this section shall be exempt from public inspection and
copying under the Public Records Act.
(e) Decisions relating to the following health care services shall not be reviewed under
this section but shall be reviewed by the review process provided by law:
(1) health care services provided by the Vermont Medicaid program or Medicaid benefits
provided through a contracted health plan; and
(2) health care services provided to incarcerated individuals by the Department of Corrections. (Recodified and amended 2025, No. 11, § 2, eff. September 1, 2025.)
§ 4064. Mental health services review
(a) The purposes of this section are to:
(1) promote the delivery of quality mental health services in a cost-effective manner;
(2) foster the practice of mental health services review as a professional collaborative
process, the primary objective of which is to enhance the effectiveness of clinical
treatment;
(3) protect clients and patients, employers, and mental health providers by ensuring that
review agents are qualified to perform service review activities and to make informed
decisions on the appropriateness of mental health care; and
(4) ensure the confidentiality of clients’ and patients’ mental health records in the
performance of service review activities in accordance with applicable State and federal
laws.
(b) Definitions. As used in this section:
(1) “License” means a review agent’s license granted by the Commissioner.
(2) “Mental health provider” means any individual, corporation, facility, or institution
certified or licensed by this State to provide mental health services, including a
physician, nurse with recognized psychiatric specialties, hospital or other health
care facility, psychologist, clinical social worker, mental health counselor, alcohol
or drug abuse counselor, or an employee or agent of such mental health provider acting
in the course and scope of employment or an agency related to mental health services.
(3) “Mental health services” mean acts of diagnosis, treatment, evaluation, or advice
or any other acts permissible under the health care laws of Vermont, whether performed
in an outpatient or institutional setting, and include treatment for substance use
disorder.
(4) “Review agent” means a person or entity performing service review activities within
one year following the date of submission of a fully compliant application for licensure
who is affiliated with, under contract with, or acting on behalf of a business entity
in this State and who provides or administers mental health benefits to members of
health insurance plans subject to the Department’s jurisdiction, including a health
insurer.
(5) “Service review” means any system for reviewing the appropriate and efficient allocation
of mental health services given or proposed to be given to a client or patient, or
to a group of clients or patients, for the purpose of recommending or determining
whether the services should be covered and includes activities of utilization review
and managed care, but does not include professional peer review that does not affect
reimbursement for or provision of services.
(c) Any person who approves or denies payment, or who recommends approval or denial of
payment, for mental health services, or whose review results in approval or denial
of payment for mental health services on a case-by-case basis, shall not review these
services in this State unless the Commissioner has granted the person a review agent’s
license. The Commissioner shall adopt rules to implement the provisions of this section,
including the procedures and standards for licensure. The rules shall differentiate
between health maintenance organizations licensed to do business within this State
and other forms of utilization review. The rules shall establish:
(1) A requirement that within 10 business days after receiving a request for them, the
review agent shall make available at no cost to the clients, patients, and providers
affected by its service review activities the specific review criteria and standards,
credentials of the reviewing professionals, and procedures and methods to be used
in evaluating proposed or delivered mental health services.
(2) A time period within which any determination regarding the provision or reimbursement
of mental health services shall be made.
(3) A requirement that any determination regarding mental health services rendered or
to be rendered to a client or patient that may result in a denial of third-party reimbursement
or a denial of precertification for that service shall include the evaluation, findings,
and concurrence of a mental health professional whose training and expertise is at
least comparable to that of the treating mental health provider.
(4) The type, qualifications, and number of personnel required to perform service review
activities.
(5) A requirement that a determination by a review agent that care rendered or to be rendered
is inappropriate shall not be made until the review agent has communicated with the
patient’s attending mental health provider concerning that care. The review shall
be prospective or concurrent with the treatment.
(6) A requirement that any determination that care rendered or to be rendered is inappropriate
shall include the written evaluation and findings of the review agent.
(7) A procedure for clients, patients, mental health providers, and hospitals to seek
prompt reconsideration before an independent review organization pursuant to section 4063 of this title of an adverse decision by a review agent. The external reviewer engaged by the independent
review organization shall have training and expertise at least comparable to that
of the treating health care provider.
(8) Policies and procedures to ensure that all applicable State and federal laws to protect
the confidentiality of individual mental health records are followed.
(9) Policies and procedures that ensure appropriate notification and concurrence of providers
and their clients or patients before client or patient interviews are conducted by
the review agent.
(10)(A) Prohibition of an agreement between the review agent and a business entity or third-party
payor in which payment to the review agent includes an incentive or contingent fee
arrangement based on the reduction of mental health services, reduction of length
of stay, reduction of treatment, or treatment setting selected.
(B) Nothing in this subdivision (10) shall prohibit capitation arrangements for reimbursement
for mental health services.
(C) A clinical decision made by the attending mental health provider regarding continued
treatment shall not be construed as a denial of services subject to the provisions
of this section.
(d) Reviewing agents shall be subject to the provisions of chapter 129 of this title governing
unfair insurance trade practices.
(e) The Commissioner shall have the authority to examine, take administrative action against,
and penalize review agents as provided in chapters 3, 101, and 129 of this title.
A person who violates any provision of this section or who submits any false information
in an application required by this section may be fined not more than $5,000.00 for
each violation.
(f) A review agent shall pay a license fee of $200.00 for the year of registration and
a renewal fee of $200.00 for each year thereafter. In addition, a review agent shall
pay any additional expenses incurred by the Commissioner to examine and investigate
an application or an amendment to an application.
(g) The confidentiality of any health care information acquired by or provided to an independent
review organization pursuant to section 4063 of this title shall be maintained in compliance with any applicable State or federal laws. Records
of, and internal materials prepared for, specific reviews under this section shall
be exempt from public inspection and copying under the Public Records Act. (Recodified and amended 2025, No. 11, § 2, eff. September 1, 2025.)
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Subchapter 009: REQUIRED COVERED BENEFITS
§ 4067. Application of subchapter
(a) Unless otherwise specified and to the extent not inconsistent with federal law, the
benefits required in this subchapter:
(1) apply only to major medical insurance plans;
(2) may be subject to deductibles, co-payment and coinsurance amounts, fee or benefit
limits, practice parameters, and utilization review consistent with any applicable
rules and guidance adopted by the Department of Financial Regulation; and
(3) do not apply to Vermont Medicaid.
(b) A health insurer may require benefits mandated in this subchapter to be provided by
a licensed health care provider under contract with the health insurer; provided,
however, that this provision shall not be construed to relieve a health insurance
plan from complying with the applicable network adequacy requirements adopted by the
Commissioner by rule. (Added 2025, No. 11, § 2, eff. September 1, 2025.)
§ 4068. Chiropractic services
(a) A health insurance plan shall provide coverage for clinically necessary health care
services provided by a chiropractic physician licensed in this State for treatment
within the scope of practice described in 26 V.S.A. chapter 10, but limiting adjunctive therapies to physiotherapy modalities and rehabilitative
exercises. A health insurance plan does not have to provide coverage for the treatment
of any visceral condition arising from problems or dysfunctions of the abdominal or
thoracic organs.
(b) A health insurer may require that the chiropractic services be provided upon referral
from a health care provider under contract with the health insurer.
(c) For silver- and bronze-level qualified health benefit plans and any reflective health
benefit plans offered at the silver or bronze level pursuant to 33 V.S.A. chapter 18, subchapter 1, health care services provided by a chiropractic physician may be subject
to a co-payment requirement, provided that any required co-payment amount shall be
between 125 and 150 percent of the amount of the co-payment applicable to care and
services provided by a primary care provider under the plan.
(d) Nothing in this section shall be construed as impeding or preventing either the provision
or coverage of health care services by licensed chiropractic physicians, within the
lawful scope of chiropractic practice, in hospital facilities on a staff or employee
basis. (Recodified and amended 2025, No. 11, § 2, eff. September 1, 2025.)
§ 4069. Prosthetic devices
(a) As used in this section, “prosthetic device” means an artificial limb device to replace,
in whole or in part, an arm or a leg.
(b) A health insurance plan shall provide coverage for prosthetic devices that is at least
equivalent to the coverage provided by the federal Medicare program. Coverage may
be limited to the prosthetic device that is the most appropriate model that is medically
necessary to meet the patient’s medical needs. Any dispute between the covered individual
and the carrier concerning coverage and the application of this section shall be subject
to independent external review under section 4063 of this title.
(c) A health insurance plan may require prior authorization for prosthetic devices in
the same manner and to the same extent as prior authorization is required for any
other covered benefit.
(d) A health insurance plan shall provide coverage under this section for the medically
necessary repair or replacement of a prosthetic device.
(e) The coverage for prosthetic devices shall not be subject to a deductible, co-payment,
or coinsurance provision that is less favorable to a covered individual than the deductible,
co-payment, or coinsurance provisions that apply generally to other nonprimary care
items and services under the health insurance plan. (Recodified and amended 2025, No. 11, § 2, eff. September 1, 2025.)
§ 4070. Hearing aid coverage in large group health insurance plans
(a) As used in this section:
(1) “Hearing aid” means any small, wearable electronic instrument or device designed and
intended for the ear for the purpose of aiding or compensating for impaired human
hearing and any related parts, attachments, or accessories, including earmolds and
associated remote microphones that pair with hearing aids to improve word comprehension
in difficult listening situations in live or telecommunication settings. The term
does not include large-audience assisted listening devices, such as those designed
for auditoriums, or stand-alone assisted listening devices that can function without
a hearing aid.
(2) “Hearing aid professional services” means the practice of fitting, selecting, dispensing,
selling, or servicing hearing aids, or a combination, including:
(A) evaluation for a hearing aid;
(B) fitting of a hearing aid;
(C) programming of a hearing aid;
(D) hearing aid repairs;
(E) follow-up adjustments, servicing, and maintenance of a hearing aid;
(F) ear mold impressions; and
(G) auditory rehabilitation and training.
(3) “Hearing care professional” means an audiologist or hearing aid dispenser licensed
under 26 V.S.A. chapter 67, a physician licensed under 26 V.S.A. chapter 23 or 33, a physician assistant licensed under 26 V.S.A. chapter 31, or an advanced practice registered nurse licensed under 26 V.S.A. chapter 28, working within that professional’s scope of practice.
(4) “Large group health insurance plan” means a major medical insurance plan that meets
the requirements of section 4041 of this title but that is not:
(A) a qualified health benefit plan or reflective health benefit plan offered in accordance
with 33 V.S.A. chapter 18, subchapter 1; or
(B) a health benefit plan offered by an intermunicipal insurance association to one or
more entities providing educational services pursuant to 24 V.S.A. chapter 121, subchapter 6.
(b)(1) A large group health insurance plan shall cover the cost of a hearing aid for each
ear and the associated hearing aid professional services when the hearing aid or aids
are prescribed, fitted, and dispensed by a hearing care professional. The coverage
shall include hearing aid batteries when prescribed by a hearing care professional.
(2) A large group health insurance plan may limit coverage to not more than one hearing
aid per ear every three years, except that a plan shall cover the cost of one or more
new hearing aids for a covered individual prior to the expiration of the three-year
period based on a hearing care professional’s determination that a new hearing aid
for one or both ears is medically necessary.
(c)(1) Subject to the limitations set forth in subdivision (b)(2) of this section, the coverage
provided by a large group health insurance plan for hearing aids and associated services
shall be limited only by medical necessity.
(2) A covered individual may select a hearing aid that exceeds the limits set forth in
subdivision (1) of this subsection and pay the additional cost.
(d) The coverage required by this section shall not be subject to a deductible, co-payment,
or coinsurance provision that is less favorable to a covered individual than the deductible,
co-payment, or coinsurance provisions that apply generally to other nonprimary care
items and services under the large group health insurance plan. (Recodified and amended 2025, No. 11, § 2, eff. September 1, 2025.)
§ 4071. Gender-affirming health care services
(a) As used in this section, “gender-affirming health care services” has the same meaning
as in 1 V.S.A. § 150.
(b)(1) A health insurance plan shall provide coverage for gender-affirming health care services
that:
(A) are medically necessary and clinically appropriate for the individual’s diagnosis
or health condition; and
(B) are included in the State’s essential health benefits benchmark plan.
(2) Nothing in this section shall prohibit a health insurance plan from providing greater
coverage for gender-affirming health care services than is required under this section.
(c) Cost sharing. A health insurance plan shall not impose greater coinsurance, co-payment, deductible,
or other cost-sharing requirements for coverage of gender-affirming health care services
than apply to the diagnosis and treatment of any other physical or mental condition
under the plan.
(d) This section shall apply to Medicaid and any other public health care assistance program
offered or administered by the State or by any subdivision or instrumentality of the
State. The coverage provided pursuant to this section by Medicaid and other public
health care assistance programs shall comply with any requirements imposed on such
coverage by the Centers for Medicare and Medicaid Services. (Recodified and amended 2025, No. 11, § 2, eff. September 1, 2025.)
§ 4072. Mental health and substance use disorder services
(a) It is the goal of the General Assembly that treatment for mental conditions be recognized
as an integral component of health care, that health insurance plans cover all necessary
and appropriate medical services without imposing practices that create barriers to
receiving appropriate care, and that integration of health care be recognized as the
standard for care in this State.
(b) As used in this section:
(1) “Mental condition” means any condition or disorder involving psychiatric disabilities
or substance use disorder that falls under any of the diagnostic categories listed
in the mental disorders section of the International Classification of Diseases, as
periodically revised.
(2) “Mental health provider” means any individual, corporation, facility, or institution
certified or licensed by this State to provide mental health services, including a
physician, nurse with recognized psychiatric specialties, hospital or other health
care facility, psychologist, clinical social worker, mental health counselor, alcohol
or drug abuse counselor, or an employee or agent of such provider acting in the course
and scope of employment or an agency related to mental health services.
(3) “Rate, term, or condition” means any lifetime or annual payment limits, deductibles,
co-payments, coinsurance, and any other cost-sharing requirements, out-of-pocket limits,
visit limits, and any other financial component of health insurance coverage that
affects the covered individual.
(c) A health insurance plan shall provide coverage for treatment of a mental condition
and shall:
(1) not establish any rate, term, or condition that places a greater burden on a covered
individual for access to treatment for a mental condition than for access to treatment
for other health conditions, including no greater co-payment for primary mental health
care or services than the co-payment applicable to care or services provided by a
primary care provider under a covered individual’s health insurance plan and no greater
co-payment for specialty mental health care or services than the co-payment applicable
to care or services provided by a specialist provider under a covered individual’s
health insurance plan;
(2) not exclude from its network or list of authorized providers any licensed mental health
or substance use disorder treatment provider located within the geographic coverage
area of the health insurance plan if the provider is willing to meet the terms and
conditions for participation established by the health insurer;
(3) make any deductible or out-of-pocket limits required under a health insurance plan
comprehensive for coverage of both mental and physical health conditions; and
(4) if the health insurance plan provides prescription drug coverage, ensure that at least
one medication in each therapeutic class approved by the U.S. Food and Drug Administration
for the treatment of substance use disorder, including for opioid use disorder, methadone,
buprenorphine, and naltrexone, is available on the lowest cost-sharing tier of the
plan’s prescription drug formulary.
(d)(1)(A) A health insurance plan that does not otherwise provide for management of care under
the plan, or that does not provide for the same degree of management of care for all
health conditions, may provide coverage for treatment of mental conditions through
a managed care organization, provided that the managed care organization is in compliance
with rules adopted by the Commissioner that ensure that the system for delivery of
treatment for mental conditions does not diminish or negate the purpose of this section.
In reviewing policy rates and forms pursuant to section 4026 of this title, the Commissioner or the Green Mountain Care Board established in 18 V.S.A. chapter 220, as appropriate, shall consider the compliance of the policy with the provisions
of this section.
(B) The rules adopted by the Commissioner shall ensure that:
(i) timely and appropriate access to care is available;
(ii) the quantity, location, and specialty distribution of health care providers is adequate;
(iii) administrative or clinical protocols do not serve to reduce access to medically necessary
treatment for any covered individual;
(iv) utilization review and other administrative and clinical protocols do not deter timely
and appropriate care, including emergency hospital admissions;
(v) in the case of a managed care organization that contracts with a health insurer to
administer the health insurer’s mental health benefits, the portion of a health insurer’s
premium rate attributable to the coverage of mental health benefits is reviewed under
section 4026, 4513, 4584, or 5104 of this title to determine whether it is excessive, inadequate, unfairly discriminatory, unjust,
unfair, inequitable, misleading, or contrary to the laws of this State;
(vi) the health insurance plan is consistent with the Blueprint for Health with respect
to mental conditions;
(vii) a quality improvement project is completed annually as a joint project between the
health insurance plan and its mental health managed care organization to implement
policies and incentives to increase collaboration among providers that will facilitate
clinical integration of services for medical and mental conditions, including:
(I) evidence of how data collected from the quality improvement project are being used
to inform the practices, policies, and future direction of care management programs
for mental conditions; and
(II) demonstration of how the quality improvement project is supporting the incorporation
of best practices and evidence-based guidelines into the utilization review of mental
conditions;
(viii) an up-to-date list of active mental health providers in the plan’s network is available
on the health insurer’s and managed care organization’s websites and provided to consumers
upon request; and
(ix) the health insurers and managed care organizations make accessible to consumers the
toll-free telephone number for the Department of Financial Regulation’s consumer protection
help line.
(C) Prior to the adoption of rules pursuant to this subdivision (d)(1), the Commissioner
shall consult with the Commissioner of Mental Health and the task force established
pursuant to subsection (h) of this section concerning:
(i) developing incentives and other measures addressing the availability of providers
of care and treatment for mental conditions, especially in medically underserved areas;
(ii) incorporating nationally recognized best practices and evidence-based guidelines into
the utilization review of mental conditions; and
(iii) establishing benefit design, infrastructure support, and payment methodology standards
for evaluating the health insurance plan’s consistency with the Blueprint for Health
with respect to the care and treatment of mental conditions.
(2) A managed care organization providing or administering coverage for treatment of mental
conditions on behalf of a health insurance plan shall comply with this section, sections
4064 and 4724 of this title, and 18 V.S.A. § 9414; with rules adopted pursuant to those provisions of law; and with all other obligations,
under Title 18 and under this title, of the health insurance plan and the health insurer
on behalf of which the managed care organization is providing or administering coverage.
A violation of any provision of this section shall constitute an unfair act or practice
in the business of insurance in violation of section 4723 of this title.
(3) A health insurer that contracts with a managed care organization to provide or administer
coverage for treatment of mental conditions is fully responsible for the acts and
omissions of the managed care organization, including any violations of this section
or a rule adopted pursuant to this section.
(4) In addition to any other remedy or sanction provided for by law, if the Commissioner,
after notice and an opportunity to be heard, finds that a health insurance plan or
managed care organization has violated this section or any rule adopted pursuant to
this section, the Commissioner may:
(A) assess a penalty on the health insurer or managed care organization under section 4726 of this title;
(B) order the health insurer or managed care organization to cease and desist in further
violations;
(C) order the health insurer or managed care organization to remediate the violation,
including issuing an order to the health insurer to terminate its contract with the
managed care organization; and
(D) revoke or suspend the license of a health insurer or managed care organization, or
permit continued licensure subject to such conditions as the Commissioner deems necessary
to carry out the purposes of this section.
(5) As used in this subsection, the term “managed care organization” includes any of the
following entities that provide or administer the coverage of mental health benefits
on behalf of a health insurance plan:
(A) a mental health review agent as defined in section 4064 of this title;
(B) a health insurer or its delegate;
(C) a managed care organization, as defined in 18 V.S.A. § 9402, or its delegate; and
(D) any other person or entity that meets the definition of a managed care organization
under 18 V.S.A. § 9402 or under rules adopted by the Commissioner.
(e) To be eligible for coverage under this section, the service shall be rendered:
(1) For treatment of a mental condition, either:
(A) by a licensed or certified mental health professional; or
(B) in a mental health facility qualified pursuant to rules adopted by the Secretary of
Human Services or in an institution, approved by the Secretary of Human Services,
that provides a program for the treatment of a mental condition pursuant to a written
plan.
(2) For treatment of substance abuse disorder, either:
(A) by a licensed alcohol and drug abuse counselor or other person approved by the Secretary
of Human Services based on rules adopted by the Secretary that establish standards
and criteria for determining eligibility under this subdivision; or
(B) in an institution, approved by the Secretary of Human Services, that provides a program
for the treatment of substance use disorder pursuant to a written plan. (Recodified and amended 2025, No. 11, § 2, eff. September 1, 2025.)
§ 4073. Diabetes treatment
(a) A health insurance plan shall provide coverage for the equipment, supplies, and outpatient
self-management training and education, including medical nutrition therapy, for the
treatment of insulin-dependent diabetes, insulin-using diabetes, gestational diabetes,
and noninsulin-using diabetes if prescribed by a health care professional.
(b) Diabetes outpatient self-management training and education required to be covered
by this section shall be provided by a certified, registered, or licensed health care
professional with specialized training in the education and management of diabetes. (Recodified and amended 2025, No. 11, § 2, eff. September 1, 2025.)
§ 4074. Treatment of inherited metabolic disorders
(a) As used in this section:
(1) “Inherited metabolic disorder” means a disorder caused by an inherited abnormality
of body chemistry for which the State screens newborn infants.
(2) “Low protein modified food product” means a food product that is specifically formulated
to have less than one gram of protein per serving and is intended to be used under
the direction of a health care professional for the dietary treatment of a metabolic
disorder.
(3) “Medical food” means an amino acid modified preparation that is intended to be used
under the direction of a health care professional for the dietary treatment of an
inherited metabolic disorder.
(b) A health insurance plan shall provide coverage for medical foods prescribed for medically
necessary treatment for an inherited metabolic disorder.
(c) Coverage for low protein modified food products prescribed for medically necessary
treatment of an inherited metabolic disorder shall be at least $2,500.00 during any
continuous period of 12 months for any covered individual. (Recodified and amended 2025, No. 11, § 2, eff. September 1, 2025.)
§ 4075. Craniofacial disorders
(a)(1) A health insurance plan shall provide coverage for diagnosis and medically necessary
treatment, including surgical and nonsurgical procedures, for a musculoskeletal disorder
that affects any bone or joint in the face, neck, or head and is the result of accident,
trauma, congenital defect, developmental defect, or pathology. Subject to subsection
(b) of this section, this coverage shall be the same as that provided under the health
insurance plan for any other musculoskeletal disorder in the body and shall be covered
when the diagnosis or treatment, or both, is prescribed or administered by a physician
or a dentist.
(2) This section shall not be construed to require coverage for dental services for the
diagnosis or treatment of dental disorders or dental pathology primarily affecting
the gums, teeth, or alveolar ridge.
(b) A health insurance plan may require a referral from a health care provider under contract
with the plan. (Recodified and amended 2025, No. 11, § 2, eff. September 1, 2025.)
§ 4076. Home health services
(a) As used in this section:
(1) “Home health agency” means a nonprofit home health agency that has been certified
under Title XVIII of the Social Security Act (42 U.S.C. § 1395 et seq.).
(2) “Home health care” means care and treatment provided by a home health agency and designed
and supervised by a health care professional, without which care and treatment a person
would require admission to a hospital or skilled nursing facility, as those terms
are defined by Medicare regulations. The care and treatment shall consist of one or
more of the following:
(A) Part-time or intermittent skilled nursing care.
(B) Physical therapy.
(C) Part-time or intermittent home health aide services that consist primarily of caring
for the patient.
(D) Medical supplies, drugs and equipment, and laboratory services to the extent that
laboratory services would have been covered if the patient had been admitted to a
hospital or skilled nursing facility. The medical necessity of equipment may be reviewed
by reference to the Medicare guidelines for durable medical equipment.
(b)(1) A major medical insurance plan shall provide coverage for home health care.
(2) A health insurer may require evidence of insurability as a prerequisite to coverage.
(3) The coverage shall consist of at least 40 visits by a home health agency in any calendar
year, or in any continuous period of 12 months, for each person covered under the
health insurance plan.
(4) Each visit by a member of a home health care agency, other than a home health aide,
shall be considered one home health care visit, and four hours of home health aide
service shall be considered one home health care visit. Coverage shall be provided
for maternity and childbirth.
(c) Nothing in this section shall be deemed to require that home health care coverage
be provided to individuals eligible for Medicare.
(d) A health insurance plan shall not impose greater coinsurance, co-payment, deductible,
or other cost-sharing requirements for coverage of home health care than apply to
the diagnosis and treatment of any other physical or mental condition under the plan. (Recodified and amended 2025, No. 11, § 2, eff. September 1, 2025.)
§ 4077. Reproductive health care services
(a)(1) A health insurance plan shall provide coverage for outpatient contraceptive services
including sterilizations, and shall provide coverage for the purchase of all prescription
contraceptives and prescription contraceptive devices approved by the U.S. Food and
Drug Administration (FDA), except that a health insurance plan that does not provide
coverage of prescription drugs is not required to provide coverage of prescription
contraceptives and prescription contraceptive devices.
(2) A health insurance plan providing coverage required under this section shall not establish
any rate, term, or condition that places a greater financial burden on a covered individual
for access to contraceptive services, prescription contraceptives, and prescription
contraceptive devices than for access to treatment, prescriptions, or devices for
any other health condition.
(b) A health insurance plan shall provide coverage without any deductible, coinsurance,
co-payment, or other cost-sharing requirement for at least one drug, device, or other
product within each method of contraception for women identified by the FDA and prescribed
by a covered individual’s health care professional.
(1) The coverage provided pursuant to this subsection shall include patient education
and counseling by the covered individual’s health care provider regarding the appropriate
use of the contraceptive method prescribed.
(2)(A) If there is a therapeutic equivalent of a drug, device, or other product for an FDA-approved
contraceptive method, a health insurance plan may provide coverage for more than one
drug, device, or other product and may impose cost-sharing requirements as long as
at least one drug, device, or other product for that method is available without cost
sharing.
(B) If a covered individual’s health care professional recommends a particular service
or FDA-approved drug, device, or other product for the covered individual based on
a determination of medical necessity, the health insurance plan shall defer to the
health care professional’s determination and judgment and shall provide coverage without
cost sharing for the drug, device, or product prescribed by the health care professional
for the covered individual.
(c) A health insurance plan shall provide coverage for voluntary sterilization procedures
for men and women without any deductible, coinsurance, co-payment, or other cost-sharing
requirement, except to the extent that such coverage would disqualify a high-deductible
health plan from eligibility for a health savings account pursuant to 26 U.S.C. § 223.
(d) A health insurance plan shall provide coverage without any deductible, coinsurance,
co-payment, or other cost-sharing requirement for clinical services associated with
providing the drugs, devices, products, and procedures covered under this section
and related follow-up services, including management of side effects, counseling for
continued adherence, and device insertion and removal.
(e)(1) A health insurance plan shall provide coverage for a supply of prescribed contraceptives
intended to last over a 12-month duration, which may be furnished or dispensed all
at once or over the course of the 12 months at the discretion of the health care provider.
The health insurance plan shall reimburse a health care provider or dispensing entity
per unit for furnishing or dispensing a supply of contraceptives intended to last
for 12 months.
(2) This subsection shall apply to Medicaid and any other public health care assistance
program offered or administered by the State or by any subdivision or instrumentality
of the State.
(f) Benefits provided under this section shall be the same for individuals covered under
the health insurance plan.
(g) The coverage requirements of this section shall apply to self-administered hormonal
contraceptives prescribed for a covered individual by a pharmacist in accordance with
26 V.S.A. § 2023. (Recodified and amended 2025, No. 11, § 2, eff. September 1, 2025.)
§ 4078. Midwifery coverage; home births [Effective until January 1, 2027; see also 8 V.S.A. § 4078 effective January 1, 2027 set out below]
(a) A health insurance plan providing maternity benefits shall also provide coverage for
services rendered by a midwife licensed pursuant to 26 V.S.A. chapter 85 or an advanced practice registered nurse licensed pursuant to 26 V.S.A. chapter 28 who is certified as a nurse midwife for services within the licensed midwife’s or
certified nurse midwife’s scope of practice and provided in a hospital or other health
care facility or at home.
(b) Coverage for services provided by a licensed midwife or certified nurse midwife shall
not be subject to any greater co-payment, deductible, or coinsurance than is applicable
to any other similar benefits provided by the health insurance plan.
(c) This section shall apply to Medicaid and any other public health care assistance program
offered or administered by the State or by any subdivision or instrumentality of the
State. (Recodified and amended 2025, No. 11, § 2, eff. September 1, 2025.)
§ 4078. Midwifery coverage [Effective January 1, 2027; see also 8 V.S.A. § 4078 effective until January 1, 2027 set out above]
(a) A health insurance plan providing maternity benefits shall also provide coverage for
services rendered by a midwife licensed pursuant to 26 V.S.A. chapter 85 or an advanced practice registered nurse licensed pursuant to 26 V.S.A. chapter 28 who is certified as a nurse midwife for services within the licensed midwife’s or
certified nurse midwife’s scope of practice and provided in a hospital, birth center,
or other health care facility or at home.
(b) Coverage for services provided by a licensed midwife or certified nurse midwife shall
not be subject to any greater co-payment, deductible, or coinsurance than is applicable
to any other similar benefits provided by the health insurance plan.
(c) This section shall apply to Medicaid and any other public health care assistance program
offered or administered by the State or by any subdivision or instrumentality of the
State. (Recodified and amended 2025, No. 11, § 2, eff. September 1, 2025; amended 2025, No. 19, § 2, eff. January 1, 2027.)
§ 4079. Abortion and abortion-related services
(a) As used in this section, “abortion” means any medical treatment intended to induce
the termination of, or to terminate, a clinically diagnosable pregnancy except for
the purpose of producing a live birth.
(b)(1) A health insurance plan shall provide coverage for abortion and abortion-related care.
(2) This section shall apply to Medicaid and any other public health care assistance program
offered or administered by the State or by any subdivision or instrumentality of the
State.
(c) The coverage required by this section shall not be subject to any co-payment, deductible,
coinsurance, or other cost-sharing requirement or additional charge, except:
(1) to the extent such coverage would disqualify a high-deductible health plan from eligibility
for a health savings account pursuant to 26 U.S.C. § 223; and
(2) for coverage provided by Medicaid. (Recodified and amended 2025, No. 11, § 2, eff. September 1, 2025.)
§ 4080. Anesthesia for certain dental procedures
(a) As used in this section:
(1) “Ambulatory surgical center” has the same meaning as in 18 V.S.A. § 2141.
(2) “Anesthesiologist” means a physician who is licensed under 26 V.S.A. chapter 23 or 33 and who either:
(A) has completed a residency in anesthesiology approved by the American Board of Anesthesiology
or the American Osteopathic Board of Anesthesiology or their predecessors or successors;
or
(B) is credentialed by a hospital to practice anesthesiology and engages in the practice
of anesthesiology at that hospital full-time.
(3) “Certified registered nurse anesthetist” means an advanced practice registered nurse
licensed by the Vermont Board of Nursing to practice as a certified registered nurse
anesthetist.
(4) “Licensed mental health professional” means a licensed physician, psychologist, psychoanalyst,
social worker, marriage and family therapist, clinical mental health counselor, or
nurse with professional training, experience, and demonstrated competence in the treatment
of a mental condition or psychiatric disability.
(b) A health insurance plan shall provide coverage for the hospital or ambulatory surgical
center charges and administration of general anesthesia administered by a licensed
anesthesiologist or certified registered nurse anesthetist for dental procedures performed
on a covered individual who is:
(1) a child seven years of age or younger who is determined by a dentist licensed pursuant
to 26 V.S.A. chapter 13 to be unable to receive needed dental treatment in an outpatient setting, where the
provider treating the covered individual certifies that due to the covered individual’s
age and the covered individual’s condition or problem, hospitalization or general
anesthesia in a hospital or ambulatory surgical center is required in order to perform
significantly complex dental procedures safely and effectively;
(2) a child 12 years of age or younger with documented phobias or a documented mental
condition or psychiatric disability, as determined by a physician licensed pursuant
to 26 V.S.A. chapter 23 or 33 or by a licensed mental health professional, whose dental needs are sufficiently
complex and urgent that delaying or deferring treatment can be expected to result
in infection, loss of teeth, or other increased oral or dental morbidity; for whom
a successful result cannot be expected from dental care provided under local anesthesia;
and for whom a superior result can be expected from dental care provided under general
anesthesia; or
(3) a person who has exceptional medical circumstances or a developmental disability,
as determined by a physician licensed pursuant to 26 V.S.A. chapter 23 or 33, that place the person at serious risk.
(c) A health insurance plan may require prior authorization for general anesthesia and
associated hospital or ambulatory surgical center charges for dental care in the same
manner that prior authorization is required for these benefits in connection with
other covered medical care.
(d) A health insurance plan may restrict coverage for general anesthesia and associated
hospital or ambulatory surgical center charges to dental care that is provided by:
(1) a fully accredited specialist in pediatric dentistry;
(2) a fully accredited specialist in oral and maxillofacial surgery; and
(3) a dentist to whom hospital privileges have been granted.
(e) The provisions of this section shall not be construed to require a health insurance
plan to provide coverage for the dental procedure or other dental care for which general
anesthesia is provided.
(f) The provisions of this section shall not be construed to prevent or require reimbursement
by a health insurance plan for the provision of general anesthesia and associated
facility charges to a dentist holding a general anesthesia endorsement issued by the
Vermont Board of Dental Examiners if the dentist has provided services pursuant to
this section on an outpatient basis in the dentist’s own office and the dentist is
in compliance with the endorsement’s terms and conditions. (Recodified and amended 2025, No. 11, § 2, eff. September 1, 2025.)
§ 4081. Tobacco cessation
(a) As used in this section, “tobacco cessation medication” means all therapies approved
by the U.S. Food and Drug Administration for use in tobacco cessation.
(b) A health insurance plan shall provide coverage of at least one three-month supply
per year of tobacco cessation medication, including over-the-counter medication, if
prescribed by a licensed health care professional for an individual covered under
the plan. A health insurance plan may require the individual to pay the plan’s applicable
prescription drug co-payment for the tobacco cessation medication.
(c) This section shall apply to Medicaid and any other public health care assistance program
offered or administered by the State or by any subdivision or instrumentality of the
State. (Recodified and amended 2025, No. 11, § 2, eff. September 1, 2025.)
§ 4082. Early childhood development disorders
(a) As used in this section:
(1) “Applied behavior analysis” means the design, implementation, and evaluation of environmental
modifications using behavioral stimuli and consequences to produce socially significant
improvement in human behavior. The term includes the use of direct observation, measurement,
and functional analysis of the relationship between environment and behavior.
(2) “Autism spectrum disorders” means one or more pervasive developmental disorders as
defined in the most recent edition of the Diagnostic and Statistical Manual of Mental
Disorders (DSM), including autistic disorder, pervasive developmental disorder not
otherwise specified, and Asperger’s disorder.
(3) “Behavioral health treatment” means evidence-based counseling and treatment programs,
including applied behavior analysis, that are:
(A) necessary to develop skills and abilities for the maximum reduction of physical or
mental disability and for restoration of an individual to the individual’s best functional
level, or to ensure that an individual 21 years of age achieves proper growth and
development; and
(B) provided or supervised by a nationally board-certified behavior analyst or by a licensed
health care professional, provided the services performed are within the health care
professional’s scope of practice and certifications.
(4) “Diagnosis of early childhood developmental disorders” means medically necessary assessments,
evaluations, or tests to determine whether an individual has an early childhood developmental
delay, including an autism spectrum disorder.
(5) “Early childhood developmental disorder” means a childhood mental or physical impairment
or combination of mental and physical impairments that results in functional limitations
in major life activities, accompanied by a diagnosis defined by the DSM or the International
Classification of Diseases (ICD), as periodically revised. The term includes autism
spectrum disorders but does not include a learning disability.
(6) “Evidence-based” has the same meaning as in 18 V.S.A. § 4621.
(7) “Medically necessary” describes health care services that are appropriate in terms
of type, amount, frequency, level, setting, and duration to the individual’s diagnosis
or condition; are informed by generally accepted medical or scientific evidence; and
are consistent with generally accepted practice parameters. Such services shall be
informed by the unique needs of each individual and each presenting situation and
shall include a determination that a service is needed to achieve proper growth and
development or to prevent the onset or worsening of a health condition.
(8) “Natural environment” means a home or child care setting.
(9) “Pharmacy care” means medications prescribed by a licensed health care professional
and any health-related services deemed medically necessary to determine the need for
or effectiveness of a medication.
(10) “Psychiatric care” means direct or consultative services provided by a licensed physician
certified in psychiatry by the American Board of Medical Specialties.
(11) “Psychological care” means direct or consultative services provided by a psychologist
licensed pursuant to 26 V.S.A. chapter 55.
(12) “Therapeutic care” means services provided by licensed or certified speech language
pathologists, occupational therapists, or physical therapists.
(13) “Treatment for early developmental disorders” means evidence-based care and related
equipment prescribed or ordered for an individual by a licensed health care professional
or a licensed psychologist who determines the care to be medically necessary, including:
(A) behavioral health treatment;
(B) pharmacy care;
(C) psychiatric care;
(D) psychological care; and
(E) therapeutic care.
(b)(1) A health insurance plan shall provide coverage for the evidence-based diagnosis and
treatment of early childhood developmental disorders, including applied behavior analysis
supervised by a nationally board-certified behavior analyst, for children, beginning
at birth and continuing until the child reaches 21 years of age.
(2) This section shall apply to Medicaid and any other public health care assistance program
offered or administered by the State or by any subdivision or instrumentality of the
State. Coverage provided pursuant to this section by Medicaid or any other public
health care assistance program shall comply with all federal requirements imposed
by the Centers for Medicare and Medicaid Services.
(3) A major medical insurance plan is not required to provide any benefits required by
this section that exceed the essential health benefits specified under Section 1302(b)
of the Patient Protection and Affordable Care Act, Public Law 111-148, as amended.
(c) The amount, frequency, and duration of treatment described in this section shall be
based on medical necessity and may be subject to a prior authorization requirement
under the health insurance plan.
(d) A health insurance plan shall not impose greater coinsurance, co-payment, deductible,
or other cost-sharing requirements for coverage of the diagnosis or treatment of early
childhood developmental disorders than apply to the diagnosis and treatment of any
other physical or mental condition under the plan.
(e)(1) A health insurance plan shall provide coverage for applied behavior analysis when
the services are provided or supervised by a licensed health care professional who
is working within the scope of the health care professional’s license or who is a
nationally board-certified behavior analyst.
(2) A health insurance plan shall provide coverage for services under this section delivered
in the natural environment when the services are furnished by a health care professional
working within the scope of the health care professional’s license or under the direct
supervision of a licensed health care professional or, for applied behavior analysis,
by or under the supervision of a nationally board-certified behavior analyst.
(f) Except for inpatient services, if an individual is receiving treatment for an early
developmental delay, the health insurance plan may require treatment plan reviews
based on the needs of the covered individual, consistent with reviews for other diagnostic
areas and with rules established by the Department of Financial Regulation. A health
insurance plan may review the treatment plan for children under eight years of age
not more frequently than once every six months.
(g) Nothing in this section shall be construed to affect any obligation to provide services
to an individual under an individualized family service plan, individualized education
program, or individualized service plan. A health insurance plan shall not reimburse
services provided under 16 V.S.A. § 2959a.
(h) It is the intent of the General Assembly that the Department of Financial Regulation
facilitate and encourage health insurance plans to bundle co-payments accrued by beneficiaries
receiving services under this section to the extent possible. (Recodified and amended 2025, No. 11, § 2, eff. September 1, 2025.)
§ 4083. Services for victims of sexual assault
(a) As used in this section, “sexual assault examination” means either or both of the
following:
(1) a physical examination of the patient, documentation of biological and physical findings,
and collection of evidence; and
(2) treatment of the patient’s injuries; providing care for sexually transmitted infections;
assessing pregnancy risk; discussing treatment options, including reproductive health
services, screening for the human immunodeficiency virus, and prophylactic treatment
when appropriate; and providing instructions and referrals for follow-up care.
(b) A health insurance plan shall not impose any co-payment or coinsurance or, to the
extent permitted under federal law, deductible or other cost-sharing requirement for
the sexual assault examination of a victim of alleged sexual assault for health care
services associated with specific procedure codes identified in a memorandum of understanding
between the health insurer and the Vermont Center for Crime Victim Services. (Recodified and amended 2025, No. 11, § 2, eff. September 1, 2025.)
§ 4084. Physical therapy co-payments for certain plans
For silver- and bronze-level qualified health benefit plans and any reflective health
benefit plans offered at the silver or bronze level pursuant to 33 V.S.A. chapter 18, subchapter 1, health care services provided by a licensed physical therapist may
be subject to a co-payment requirement, provided that any required co-payment amount
shall be between 125 and 150 percent of the amount of the co-payment applicable to
care and services provided by a primary care provider under the plan. (Recodified 2025, No. 11, § 2, eff. September 1, 2025.)
-
Subchapter 010: PRESCRIPTION DRUG COVERAGE
§ 4091. Definitions
As used in this subchapter:
(1) “Direct solicitation” means direct contact, including telephone, computer, email,
instant messaging, or in-person contact, by a pharmacy provider or its agent to an
individual covered under a health insurance plan without the covered individual’s
consent for the purpose of marketing the pharmacy provider’s services.
(2) “Health care professional” means an individual licensed to practice medicine under
26 V.S.A. chapter 23 or 33, an individual licensed as a physician assistant under 26 V.S.A. chapter 31, or an individual licensed as an advanced practice registered nurse under 26 V.S.A. chapter 28.
(3) “Health insurance plan” has the same meaning as in section 4011 of this chapter and
includes prescription drug benefits managed by a health insurer or by a pharmacy benefit
manager on behalf of a health insurer.
(4) “Interchangeable biological products” has the same meaning as in 18 V.S.A. § 4601.
(5) “Out-of-pocket expenditure” means a co-payment, coinsurance, deductible, or other
cost-sharing mechanism.
(6) “Pharmacy benefit manager” means an entity that performs pharmacy benefit management.
“Pharmacy benefit management” means an arrangement for the procurement of prescription
drugs at negotiated dispensing rates, the administration or management of prescription
drug benefits provided by a health insurance plan for the benefit of beneficiaries,
or any of the following services provided with regard to the administration of pharmacy
benefits:
(A) mail service pharmacy;
(B) claims processing, retail network management, and payment of claims to pharmacies
for prescription drugs dispensed to beneficiaries;
(C) clinical formulary development and management services;
(D) rebate contracting and administration;
(E) certain patient compliance, therapeutic intervention, and generic substitution programs;
and
(F) disease management programs.
(7) “Pharmacy benefit manager affiliate” means a pharmacy or pharmacist that, directly
or indirectly, through one or more intermediaries, is owned or controlled by, or is
under common ownership or control with, a pharmacy benefit manager.
(8) “Prescription drug” or “drug” has the same meaning as “prescription drug” in 26 V.S.A. § 2022 and includes:
(A) biological products, as defined in 18 V.S.A. § 4601;
(B) medications used to treat complex, chronic conditions, including medications that
require administration, infusion, or injection by a health care professional;
(C) medications for which the manufacturer or the U.S. Food and Drug Administration requires
exclusive, restricted, or limited distribution; and
(D) medications with specialized handling, storage, or inventory reporting requirements.
(9) “Prescription insulin medication” means a prescription drug that contains insulin
and is used to treat diabetes.
(10) “Step therapy” means protocols that establish the specific sequence in which prescription
drugs for a specific medical condition are to be prescribed. (Recodified and amended 2025, No. 11, § 2, eff. September 1, 2025.)
§ 4092. Prescription drug coverage
(a) A health insurance plan shall not include an annual dollar limit on prescription drug
benefits.
(b) A health insurance plan shall limit a covered individual’s out-of-pocket expenditures
for all prescription drugs to not more for self-only and family coverage per year
than the minimum dollar amounts in effect under Section 223(c)(2)(A)(i) of the Internal Revenue Code of 1986 for self-only and family coverage, respectively.
(c)(1) For prescription drug benefits offered in conjunction with a high-deductible health
plan (HDHP), the plan shall not provide prescription drug benefits until the expenditures
applicable to the deductible under the HDHP have met the amount of the minimum annual
deductibles in effect for self-only and family coverage under Section 223(c)(2)(A)(i) of the Internal Revenue Code of 1986 for self-only and family coverage, respectively, except that a plan may offer first-dollar
prescription drug benefits to the extent permitted under federal law.
(2) Once the applicable expenditure amount set forth in subdivision (1) of this subsection
has been met under the HDHP, coverage for prescription drug benefits shall begin,
and the limit on out-of-pocket expenditures for prescription drug benefits shall be
as specified in subsection (b) of this section.
(d)(1) A health insurance plan that uses step-therapy protocols shall:
(A) not require failure, including discontinuation due to lack of efficacy or effectiveness,
diminished effect, or an adverse event, on the same drug on more than one occasion
for covered individuals who are continuously enrolled in a plan offered by the health
insurer or its pharmacy benefit manager; and
(B) grant an exception to its step-therapy protocols upon request of a covered individual
or the covered individual’s treating health care professional under the same time
parameters as set forth for prior authorization requests in 18 V.S.A. § 9418b(g)(4) if any one or more of the following conditions apply:
(i) the prescription drug required under the step-therapy protocol is contraindicated
or will likely cause an adverse reaction or physical or mental harm to the covered
individual;
(ii) the prescription drug required under the step-therapy protocol is expected to be ineffective
based on the covered individual’s known clinical history, condition, and prescription
drug regimen;
(iii) the covered individual has already tried the prescription drugs on the protocol, or
other prescription drugs in the same pharmacologic class or with the same mechanism
of action, which have been discontinued due to lack of efficacy or effectiveness,
diminished effect, or an adverse event, regardless of whether the covered individual
was covered at the time on a plan offered by the current insurer or its pharmacy benefit
manager;
(iv) the covered individual is stable on a prescription drug selected by the covered individual’s
treating health care professional for the medical condition under consideration; or
(v) the step-therapy protocol or a prescription drug required under the protocol is not
in the covered individual’s best interests because it will:
(I) pose a barrier to adherence;
(II) likely worsen a comorbid condition; or
(III) likely decrease the covered individual’s ability to achieve or maintain reasonable
functional ability.
(2) Nothing in this subsection shall be construed to prohibit the use of tiered co-payments
for covered individuals not subject to a step-therapy protocol.
(3) Notwithstanding any provision of subdivision (1) of this subsection to the contrary,
a health insurance shall not utilize a step-therapy, “fail first,” or other protocol
that requires documented trials of a prescription drug, including a trial documented
through a “MedWatch” (FDA Form 3500), before approving a prescription for the treatment
of substance use disorder.
(e)(1) A health insurance plan shall not require, as a condition of coverage, use of drugs
not indicated by the U.S. Food and Drug Administration for the condition diagnosed
and being treated under the supervision of a health care professional.
(2) Nothing in this subsection shall be construed to prevent a health care professional
from prescribing a prescription drug for off-label use.
(f) A health insurance plan shall apply the same cost-sharing requirements to interchangeable
biological products as apply to generic drugs under the plan.
(g)(1) A health insurance plan shall limit a covered individual’s total out-of-pocket responsibility
for prescription insulin drugs to not more than $100.00 per 30-day supply, regardless
of the amount, type, or number of insulin drugs prescribed for the covered individual.
(2) The $100.00 monthly limit on out-of-pocket spending for prescription insulin drugs
set forth in subdivision (1) of this subsection shall apply regardless of whether
the covered individual has satisfied any applicable deductible requirement under the
health insurance plan.
(h) A health insurance plan shall cover, without requiring prior authorization, at least
one readily available asthma controller drug from each class of drug and mode of administration.
As used in this subsection, “readily available” means that the medication is not listed
on a national drug shortage list, including lists maintained by the U.S. Food and
Drug Administration and by the American Society of Health-System Pharmacists.
(i) On a periodic basis but not less than once per calendar year, each health insurer
shall notify all individuals covered under its health insurance plans of any changes
in pharmaceutical coverage and provide access to the preferred drug list maintained
by the health insurer or its pharmacy benefit manager.
(j) The Department of Financial Regulation shall enforce this section and may adopt rules
as necessary to carry out the purposes of this section.
(k) A health insurance plan shall provide coverage for prescription drugs purchased in
Canada and used in Canada or reimported legally on the same benefit terms and conditions
as prescription drugs purchased in this country. For drugs purchased by mail or through
the internet, the plan may require accreditation by the Internet and Mailorder Pharmacy
Accreditation Commission (IMPAC™) or similar organization. (Recodified and amended 2025, No. 11, § 2, eff. September 1, 2025.)
§ 4093. Retail pharmacies; filling of prescriptions
(a) A health insurer or pharmacy benefit manager doing business in Vermont shall permit
a retail pharmacist licensed under 26 V.S.A. chapter 36 to fill prescriptions for all prescription drugs in the same manner and at the same
level of reimbursement as they are filled by any other pharmacist or pharmacy, including
a mail-order pharmacy or a pharmacy benefit manager affiliate, with respect to the
quantity of drugs or days’ supply of drugs dispensed under each prescription.
(b) Notwithstanding any provision of a health insurance plan to the contrary, if a health
insurance plan provides for payment or reimbursement that is within the lawful scope
of practice of a pharmacist, the health insurer may provide payment or reimbursement
for the service when the service is provided by a pharmacist.
(c)(1) A health insurer or pharmacy benefit manager shall permit a participating network
pharmacy to perform all pharmacy services within the lawful scope of the profession
of pharmacy as set forth in 26 V.S.A. chapter 36.
(2) A health insurer or pharmacy benefit manager shall not do any of the following:
(A) Require a covered individual, as a condition of payment or reimbursement, to purchase
pharmacist services, including prescription drugs, exclusively through a mail-order
pharmacy or a pharmacy benefit manager affiliate.
(B) Offer or implement plan designs that require a covered individual to use a mail-order
pharmacy or a pharmacy benefit manager affiliate.
(C) Order a covered individual, orally or in writing, including through online messaging,
to use a mail-order pharmacy or a pharmacy benefit manager affiliate.
(D) Establish network requirements that are more restrictive than or inconsistent with
State or federal law, rules adopted by the Board of Pharmacy, or guidance provided
by the Board of Pharmacy or by drug manufacturers that operate to limit or prohibit
a pharmacy or pharmacist from dispensing or prescribing drugs.
(E) Offer or implement plan designs that increase plan or patient costs if the covered
individual chooses not to use a mail-order pharmacy or a pharmacy benefit manager
affiliate. The prohibition in this subdivision (E) includes requiring a covered individual
to pay the full cost for a prescription drug when the covered individual chooses not
to use a mail-order pharmacy or a pharmacy benefit manager affiliate.
(F)(i) Exclude any amount paid by or on behalf of a covered individual, including any third-party
payment, financial assistance, discount, coupon, or other reduction, when calculating
a covered individual’s contribution toward:
(I) the out-of-pocket limits for prescription drug costs under section 4092 of this title;
(II) the covered individual’s deductible, if any; or
(III) to the extent not inconsistent with Sec. 2707 of the Public Health Service Act, 42 U.S.C. § 300gg-6, the annual out-of-pocket maximums applicable to the covered individual’s health
benefit plan.
(ii) The provisions of subdivision (i) of this subdivision (F) relating to a third-party
payment, financial assistance, discount, coupon, or other reduction in out-of-pocket
expenses made on behalf of a covered individual shall only apply to a prescription
drug:
(I) for which there is no generic drug or interchangeable biological product, as those
terms are defined in 18 V.S.A. § 4601; or
(II) for which there is a generic drug or interchangeable biological product, as those
terms are defined in 18 V.S.A. § 4601, but for which the covered individual has obtained access through prior authorization,
a step therapy protocol, or the pharmacy benefit manager’s or health insurer’s exceptions
and appeals process.
(iii) The provisions of subdivision (i) of this subdivision (F) shall apply to a high-deductible
health plan only to the extent that it would not disqualify the plan from eligibility
for a health savings account pursuant to 26 U.S.C. § 223.
(3) A health insurer or pharmacy benefit manager shall not, by contract, written policy,
or written procedure, require that a pharmacy designated by the health insurer or
pharmacy benefit manager dispense a medication directly to a covered individual with
the expectation or intention that the covered individual will transport the medication
to a health care setting for administration by a health care professional.
(4) A health insurer or pharmacy benefit manager shall not, by contract, written policy,
or written procedure, require that a pharmacy designated by the health insurer or
pharmacy benefit manager dispense a medication directly to a health care setting for
a health care professional to administer to a covered individual.
(5) A health insurer or pharmacy benefit manager shall adhere to the definitions of prescription
drugs and the requirements and guidance regarding the pharmacy profession established
by State and federal law and the Vermont Board of Pharmacy and shall not establish
classifications of or distinctions between prescription drugs, impose penalties on
prescription drug claims, attempt to dictate the behavior of pharmacies or pharmacists,
or place restrictions on pharmacies or pharmacists that are more restrictive than
or inconsistent with State or federal law or with rules adopted or guidance provided
by the Board of Pharmacy.
(6) A pharmacy benefit manager or licensed pharmacy shall not make a direct solicitation
to an individual covered by a health insurance plan unless one or more of the following
applies:
(A) the covered individual has given written permission to the supplier or the ordering
health care professional to contact the covered individual regarding the furnishing
of a prescription item that is to be rented or purchased;
(B) the supplier has furnished a prescription item to the covered individual and is contacting
the covered individual to coordinate delivery of the item; or
(C) if the contact relates to the furnishing of a prescription item other than a prescription
item already furnished to the covered individual, the supplier has furnished at least
one prescription item to the covered individual within the 15-month period preceding
the date on which the supplier attempts to make the contact.
(d) A health insurer or pharmacy benefit manager shall not alter a covered individual’s
prescription drug order or the pharmacy chosen by the covered individual without the
covered individual’s consent; provided, however, that nothing in this subsection shall
be construed to affect the duty of a pharmacist to substitute a lower-cost drug or
biological product in accordance with the provisions of 18 V.S.A. § 4605.
(e) All of the provisions of this section except subsection (c) shall apply to Medicaid
and any other public health care assistance program offered or administered by the
State or by any subdivision or instrumentality of the State. (Recodified and amended 2025, No. 11, § 2, eff. September 1, 2025.)
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Subchapter 011: PREVENTION AND TREATMENT OF CANCER
§ 4095a. Colorectal cancer screening
(a) As used in this section, “colonoscopy” means a procedure that enables a health care
professional to examine visually the inside of a patient’s entire colon and includes
the concurrent removal of polyps or biopsy, or both.
(b) A health insurance plan shall provide coverage for colorectal cancer screening, including:
(1) for a covered individual who is not at high risk for colorectal cancer, colorectal
cancer screening examinations and laboratory tests in accordance with the most recently
published recommendations established by the U.S. Preventive Services Task Force for
average-risk individuals; and
(2) for a covered individual who is at high risk for colorectal cancer, colorectal cancer
screening examinations and laboratory tests as recommended by the treating health
care professional.
(c) For the purposes of subdivision (b)(2) of this section, an individual is at high risk
for colorectal cancer if the individual has:
(1) a family medical history of colorectal cancer or a genetic syndrome predisposing the
individual to colorectal cancer;
(2) a prior occurrence of colorectal cancer or precursor polyps;
(3) a prior occurrence of a chronic digestive disease condition such as inflammatory bowel
disease, Crohn’s disease, or ulcerative colitis; or
(4) other predisposing factors as determined by the individual’s treating health care
professional.
(d) Colorectal cancer screening services performed under contract with the insurer shall
not be subject to any co-payment, deductible, coinsurance, or other cost-sharing requirement.
In addition, a covered individual shall not be subject to any additional charge for
any service associated with a procedure or test for colorectal cancer screening, which
may include one or more of the following:
(1) removal of tissue or other matter;
(2) laboratory services;
(3) health care professional services;
(4) facility use; and
(5) anesthesia. (Recodified and amended 2025, No. 11, § 2, eff. September 1, 2025.)
§ 4095b. Mammography and other breast imaging services
(a)(1) A health insurance plan shall provide coverage for screening mammography and for other
medically necessary breast imaging services upon recommendation of a health care professional
as needed to detect the presence of breast cancer and other abnormalities of the breast
or breast tissue. In addition, a health insurance plan shall provide coverage for
screening by ultrasound or another appropriate imaging service for a covered individual
for whom the results of a screening mammogram were inconclusive or who has dense breast
tissue, or both.
(2) Benefits provided shall cover the full cost of the mammography, ultrasound, and other
breast imaging services and shall not be subject to any co-payment, deductible, coinsurance,
or other cost-sharing requirement or additional charge, except to the extent that
such coverage would disqualify a high-deductible health plan from eligibility for
a health savings account pursuant to 26 U.S.C. § 223.
(b) This section shall apply only to procedures conducted by test facilities accredited
by the American College of Radiologists.
(c) As used in this section:
(1) “Mammography” means the x-ray examination of the breast using equipment dedicated
specifically for mammography, including the x-ray tube, filter, compression device,
and digital detector. The term includes breast tomosynthesis.
(2) “Other breast imaging services” means diagnostic mammography, ultrasound, and magnetic
resonance imaging services that enable health care professionals to detect the presence
or absence of breast cancer and other abnormalities affecting the breast or breast
tissue.
(3) “Screening” includes the mammography or ultrasound test procedure and a qualified
health care professional’s interpretation of the results of the procedure, including
additional views and interpretation as needed. (Recodified and amended 2025, No. 11, § 2, eff. September 1, 2025.)
§ 4095c. Prostate cancer screenings
A health insurance plan shall provide coverage for prostate cancer screenings consistent
with the recommendations of the Centers for Disease Control and Prevention or upon
recommendation of the covered individual’s health care professional. Benefits provided
shall be at least as favorable as coverage for other cancer screening procedures and
subject to the same dollar limits, deductibles, and coinsurance factors within the
provisions of the policy. (Recodified and amended 2025, No. 11, § 2, eff. September 1, 2025.)
§ 4095d. Chemotherapy treatment and oral anticancer medications
(a) A health insurance plan shall provide coverage for medically necessary growth cell
stimulating factor injections taken as part of a prescribed chemotherapy regimen.
(b) A health insurance plan shall provide coverage for prescribed, orally administered
anticancer medications used to kill or slow the growth of cancerous cells that is
not less favorable on a financial basis than intravenously administered or injected
anticancer medications covered under the covered individual’s plan. (Recodified and amended 2025, No. 11, § 2, eff. September 1, 2025.)
§ 4095e. Clinical trials for cancer patients
(a) The Commissioner shall, after notice and hearing, adopt rules requiring that all health
insurance plans issued in this State provide coverage for routine costs for covered
individuals who participate in cancer clinical trials.
(1) Any rules adopted under this section shall be limited to the coverage of routine costs
for covered individuals who participate in a cancer clinical trial.
(2) Any rules adopted under this section shall be restricted to approved cancer clinical
trials conducted under the auspices of the following cancer care providers (cancer
care providers): The University of Vermont Medical Center, the Norris Cotton Cancer
Center at Dartmouth-Hitchcock Medical Center, and approved clinical trials administered
by a hospital and its affiliated, qualified cancer care providers.
(3) For participation in clinical trials located outside Vermont, coverage under this
section shall be required only if the covered individual provides notice to the health
insurance plan prior to participation in the clinical trial, and one or more of the
following circumstances applies:
(A) no clinical trial is available at the Vermont or New Hampshire cancer care providers
described in subdivision (2) of this subsection (a);
(B) the covered individual already has completed a clinical trial at one of the Vermont
or New Hampshire cancer care providers described in subdivision (2) of this subsection
(a) and the covered individual’s cancer care provider determines that a subsequent
clinical trial related to the original diagnosis is available outside the health benefit
plan’s network and that participation in that clinical trial would be in the best
interests of the covered individual, even if a comparable clinical trial is available
at that time at one or both of the Vermont or New Hampshire cancer care providers
described in subdivision (2) of this subsection (a); or
(C) the health insurance plan has already approved a referral of the covered individual
to an out-of-network cancer care provider and an out-of-network clinical trial becomes
available and the covered individual’s cancer care provider determines participation
in that clinical trial would be in the best interests of the covered individual, even
if a comparable clinical trial is available at one or both of the Vermont or New Hampshire
cancer care providers described in subdivision (2) of this subsection (a).
(4) If a covered individual participates in a clinical trial administered by a cancer
care provider that is not in the health insurance plan’s provider network, the health
insurance plan may require that routine follow-up care be provided within the health
insurance plan’s network, unless the cancer care provider determines this would not
be in the best interests of the covered individual.
(b) This section shall apply to Medicaid and any other public health care assistance program
offered or administered by the State or by any subdivision or instrumentality of the
State. (Recodified and amended 2025, No. 11, § 2, eff. September 1, 2025.)
§ 4095f. Off-label use of prescription drugs for cancer
(a) As used in this section:
(1) “Medical or scientific evidence” means one or more of the following sources:
(A) peer-reviewed scientific studies published in or accepted for publication by medical
journals that meet nationally recognized requirements for scientific manuscripts and
that submit most of their published articles for review by experts who are not part
of the editorial staff;
(B) peer-reviewed literature, biomedical compendia, and other medical literature that
meet the criteria of the National Institutes of Health’s National Library of Medicine
for indexing in Index Medicus, Excerpta Medicus (EMBASE), Medline, and MEDLARS database
Health Services Technology Assessment Research (HSTAR);
(C) medical journals recognized by the Secretary of the U.S. Department of Health and
Human Services under Section 1861(t)(2) of the Social Security Act;
(D) the following standard reference compendia: the American Hospital Formulary Service-Drug
Information, the American Medical Association Drug Evaluation, and the United States
Pharmacopoeia-Drug Information;
(E) findings, studies, or research conducted by or under the auspices of federal government
agencies and nationally recognized federal research institutes, including the Agency
for Health Care Policy and Research, National Institutes of Health, National Cancer
Institute, National Academy of Sciences, Centers for Medicare and Medicaid Services,
and any national board recognized by the National Institutes of Health for the purpose
of evaluating the medical value of health services; and
(F) peer-reviewed abstracts accepted for presentation at major medical association meetings.
(2) “Medically accepted indication” includes any use of a drug that has been approved
by the U.S. Food and Drug Administration and includes another use of the drug if that
use is prescribed by the covered individual’s health care professional and supported
by medical or scientific evidence.
(3) “Off-label use” means the prescription and use of drugs for medically accepted indications
other than those stated in the labeling approved by the U.S. Food and Drug Administration.
(b) A health insurance plan shall provide coverage for off-label use in cancer treatment
in accordance with the following:
(1) A health insurance plan contract shall not exclude coverage for any drug used for
the treatment of cancer on grounds that the drug has not been approved by the U.S.
Food and Drug Administration, provided the use of the drug is a medically accepted
indication for the treatment of cancer.
(2) Coverage of a drug required by this section also includes medically necessary services
associated with the administration of the drug.
(3) This section shall not be construed to require coverage for a drug when the U.S. Food
and Drug Administration has determined its use to be contraindicated for treatment
of the current indication.
(4) A drug use that is covered under subdivision (1) of this subsection shall not be denied
coverage based on a “medical necessity” requirement except for a reason unrelated
to the legal status of the drug use.
(5) A health insurance plan that provides coverage of a drug as required by this section
may contain provisions for maximum benefits and coinsurance and reasonable limitations,
deductibles, and exclusions to the same extent these provisions are applicable to
coverage of all prescription drugs and are not inconsistent with the requirements
of this section.
(c) A determination by a health insurer that an off-label use of a prescription drug under
this section is not a medically accepted indication supported by medical or scientific
evidence is eligible for review under section 4063 of this title.
(d) This section shall apply to Medicaid and any other public health care assistance program
offered or administered by the State or by any subdivision or instrumentality of the
State. (Recodified and amended 2025, No. 11, § 2, eff. September 1, 2025.)
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Subchapter 012: SERVICE DELIVERY AND TREATMENT MODALITIES
§ 4098a. Coverage of health care services delivered through telemedicine and by store-and-forward
means
(a) As used in this section:
(1) “Distant site” means the location of the health care provider delivering services
through telemedicine at the time the services are provided.
(2) “Health insurance plan” has the same meaning as in section 4011 of this title and also includes a stand-alone dental plan or policy or other dental insurance plan
offered by a dental insurer.
(3) “Health care facility” has the same meaning as in 18 V.S.A. § 9402.
(4) “Health care provider” means a person, partnership, or corporation, other than a facility
or institution, that is licensed, certified, or otherwise authorized by law to provide
professional health care services, including dental services, in this State to an
individual during that individual’s medical care, treatment, or confinement.
(5) “Originating site” means the location of the patient, whether or not accompanied by
a health care provider, at the time services are provided by a health care provider
through telemedicine, including a health care provider’s office, a hospital, or a
health care facility, or the patient’s home or another nonmedical environment such
as a school-based health center, a university-based health center, or the patient’s
workplace.
(6) “Store-and-forward” means an asynchronous transmission of medical information, such
as one or more video clips, audio clips, still images, x-rays, magnetic resonance
imaging scans, electrocardiograms, electroencephalograms, or laboratory results, sent
over a secure connection that complies with the requirements of the Health Insurance
Portability and Accountability Act of 1996, Pub. L. No. 104-191, to be reviewed at a later date by a health care provider at a distant site who is
trained in the relevant specialty. In store-and-forward, the health care provider
at the distant site reviews the medical information without the patient present in
real time and communicates a care plan or treatment recommendation back to the patient
or referring provider, or both.
(7) “Telemedicine” means the delivery of health care services, including dental services,
such as diagnosis, consultation, or treatment, through the use of live interactive
audio and video over a secure connection that complies with the requirements of the
Health Insurance Portability and Accountability Act of 1996, Pub. L. No. 104-191.
(b)(1) A health insurance plan shall provide coverage for health care services and dental
services delivered through telemedicine by a health care provider at a distant site
to a covered individual at an originating site to the same extent that the plan would
cover the services if they were provided through in-person consultation.
(2)(A) A health insurance plan shall provide the same reimbursement rate for services billed
using equivalent procedure codes and modifiers, subject to the terms of the health
insurance plan and provider contract, regardless of whether the service was provided
through an in-person visit with the health care provider or through telemedicine.
(B) The provisions of subdivision (A) of this subdivision (2) shall not apply:
(i) to services provided pursuant to the health insurance plan’s contract with a third-party
telemedicine vendor to provide health care or dental services; or
(ii) in the event that a health insurer and health care provider enter into a value-based
contract for health care services that include care delivered through telemedicine
or by store-and-forward means.
(c) A health insurance plan may charge a deductible, co-payment, or coinsurance for a
health care service or dental service provided through telemedicine as long as it
does not exceed the deductible, co-payment, or coinsurance applicable to an in-person
consultation.
(d) A health insurance plan may limit coverage to health care providers in the plan’s
network. A health insurance plan shall not impose limitations on the number of telemedicine
consultations a covered individual may receive that exceed limitations otherwise placed
on in-person covered services.
(e) Nothing in this section shall be construed to prohibit a health insurance plan from
providing coverage for only those services that are medically necessary and are clinically
appropriate for delivery through telemedicine, subject to the terms and conditions
of the covered individual’s policy.
(f)(1) A health insurance plan shall reimburse for health care services and dental services
delivered by store-and-forward means.
(2) A health insurance plan shall not impose more than one cost-sharing requirement on
a covered individual for receipt of health care services or dental services delivered
by store-and-forward means. If the services would require cost sharing under the terms
of the covered individual’s health insurance plan, the plan may impose the cost sharing
requirement on the services of the originating site health care provider or of the
distant site health care provider, but not both.
(g) A health insurance plan shall not construe a covered individual’s receipt of services
delivered through telemedicine or by store-and-forward means as limiting in any way
the covered individual’s ability to receive additional covered in-person services
from the same or a different health care provider for diagnosis or treatment of the
same condition.
(h) Nothing in this section shall be construed to require a health insurance plan to reimburse
the distant site health care provider if the distant site health care provider has
insufficient information to render an opinion.
(i) In order to facilitate the use of telemedicine in treating substance use disorder,
when the originating site is a health care facility, health insurers and the Department
of Vermont Health Access shall ensure that the health care provider at the distant
site and the health care facility at the originating site are both reimbursed for
the services rendered, unless the health care providers at both the distant and originating
sites are employed by the same entity.
(j) This section shall apply to Medicaid and any other public health care assistance program
offered or administered by the State or by any subdivision or instrumentality of the
State. (Recodified and amended 2025, No. 11, § 2, eff. September 1, 2025.)
§ 4098b. Coverage of health care services delivered by audio-only telephone
(a) As used in this section, “health care provider” means a person, partnership, or corporation,
other than a facility or institution, that is licensed, certified, or otherwise authorized
by law to provide professional health care services in this State to an individual
during that individual’s medical care, treatment, or confinement.
(b)(1) A health insurance plan shall provide coverage for all medically necessary, clinically
appropriate health care services delivered remotely by audio-only telephone to the
same extent that the plan would cover the services if they were provided through in-person
consultation. Services covered under this subdivision shall include services that
are covered when provided in the home by home health agencies.
(2)(A) A health insurance plan shall provide the same reimbursement rate for services billed
using equivalent procedure codes and modifiers, subject to the terms of the health
insurance plan and provider contract, regardless of whether the service was provided
through an in-person visit with the health care provider or by audio-only telephone.
(B) The provisions of subdivision (A) of this subdivision (2) shall not apply in the event
that a health insurer and health care provider enter into a value-based contract for
health care services that include care delivered by audio-only telephone.
(c) A health insurance plan may charge an otherwise permissible deductible, co-payment,
or coinsurance for a health care service delivered by audio-only telephone, provided
that it does not exceed the deductible, co-payment, or coinsurance applicable to an
in-person consultation.
(d) A health insurance plan shall not require a health care provider to have an existing
relationship with a covered individual in order to be reimbursed for health care services
delivered by audio-only telephone.
(e) This section shall apply to Medicaid, to the extent permitted by the Centers for Medicare
and Medicaid Services, and any other public health care assistance program offered
or administered by the State or by any subdivision or instrumentality of the State. (Recodified and amended 2025, No. 11, § 2, eff. September 1, 2025.)
§ 4098c. Covered services provided by naturopathic physicians
(a) A health insurance plan shall provide coverage for medically necessary health care
services covered by the plan when provided by a naturopathic physician licensed in
this State for treatment within the scope of practice described in 26 V.S.A. chapter 81 and shall recognize naturopathic physicians who practice primary care to be primary
care physicians.
(b) Health care services provided by naturopathic physicians may be subject to reasonable
deductibles, co-payment and coinsurance amounts, and fee or benefit limits consistent
with those applicable to other primary care physicians under the plan, as well as
practice parameters, cost-effectiveness and clinical efficacy standards, and utilization
review consistent with any applicable rules published by the Department of Financial
Regulation. Any amounts, limits, standards, and review shall not function to direct
treatment in a manner unfairly discriminative against naturopathic care, and collectively
shall be not more restrictive than those applicable under the same plan to care or
services provided by other primary care physicians, but may allow for the management
of the benefit consistent with variations in practice patterns and treatment modalities
among different types of health care professionals.
(c) A health insurance plan may require that the naturopathic physician’s services be
provided by a licensed naturopathic physician under contract with the insurer or shall
be covered in a manner consistent with out-of-network provider reimbursement practices
for primary care physicians; however, this shall not relieve a health insurance plan
from compliance with the applicable network adequacy requirements adopted by the Commissioner
by rule.
(d) Nothing contained in this section shall be construed as impeding or preventing either
the provision or the coverage of health care services by licensed naturopathic physicians,
within the lawful scope of naturopathic practice, in hospital facilities on a staff
or employee basis.
(e) This section shall apply to Medicaid and any other public health care assistance program
offered or administered by the State or by any subdivision or instrumentality of the
State. (Recodified and amended 2025, No. 11, § 2, eff. September 1, 2025.)
§ 4098d. Covered services provided by athletic trainers
(a) To the extent a health insurance plan provides coverage for a particular type of health
care service or for any particular medical condition that is within the scope of practice
of athletic trainers, a licensed athletic trainer who acts within the scope of practice
authorized by 26 V.S.A. chapter 83 shall not be denied reimbursement by the health insurance plan for those covered
services if the health insurance plan would reimburse another health care professional
for those services.
(b) Health care services provided by athletic trainers may be subject to reasonable deductibles,
co-payment and coinsurance amounts, fee or benefit limits, practice parameters, and
utilization review consistent with applicable rules adopted by the Department of Financial
Regulation, provided that the amounts, limits, and review shall not function to direct
treatment in a manner unfairly discriminative against athletic trainer care, and collectively
shall be not more restrictive than those applicable under the same policy for care
or services provided by other health care professionals but allowing for the management
of the benefit consistent with variations in practice patterns and treatment modalities
among different types of health care professionals.
(c) A health insurer may require that the athletic trainer services be provided by a licensed
athletic trainer under contract with the insurer.
(d) Nothing in this section shall be construed as impeding or preventing either the provision
or coverage of health care services by licensed athletic trainers within the lawful
scope of athletic trainer practice. (Recodified and amended 2025, No. 11, § 2, eff. September 1, 2025.)
§ 4098e. Choice of providers for vision care and medical eye care services
(a) As used in this section:
(1) “Covered services” means services and materials for which reimbursement from a vision
care plan or other health insurance plan is provided by a member’s or subscriber’s
plan contract, or for which a reimbursement would be available but for application
of the deductible, co-payment, or coinsurance requirements under the member’s or subscriber’s
health insurance plan.
(2) “Health insurance plan” has the same meaning as in section 4011 of this chapter and
also includes vision care plans.
(3) “Materials” includes lenses, devices containing lenses, prisms, lens treatments and
coatings, contact lenses, and prosthetic devices to correct, relieve, or treat defects
or abnormal conditions of the human eye or its adnexa.
(4) “Ophthalmologist” means a physician licensed pursuant to 26 V.S.A. chapter 23 or an osteopathic physician licensed pursuant to 26 V.S.A. chapter 33 who has had special training in the field of ophthalmology.
(5) “Optician” means a person licensed pursuant to 26 V.S.A. chapter 47.
(6) “Optometrist” means a person licensed pursuant to 26 V.S.A. chapter 30.
(7) “Vision care plan” means an integrated or stand-alone plan, policy, or contract providing
vision benefits to enrollees with respect to covered services or covered materials,
or both.
(b) To the extent a health insurance plan provides coverage for vision care or medical
eye care services, it shall cover those services whether provided by a licensed optometrist
or by a licensed ophthalmologist, provided the health care professional is acting
within the health care professional’s authorized scope of practice and participates
in the plan’s network.
(c) A health insurance plan shall impose no greater co-payment, coinsurance, or other
cost-sharing amount for services when provided by an optometrist than for the same
service when provided by an ophthalmologist.
(d) A health insurance plan shall provide to a licensed health care professional acting
within the health care professional’s scope of practice the same level of reimbursement
or other compensation for providing vision care and medical eye care services that
are within the lawful scope of practice of the professions of medicine, optometry,
and osteopathy, regardless of whether the health care professional is an optometrist
or an ophthalmologist.
(e)(1) A health insurer shall permit a licensed optometrist to participate in plans or contracts
providing for vision care or medical eye care to the same extent as it does an ophthalmologist.
(2) A health insurer shall not require a licensed optometrist or ophthalmologist to provide
discounted materials benefits or to participate as a provider in another health insurance
or vision care plan or contract as a condition or requirement for the optometrist’s
or ophthalmologist’s participation as a provider in any health insurance or vision
care plan or contract.
(f)(1) An agreement between a health insurer and an optometrist or ophthalmologist for the
provision of vision services to plan members or subscribers in connection with coverage
under a stand-alone vision care plan or other health insurance plan shall not require
that an optometrist or ophthalmologist provide services or materials at a fee limited
or set by the plan or insurer unless the services or materials are reimbursed as covered
services under the contract.
(2) An optometrist or ophthalmologist shall not charge more for services and materials
that are noncovered services under a vision care plan or other health insurance plan
than the optometrist’s or ophthalmologist’s usual and customary rate for those services
and materials.
(3) Reimbursement paid by a vision care plan or other health insurance plan for covered
services and materials shall be reasonable and shall not provide nominal reimbursement
in order to claim that services and materials are covered services.
(4)(A) A vision care plan or other health insurance plan shall not restrict or otherwise
limit, directly or indirectly, an optometrist’s, ophthalmologist’s, or independent
optician’s choice of or relationship with sources and suppliers of products, services,
or materials or use of optical laboratories if the optometrist, ophthalmologist, or
optician determines that the source, supplier, or laboratory that the optometrist,
ophthalmologist, or optician has selected offers the products, services, or materials
in a manner that is more beneficial to the consumer, including with respect to cost,
quality, timing, or selection, than the source, supplier, or laboratory selected by
the vision care plan or other health insurance plan. The plan shall not impose any
penalty or fee on an optometrist, ophthalmologist, or independent optician for using
any supplier, optical laboratory, product, service, or material.
(B) The optometrist, ophthalmologist, or optician shall notify the consumer of any additional
costs the consumer may incur as the result of procuring the products, services, or
materials from the source, supplier, or laboratory selected by the optometrist, ophthalmologist,
or optician instead of from the source, supplier, or laboratory selected by the vision
care plan or other health insurance plan.
(C) Nothing in this subdivision (4) shall be construed to prevent a vision care plan or
other health insurance plan from informing its policyholders of the benefits available
under the plan or from conducting an audit of an optometrist’s, ophthalmologist’s,
or optician’s use of alternative sources, suppliers, or laboratories.
(D) The provisions of this subdivision (4) shall not apply to Medicaid.
(g)(1) Except as otherwise specified in subdivision (f)(4), this section shall apply to Medicaid
and any other public health care assistance program offered or administered by the
State or by any subdivision or instrumentality of the State.
(2) The Department of Financial Regulation shall enforce the provisions of this section
as they relate to health insurance plans and vision care plans other than Medicaid. (Recodified and amended 2025, No. 11, § 2, eff. September 1, 2025.)