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Subchapter 001: VERMONT HEALTH BENEFIT EXCHANGE
§ 1801. Purpose
(a) It is the intent of the General Assembly to establish a Vermont Health Benefit Exchange
which meets the policy established in 18 V.S.A. § 9401 and, to the extent allowable under federal law or a waiver of federal law, becomes
the mechanism to create Green Mountain Care.
(b) The purpose of the Vermont Health Benefit Exchange is to facilitate the purchase of
affordable, qualified health benefit plans in the individual and group markets in
this State in order to reduce the number of uninsured and underinsured; to reduce
disruption when individuals lose employer-based insurance; to reduce administrative
costs in the insurance market; to contain costs; to promote health, prevention, and
healthy lifestyles by individuals; and to improve quality of health care.
(c) Nothing in this chapter shall be construed to reduce, diminish, or otherwise infringe
upon the benefits provided to eligible individuals under Medicare. (Added 2011, No. 48, § 4.)
§ 1802. Definitions
As used in this subchapter:
(1) “Affordable Care Act” means the federal Patient Protection and Affordable Care Act,
Pub. L. No. 111-148, as amended by the federal Health Care and Education Reconciliation
Act of 2010, Pub. L. No. 111-152, and as further amended.
(2) “Commissioner” means the Commissioner of Vermont Health Access.
(3) “Health benefit plan” means a policy, contract, certificate, or agreement offered
or issued by a health insurer to provide, deliver, arrange for, pay for, or reimburse
any of the costs of health services. This term does not include coverage only for
accident or disability income insurance, liability insurance, coverage issued as a
supplement to liability insurance, workers’ compensation or similar insurance, automobile
medical payment insurance, credit-only insurance, coverage for on-site medical clinics,
or other similar insurance coverage where benefits for health services are secondary
or incidental to other insurance benefits as provided under the Affordable Care Act.
The term also does not include stand-alone dental or vision benefits; long-term care
insurance; short-term, limited-duration health insurance; specific disease or other
limited benefit coverage, Medicare supplemental health benefits, Medicare Advantage
plans, and other similar benefits excluded under the Affordable Care Act.
(4) “Health insurer” shall have the same meaning as in 18 V.S.A. § 9402.
[Subdivision (5) effective until January 1, 2026; see also subdivision (5) effective
January 1, 2026 set out below.]
(5) “Qualified employer”:
(A) means an entity that employed an average of not more than 50 employees on working
days during the preceding calendar year and that:
(i) has its principal place of business in this State and elects to provide coverage for
its eligible employees through the Vermont Health Benefit Exchange, regardless of
where an employee resides; or
(ii) elects to provide coverage through the Vermont Health Benefit Exchange for all of
its eligible employees who are principally employed in this State;
(B) on and after January 1, 2016, shall include an entity that:
(i) employed an average of not more than 100 employees on working days during the preceding
calendar year; and
(ii) meets the requirements of subdivisions (A)(i) and (A)(ii) of this subdivision (5).
(C) [Repealed.]
[Subdivision (5) effective January 1, 2026; see also subdivision (5) effective until
January 1, 2026 set out above.]
(5) “Qualified employer” means an entity that employed an average of not more than 100
employees on working days during the preceding calendar year and that:
(A) has its principal place of business in this State and elects to provide coverage for
its eligible employees through the Vermont Health Benefit Exchange, regardless of
where an employee resides; or
(B) elects to provide coverage through the Vermont Health Benefit Exchange for all of
its eligible employees who are principally employed in this State.
(C) [Repealed.]
(6) “Qualified entity” means an entity with experience in individual and group health
insurance, benefit administration, or other experience relevant to health benefit
program eligibility, enrollment, or support.
(7) “Qualified health benefit plan” means a health benefit plan that meets the requirements
set forth in section 1806 of this title.
(8) “Qualified individual” means an individual, including a minor, who is a Vermont resident
and, at the time of enrollment:
(A) is not incarcerated, or is only incarcerated awaiting disposition of charges; and
(B) is, or is reasonably expected to be during the time of enrollment, a citizen or national
of the United States or an immigrant lawfully present in the United States as defined
by federal law.
(9) “Modified adjusted gross income” shall have the same meaning as in 26 U.S.C. § 36B(d)(2)(B).
(10) “Reflective health benefit plan” means a health benefit plan that meets the requirements
set forth in section 1813 of this title. (Added 2011, No. 48, § 4; amended 2011, No. 171 (Adj. Sess.), § 1; 2013, No. 50, § E.307, eff. Oct. 1, 2013; 2015, No. 54, § 13, eff. June 5, 2015; 2015, No. 151 (Adj. Sess.), § 1. 2018; 2017, No. 88 (Adj. Sess.), § 2, eff. Feb. 20, 2018; 2017, No. 131 (Adj. Sess.), § 5, eff. May 16, 2018; 2019, No. 19, § 4, eff. Jan. 1, 2020; 2025, No. 2, § 1, eff. January 1, 2026.)
§ 1803. Vermont Health Benefit Exchange
(a)(1) The Department of Vermont Health Access shall establish the Vermont Health Benefit
Exchange, which shall be administered by the Department in consultation with the Advisory
Committee established in section 402 of this title.
(2) The Vermont Health Benefit Exchange shall be considered a division within the Department
of Vermont Health Access and shall be headed by a Deputy Commissioner as provided
in 3 V.S.A. chapter 53.
(b)(1)(A) The Vermont Health Benefit Exchange shall provide qualified individuals and qualified
employers with qualified health benefit plans, including the multistate plans required
by the Affordable Care Act, with effective dates beginning on or before January 1,
2014. The Vermont Health Benefit Exchange may contract with qualified entities or
enter into intergovernmental agreements to facilitate the functions provided by the
Vermont Health Benefit Exchange.
(B) Prior to contracting with any health insurer, the Vermont Health Benefit Exchange
shall consider the insurer’s historic rate increase information required under section 1806 of this title, along with the information and the recommendations provided to the Vermont Health
Benefit Exchange by the Commissioner of Financial Regulation under Section 2794(b)(1)(B)
of the federal Public Health Service Act.
(2) To the extent allowable under federal law, the Vermont Health Benefit Exchange may
offer health benefits to populations in addition to those eligible under Subtitle
D of Title I of the Affordable Care Act, including:
(A) to individuals and employers who are not qualified individuals or qualified employers
as defined by this subchapter and by the Affordable Care Act;
(B) Medicaid benefits to individuals who are eligible, upon approval by the Centers for
Medicare and Medicaid Services and provided that including these individuals in the
Health Benefit Exchange would not reduce their Medicaid benefits;
(C) Medicare benefits to individuals who are eligible, upon approval by the Centers for
Medicare and Medicaid Services and provided that including these individuals in the
Health Benefit Exchange would not reduce their Medicare benefits; and
(D) State employees and municipal employees, including teachers.
(3) To the extent allowable under federal law, the Vermont Health Benefit Exchange may
offer health benefits to employees for injuries arising out of or in the course of
employment in lieu of medical benefits provided pursuant to 21 V.S.A. chapter 9 (workers’ compensation).
(4) To the extent permitted by the U.S. Department of Health and Human Services, the Vermont
Health Benefit Exchange shall permit qualified individuals and qualified employers
to purchase qualified health benefit plans through the Exchange website, through navigators,
by telephone, or directly from a health insurer under contract with the Vermont Health
Benefit Exchange.
(c)(1) The Vermont Health Benefit Exchange may determine an appropriate method to provide
a unified, simplified administration system for health insurers offering qualified
health benefit plans. The Exchange may include claims administration, benefit management,
billing, or other components in the unified system and may achieve simplification
by contracting with a single entity for administration and management of all qualified
health benefit plans, by licensing or requiring the use of particular software, by
requiring health insurers to conform to a standard set of systems and rules, or by
another method determined by the Commissioner.
(2) The Vermont Health Benefit Exchange may offer certain services, such as wellness programs
and services designed to simplify administrative processes, to health insurers offering
plans outside the Exchange, to workers’ compensation insurers, to employers, and to
other entities.
(d) The Vermont Health Benefit Exchange may enter into information-sharing agreements
with federal and State agencies and other state exchanges to carry out its responsibilities
under this subchapter, provided such agreements include adequate protections with
respect to the confidentiality of the information to be shared and provided such agreements
comply with all applicable State and federal laws and regulations. (Added 2011, No. 48, § 4; amended 2013, No. 144 (Adj. Sess.), § 2, eff. May 27, 2014; 2015, No. 54, § 11, eff. June 5, 2015.)
§ 1804. Qualified employers [Effective until January 1, 2026; see also 33 V.S.A. § 1804 effective January 1, 2026 set out below]
(a)(1) Until January 1, 2016, a qualified employer shall be an entity that employed an average
of not more than 50 employees on working days during the preceding calendar year,
and the term “qualified employer” includes self-employed persons to the extent permitted
under the Affordable Care Act. Calculation of the number of employees of a qualified
employer shall not include a part-time employee who works fewer than 30 hours per
week or a seasonal worker as defined in 26 U.S.C. § 4980H(c)(2)(B).
(2) An employer with 50 or fewer employees that offers a qualified health benefit plan
to its employees through the Vermont Health Benefit Exchange may continue to participate
in the Exchange even if the employer’s size grows beyond 50 employees, as long as
the employer continuously makes qualified health benefit plans in the Vermont Health
Benefit Exchange available to its employees.
(b)(1) On and after January 1, 2016, a qualified employer shall be an entity that employed
an average of not more than 100 employees on working days during the preceding calendar
year, and the term “qualified employer” includes self-employed persons to the extent
permitted under the Affordable Care Act. The number of employees shall be calculated
using the method set forth in 26 U.S.C. § 4980H(c)(2).
(2) An employer with 100 or fewer employees that offers a qualified health benefit plan
to its employees through the Vermont Health Benefit Exchange may continue to participate
in the Exchange even if the employer’s size grows beyond 100 employees, as long as
the employer continuously makes qualified health benefit plans in the Vermont Health
Benefit Exchange available to its employees.
(c) [Repealed.] (Added 2011, No. 171 (Adj. Sess.), § 2; amended 2013, No. 79, § 28, eff. Oct. 1, 2013; 2015, No. 54, § 14, eff. June 5, 2015; 2015, No. 151 (Adj. Sess.), § 2.)
§ 1804. Qualified employers [Effective January 1, 2026; see also 33 V.S.A. § 1804 effective until January 1, 2026 set out above]
(a) [Repealed.]
(b)(1) A qualified employer shall be an entity that employed an average of not more than
100 employees on working days during the preceding calendar year, and the term “qualified
employer” includes self-employed persons to the extent permitted under the Affordable
Care Act. The number of employees shall be calculated using the method set forth in
26 U.S.C. § 4980H(c)(2).
(2) An employer with 100 or fewer employees that offers a qualified health benefit plan
to its employees through the Vermont Health Benefit Exchange may continue to participate
in the Exchange even if the employer’s size grows beyond 100 employees, provided the
employer continuously makes qualified health benefit plans in the Vermont Health Benefit
Exchange available to its employees.
(c) [Repealed.] (Added 2011, No. 171 (Adj. Sess.), § 2; amended 2013, No. 79, § 28, eff. Oct. 1, 2013; 2015, No. 54, § 14, eff. June 5, 2015; 2015, No. 151 (Adj. Sess.), § 2; 2025, No. 2, § 2, eff. January 1, 2026.)
§ 1805. Duties and responsibilities
The Vermont Health Benefit Exchange shall have the following duties and responsibilities
consistent with the Affordable Care Act:
(1) offering coverage for health services through qualified health benefit plans, including
by creating a process for:
(A) the certification, decertification, and recertification of qualified health benefit
plans as described in section 1806 of this title;
(B) enrolling qualified individuals in qualified health benefit plans, including through
open enrollment periods as provided in the Affordable Care Act, and ensuring that
individuals may transfer coverage between qualified health benefit plans and other
sources of coverage as seamlessly as possible; and
(C) creating a simplified and uniform system for the administration of health benefits;
(2) determining eligibility for and enrolling individuals in Medicaid, Dr. Dynasaur, and
VPharm pursuant to chapter 19 of this title, as well as any other public health benefit
program;
(3) creating and maintaining consumer assistance tools, including a website through which
enrollees and prospective enrollees of qualified health benefit plans may obtain standardized
comparative information on such plans, a toll-free telephone hotline to respond to
requests for assistance, and interactive online communication tools, in a manner that
complies with the Americans with Disabilities Act;
(4) creating standardized forms and formats for presenting health benefit options in the
Vermont Health Benefit Exchange, including the use of the uniform outline of coverage
established under Section 2715 of the federal Public Health Services Act;
(5) assigning a quality and wellness rating to each qualified health benefit plan offered
through the Vermont Health Benefit Exchange and determining each qualified health
benefit plan’s level of coverage in accordance with regulations issued by the U.S.
Department of Health and Human Services;
(6) determining enrollee subsidies as required by the Secretary of the U.S. Department
of the Treasury or of the U.S. Department of Health and Human Services and informing
consumers of eligibility for subsidies, including by providing an electronic calculator
to determine the actual cost of coverage after application of any premium tax credit
under Section 36B of the Internal Revenue Code of 1986 and any cost-sharing reduction under Section 1402 of the Affordable Care Act;
[Subdivision (7) effective until January 1, 2026; see also subdivision (7) effective
January 1, 2026 set out below.]
(7) transferring to the Secretary of the U.S. Department of the Treasury the name and
taxpayer identification number of each individual who was an employee of an employer
but who was determined to be eligible for the premium tax credit under Section 36B of the Internal Revenue Code of 1986 for the following reasons:
(A) the employer did not provide minimum essential coverage; or
(B) the employer provided the minimum essential coverage, but it was determined under
Section 36B(c)(2)(C) of the Internal Revenue Code to be either unaffordable to the employee or not to provide the required minimum
actuarial value;
[Subdivision (7) effective January 1, 2026; see also subdivision (7) effective until
January 1, 2026 set out above.]
(7) transferring to the Secretary of the U.S. Department of the Treasury the name and
taxpayer identification number of each individual determined to be eligible for the
premium tax credit under Section 36B of the Internal Revenue Code of 1986, including each individual who was an employee of an employer but who was determined
to be eligible for the premium tax credit for one of the following reasons:
(A) the employer did not provide minimum essential coverage; or
(B) the employer provided the minimum essential coverage, but it was determined under
Section 36B(c)(2)(C) of the Internal Revenue Code to be either unaffordable to the employee or not to provide the required minimum
actuarial value;
(8) performing duties required by the Secretary of the U.S. Department of Health and Human
Services or the Secretary of the U.S. Department of the Treasury related to determining
eligibility for the individual responsibility requirement exemptions, including:
(A) granting a certification attesting that an individual is exempt from the individual
responsibility requirement or from the penalty for violating that requirement, if
there is no affordable qualified health benefit plan available through the Vermont
Health Benefit Exchange or the individual’s employer for that individual or if the
individual meets the requirements for any exemption from the individual responsibility
requirement or from the penalty pursuant to Section 5000A of the Internal Revenue Code of 1986; and
(B) transferring to the Secretary of the U.S. Department of the Treasury a list of the
individuals who are issued a certification under subdivision (8)(A) of this section,
including the name and taxpayer identification number of each individual;
[Subdivision (9) effective until January 1, 2026; see also subdivision (9) effective
January 1, 2026 set out below.]
(9)(A) transferring to the Secretary of the U.S. Department of the Treasury the name and
taxpayer identification number of each individual who notifies the Vermont Health
Benefit Exchange that he or she has changed employers and of each individual who ceases
coverage under a qualified health benefit plan during a plan year and the effective
date of that cessation; and
(B) communicating to each employer the name of each of its employees and the effective
date of the cessation reported to the U.S. Department of the Treasury under this subdivision;
[Subdivision (9) effective January 1, 2026; see also subdivision (9) effective until
January 1, 2026 set out above.]
(9) transferring to the Secretary of the U.S. Department of the Treasury the name and
taxpayer identification number of each individual who ceases coverage under a qualified
health benefit plan during a plan year and the effective date of that cessation;
(10) establishing a navigator program as described in section 1807 of this title;
(11) reviewing the rate of premium growth within and outside the Vermont Health Benefit
Exchange;
(12) [Repealed.]
(13) providing consumers and health care professionals with satisfaction surveys and other
mechanisms for evaluating the performance of qualified health benefit plans and informing
the Commissioner of Vermont Health Access and the Commissioner of Financial Regulation
of such performance;
(14) ensuring consumers have easy and simple access to the relevant grievance and appeals
processes pursuant to 8 V.S.A. chapter 107 and 3 V.S.A. § 3090 (Human Services Board);
(15) consulting with the Advisory Committee established in section 402 of this title to obtain information and advice as necessary to fulfill the duties outlined in this
subchapter;
(16) referring consumers to the Office of the Health Care Advocate for assistance with
grievances, appeals, and other issues involving the Vermont Health Benefit Exchange;
and
[Subdivision (17) effective until January 1, 2026; see also subdivision (17) effective
January 1, 2026 set out below.]
(17) establishing procedures, including payment mechanisms and standard fee or compensation
schedules, that allow licensed insurance agents and brokers to be appropriately compensated
outside the navigator program established in section 1807 of this title for:
(A) assisting with the enrollment of qualified individuals and qualified employers in
any qualified health plan offered through the Exchange for which the individual or
employer is eligible; and
(B) assisting qualified individuals in applying for premium tax credits and cost-sharing
reductions for qualified health benefit plans purchased through the Exchange.
[Subdivision (17) effective January 1, 2026; see also subdivision (17) effective until
January 1, 2026 set out above.]
(17) establishing procedures that allow licensed insurance agents and brokers to:
(A) assist with the enrollment of qualified individuals and qualified employers in any
qualified health plan offered through the Exchange for which the individual or employer
is eligible; and
(B) assist qualified individuals in applying for premium tax credits and cost-sharing
reductions for qualified health benefit plans purchased through the Exchange. (Added 2011, No. 48, § 4; amended 2011, No. 78 (Adj. Sess.), § 2, eff. April 2, 2012; 2011, No. 171 (Adj. Sess.), § 2d; 2013, No. 79, § 29, eff. Oct. 1, 2013; 2013, No. 79, § 35g, eff. January 1, 2014; 2021, No. 74, § E.306.1, eff. Oct. 1, 2021; 2025, No. 2, § 3, eff. January 1, 2026.)
§ 1806. Qualified health benefit plans
(a) Prior to contracting with a health insurer to offer a qualified health benefit plan,
the Commissioner shall determine that making the plan available through the Vermont
Health Benefit Exchange is in the best interests of individuals and qualified employers
in this State. In determining the best interests, the Commissioner shall consider
affordability; promotion of high-quality care, prevention, and wellness; promotion
of access to health care; participation in the State’s health care reform efforts;
and such other criteria as the Commissioner, in the Commissioner’s discretion, deems
appropriate.
(b)(1) A qualified health benefit plan shall provide the following benefits:
(A) The essential benefits package required by Section 1302(a) of the Affordable Care
Act and any additional benefits required by the Secretary of Human Services by rule
after consultation with the Advisory Committee established in section 402 of this title and after approval from the Green Mountain Care Board established in 18 V.S.A. chapter 220.
(B) Notwithstanding subdivision (1)(A) of this subsection (b), a health insurer or a stand-alone
dental insurer, including a nonprofit dental service corporation, may offer a plan
that provides only limited dental benefits, either separately or in conjunction with
a qualified health benefit plan, if it meets the requirements of Section 9832(c)(2)(A) of the Internal Revenue Code and provides pediatric dental benefits meeting the requirements of Section 1302(b)(1)(J)
of the Affordable Care Act. Said plans may include child-only policies or family policies.
If permitted under federal law, a qualified health benefit plan offered in conjunction
with a stand-alone dental plan providing pediatric dental benefits meeting the requirements
of Section 1302(b)(1)(J) of the Affordable Care Act shall be deemed to meet the requirements
of this subsection.
(2) At least the bronze level of coverage as defined by Section 1302 of the Affordable
Care Act and the cost-sharing limitations for individuals provided in Section 1302
of the Affordable Care Act, as well as any more restrictive cost-sharing requirements
specified by the Secretary of Human Services by rule after consultation with the Advisory
Committee established in section 402 of this title and after approval from the Green Mountain Care Board established in 18 V.S.A. chapter 220.
(3) For qualified health benefit plans offered to employers, a deductible that meets the
limitations provided in Section 1302 of the Affordable Care Act and any more restrictive
deductible requirements specified by the Secretary of Human Services by rule after
consultation with the Advisory Committee established in section 402 of this title and after approval from the Green Mountain Care Board established in 18 V.S.A. chapter 220.
(c) A qualified health benefit plan shall meet the following minimum prevention, quality,
and wellness requirements:
(1) standards for marketing practices, network adequacy, essential community providers
in underserved areas, appropriate services to enable access for underserved individuals
or populations, accreditation, quality improvement, and information on quality measures
for health benefit plan performance, as provided in Section 1311 of the Affordable
Care Act and any more restrictive requirements provided by 8 V.S.A. chapter 107;
(2) quality and wellness standards, including a requirement for joint quality improvement
activities with other plans, as specified in rule by the Secretary of Human Services,
after consultation with the Commissioners of Health and of Financial Regulation and
with the Advisory Committee established in section 402 of this title; and
(3) standards for participation in the Blueprint for Health as provided in 18 V.S.A. chapter 13.
(d) A health insurer offering a qualified health benefit plan shall use the uniform enrollment
forms and descriptions of coverage provided by the Commissioners of Vermont Health
Access and of Financial Regulation.
(e)(1) A health insurer offering a qualified health benefit plan shall comply with the following
insurance and consumer information requirements:
(A)(i) obtain premium approval through the rate review process provided in 8 V.S.A. chapter 107; and
(ii) submit to the Commissioner of Financial Regulation a justification for any premium
increase before implementation of that increase and prominently post this information
on the health insurer’s website.
(B) Offer at least one qualified health benefit plan at the silver level and at least
one qualified health benefit plan at the gold level that meet the requirements of
Section 1302 of the Affordable Care Act and any additional requirements specified
by the Secretary of Human Services by rule. In addition, a health insurer may choose
to offer one or more qualified health benefit plans at the platinum level that meet
the requirements of Section 1302 of the Affordable Care Act and any additional requirements
specified by the Secretary of Human Services by rule.
(C) Charge the same premium rate for a health benefit plan without regard to whether the
plan is offered through the Vermont Health Benefit Exchange and without regard to
whether the plan is offered directly from the carrier or through an insurance agent.
(D) Provide accurate and timely disclosure of information to the public and to the Vermont
Health Benefit Exchange relating to claims denials, enrollment data, rating practices,
out-of-network coverage, enrollee and participant rights provided by Title I of the
Affordable Care Act, and other information as required by the Commissioner of Vermont
Health Access or by the Commissioner of Financial Regulation. The Commissioner of
Financial Regulation shall define, by rule, the acceptable time frame for provision
of information in accordance with this subdivision.
(E) Provide information in a timely manner to an individual, upon request, regarding the
cost-sharing amounts for that individual’s health benefit plan.
(2) A health insurer offering a qualified health benefit plan shall comply with all other
insurance requirements for health insurers as provided in 8 V.S.A. chapter 107 and as specified by rule by the Commissioner of Financial Regulation.
(f) Consistent with Section 1311(e)(1)(B) of the Affordable Care Act, the Vermont Health
Benefit Exchange shall not exclude a health benefit plan:
(1) on the basis that the plan is a fee-for-service plan;
(2) through the imposition of premium price controls by the Vermont Health Benefit Exchange;
or
(3) on the basis that the health benefit plan provides for treatments necessary to prevent
patients’ deaths in circumstances the Vermont Health Benefit Exchange determines are
inappropriate or too costly.
(g) The Vermont Health Benefit Exchange shall clearly indicate to any prospective purchaser
of a bronze-level plan, and of other plans as appropriate, the potential for significant
out-of-pocket costs, in addition to the premium, associated with the plan. (Added 2011, No. 48, § 4; amended 2011, No. 171 (Adj. Sess.), §§ 2a, 2h; 2021, No. 20, § 297.)
§ 1807. Navigators
(a)(1) The Vermont Health Benefit Exchange shall establish a navigator program to assist
individuals and employers in enrolling in a qualified health benefit plan offered
under the Vermont Health Benefit Exchange. The Vermont Health Benefit Exchange shall
select individuals and entities qualified to serve as navigators and shall award grants
to navigators for the performance of their duties.
(2) The Vermont Health Benefit Exchange shall ensure that navigators are available to
provide assistance in person or through interactive technology to individuals in all
regions of the State in a manner that complies with the Americans with Disabilities
Act.
(3) Consistent with Section 1311(i)(4) of the Affordable Care Act, health insurers shall
not serve as navigators, and no navigator shall receive any compensation from a health
insurer in connection with enrolling individuals or employees in qualified health
benefit plans.
(b) Navigators shall have the following duties:
(1) conduct public education activities to raise awareness of the availability of qualified
health benefit plans;
(2) distribute fair and impartial information concerning enrollment in qualified health
benefit plans and concerning the availability of premium tax credits and cost-sharing
reductions;
(3) facilitate enrollment in qualified health benefit plans, Medicaid, Dr. Dynasaur, VPharm,
and other public health benefit programs;
(4) provide referrals to the Office of the Health Care Advocate and any other appropriate
agency for any enrollee with a grievance, complaint, or question regarding his or
her health benefit plan, coverage, or a determination under that plan or coverage;
(5) provide information in a manner that is culturally and linguistically appropriate
to the needs of the population being served by the Vermont Health Benefit Exchange;
and
(6) distribute information to health care professionals, community organizations, and
others to facilitate the enrollment of individuals who are eligible for Medicaid,
Dr. Dynasaur, VPharm, other public health benefit programs, or the Vermont Health
Benefit Exchange in order to ensure that all eligible individuals are enrolled.
(7) [Repealed.] (Added 2011, No. 48, § 4; amended 2011, No. 171 (Adj. Sess.), § 2b; 2013, No. 79, §§ 22, 35h, eff. Jan. 1, 2014; 2019, No. 15, § 1, eff. May 6, 2019.)
§ 1808. Financial integrity
(a) The Vermont Health Benefit Exchange shall:
(1) keep an accurate accounting of all activities, receipts, and expenditures and submit
this information annually as required by federal law; and
(2) cooperate with the Secretary of the U.S. Department of Health and Human Services or
the Inspector General of the U.S. Department of Health and Human Services in any investigation
into the affairs of the Vermont Health Benefit Exchange, any examination of the properties
and records of the Vermont Health Benefit Exchange, or any requirement for periodic
reports in relation to the activities undertaken by the Vermont Health Benefit Exchange.
(b) In carrying out its activities under this subchapter, the Vermont Health Benefit Exchange
shall not use any funds intended for the administrative and operational expenses of
the Vermont Health Benefit Exchange for staff retreats, promotional giveaways, excessive
executive compensation, or promotion of federal or State legislative or regulatory
modifications. (Added 2011, No. 48, § 4.)
§ 1809. Publication of costs and satisfaction surveys
(a) The Vermont Health Benefit Exchange shall publish the average costs of licensing,
regulatory fees, and any other payments required by the Exchange, as well as the administrative
costs of the Exchange, on a website intended to educate consumers about such costs.
This information shall include information on monies lost to waste, fraud, and abuse.
(b) The Vermont Health Benefit Exchange shall publish the deidentified results of the
satisfaction surveys and other evaluation mechanisms required pursuant to subdivision 1805(13) of this title on a website intended to enable consumers to compare the qualified health benefit
plans offered through the Exchange. (Added 2011, No. 48, § 4.)
§ 1810. Rules
The Secretary of Human Services may adopt rules pursuant to 3 V.S.A. chapter 25 as needed to carry out the duties and functions established in this subchapter. (Added 2011, No. 48, § 4.)
§ 1811. Health benefit plans for individuals and small employers
(a) As used in this section:
[Subdivision (a)(1) effective until January 1, 2026; see also subdivision (a)(1) effective
January 1, 2026 set out below.]
(1) “Health benefit plan” means a health insurance policy, a nonprofit hospital or medical
service corporation service contract, or a health maintenance organization health
benefit plan offered through the Vermont Health Benefit Exchange or a reflective health
benefit plan offered in accordance with section 1813 of this title that is issued to an individual or to an employee of a small employer. The term does
not include coverage only for accident or disability income insurance, liability insurance,
coverage issued as a supplement to liability insurance, workers’ compensation or similar
insurance, automobile medical payment insurance, credit-only insurance, coverage for
on-site medical clinics, or other similar insurance coverage in which benefits for
health services are secondary or incidental to other insurance benefits as provided
under the Affordable Care Act. The term also does not include stand-alone dental or
vision benefits; long-term care insurance; short-term, limited-duration health insurance;
specific disease or other limited benefit coverage; Medicare supplemental health benefits;
Medicare Advantage plans; and other similar benefits excluded under the Affordable
Care Act.
[Subdivision (a)(1) effective January 1, 2026; see also subdivision (a)(1) effective
until January 1, 2026 set out above.]
(1) “Health benefit plan” means a health insurance policy, a nonprofit hospital or medical
service corporation service contract, or a health maintenance organization health
benefit plan offered through the Vermont Health Benefit Exchange or a reflective health
benefit plan offered in accordance with section 1813 of this title that is issued to an individual in the individual market or to an employee of a small
employer in the small group market. The term does not include coverage only for accident
or disability income insurance, liability insurance, coverage issued as a supplement
to liability insurance, workers’ compensation or similar insurance, automobile medical
payment insurance, credit-only insurance, coverage for on-site medical clinics, or
other similar insurance coverage in which benefits for health services are secondary
or incidental to other insurance benefits as provided under the Affordable Care Act.
The term also does not include stand-alone dental or vision benefits; long-term care
insurance; short-term, limited-duration health insurance; specific disease or other
limited benefit coverage; Medicare supplemental health benefits; Medicare Advantage
plans; and other similar benefits excluded under the Affordable Care Act.
(2) “Registered carrier” means any person, except an insurance agent, broker, appraiser,
or adjuster, who issues a health benefit plan and who has a registration in effect
with the Commissioner of Financial Regulation as required by this section.
[Subdivision (a)(3) effective until January 1, 2026; see also subdivision (a)(3) effective
January 1, 2026 set out below.]
(3)(A) Until January 1, 2016, “small employer” means an entity that employed an average of
not more than 50 employees on working days during the preceding calendar year. The
term includes self-employed persons to the extent permitted under the Affordable Care
Act. Calculation of the number of employees of a small employer shall not include
a part-time employee who works fewer than 30 hours per week or a seasonal worker as
defined in 26 U.S.C. § 4980H(c)(2)(B). An employer may continue to participate in the Exchange even if the employer’s size
grows beyond 50 employees, as long as the employer continuously makes qualified health
benefit plans in the Vermont Health Benefit Exchange available to its employees.
(B) Beginning on January 1, 2016, “small employer” means an entity that employed an average
of not more than 100 employees on working days during the preceding calendar year.
The term includes self-employed persons to the extent permitted under the Affordable
Care Act. The number of employees shall be calculated using the method set forth in
26 U.S.C. § 4980H(c)(2). An employer may continue to participate in the Exchange even if the employer’s size
grows beyond 100 employees, as long as the employer continuously makes qualified health
benefit plans in the Vermont Health Benefit Exchange available to its employees.
[Subdivision (a)(3) effective January 1, 2026; see also subdivision (a)(3) effective
until January 1, 2026 set out above.]
(3) “Small employer” means an entity that employed an average of not more than 100 employees
on working days during the preceding calendar year. The term includes self-employed
persons to the extent permitted under the Affordable Care Act. The number of employees
shall be calculated using the method set forth in 26 U.S.C. § 4980H(c)(2). An employer may continue to participate in the Exchange even if the employer’s size
grows beyond 100 employees, provided the employer continuously makes qualified health
benefit plans in the Vermont Health Benefit Exchange available to its employees.
[Subsection (b) effective until January 1, 2026; see also subsection (b) effective
January 1, 2026 set out below.]
(b)(1) To the extent permitted by the U.S. Department of Health and Human Services, an individual
may purchase a health benefit plan through the Exchange website, through navigators,
by telephone, or directly from a registered carrier under contract with the Vermont
Health Benefit Exchange, if the carrier elects to make direct enrollment available.
A registered carrier enrolling individuals in health benefit plans directly shall
comply with all open enrollment and special enrollment periods applicable to the Vermont
Health Benefit Exchange.
(2) To the extent permitted by the U.S. Department of Health and Human Services, a small
employer or an employee of a small employer may purchase a health benefit plan through
the Exchange website, through navigators, by telephone, or directly from a registered
carrier under contract with the Vermont Health Benefit Exchange.
(3) No person may provide a health benefit plan to an individual or small employer unless
the plan complies with the provisions of this subchapter.
[Subsection (b) effective January 1, 2026; see also subsection (b) effective until
January 1, 2026 set out above.]
(b)(1) An individual may purchase a health benefit plan through the Exchange website, through
navigators, by telephone, or directly from a registered carrier under contract with
the Vermont Health Benefit Exchange. A registered carrier enrolling individuals in
health benefit plans directly shall comply with all open enrollment and special enrollment
periods applicable to the Vermont Health Benefit Exchange.
(2) A small employer or an employee of a small employer may purchase a health benefit
plan directly from a registered carrier under contract with the Vermont Health Benefit
Exchange.
(3) No person may provide a health benefit plan to an individual or to a small employer
unless the plan complies with the provisions of this subchapter.
[Subsection (c) effective until January 1, 2026; see also subsection (c) effective
January 1, 2026 set out below.]
(c) No person may provide a health benefit plan to an individual or small employer unless
such person is a registered carrier. The Commissioner of Financial Regulation shall
establish, by rule, the minimum financial, marketing, service, and other requirements
for registration. Such registration shall be effective upon approval by the Commissioner
of Financial Regulation and shall remain in effect until revoked or suspended by the
Commissioner of Financial Regulation for cause or until withdrawn by the carrier.
A carrier may withdraw its registration upon at least six months’ prior written notice
to the Commissioner of Financial Regulation. A registration filed with the Commissioner
of Financial Regulation shall be deemed to be approved unless it is disapproved by
the Commissioner of Financial Regulation within 30 days of filing.
[Subsection (c) effective January 1, 2026; see also subsection (c) effective until
January 1, 2026 set out above.]
(c) No person may provide a health benefit plan to an individual or to a small employer
unless such person is a registered carrier. The Commissioner of Financial Regulation
shall establish, by rule, the minimum financial, marketing, service, and other requirements
for registration. Such registration shall be effective upon approval by the Commissioner
of Financial Regulation and shall remain in effect until revoked or suspended by the
Commissioner of Financial Regulation for cause or until withdrawn by the carrier.
A carrier may withdraw its registration upon at least six months’ prior written notice
to the Commissioner of Financial Regulation. A registration filed with the Commissioner
of Financial Regulation shall be deemed to be approved unless it is disapproved by
the Commissioner of Financial Regulation within 30 days of filing.
[Subdivision (d)(1) effective until January 1, 2026; see also subdivision (d)(1) effective
January 1, 2026 set out below.]
(d)(1) Guaranteed issue. A registered carrier shall guarantee acceptance of all individuals, small employers,
and employees of small employers, and each dependent of such individuals and employees,
for any health benefit plan offered by the carrier, regardless of any outstanding
premium amount a subscriber may owe to the carrier for coverage provided during the
previous plan year.
[Subdivision (d)(1) effective January 1, 2026; see also subdivision (d)(1) effective
until January 1, 2026 set out above.]
(1) Guaranteed issue. (A) A registered carrier shall guarantee acceptance of all individuals and their dependents
for any health benefit plan offered by the carrier in the individual market, regardless
of any outstanding premium amount a subscriber may owe to the carrier for coverage
provided during the previous plan year.
(B) A registered carrier shall guarantee acceptance of all small employers, their employees,
and their employees’ dependents for any health benefit plan offered by the carrier
in the small group market, regardless of any outstanding premium amount a subscriber
may owe to the carrier for coverage provided during the previous plan year.
(2) Preexisting condition exclusions. A registered carrier shall not exclude, restrict, or otherwise limit coverage under
a health benefit plan for any preexisting health condition.
(3) 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).
(4) Ban on annual and lifetime limits. A health benefit plan 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 plan, regardless
of whether the services are provided in-network or out-of-network.
(5)(A) No cost sharing for preventive services. A health benefit plan 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
(5)(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 (5) 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.
(e) A registered carrier shall offer a health benefit plan rate structure that at least
differentiates between single person, two person, and family rates.
[Subdivision (f)(1) effective until January 1, 2026; see also subdivision (f)(1) effective
January 1, 2026 set out below.]
(f)(1) A registered carrier shall use a community rating method acceptable to the Commissioner
of Financial Regulation for determining premiums for health benefit plans. Except
as provided in subdivision (2) of this subsection, the following risk classification
factors are prohibited from use in rating individuals, small employers, or employees
of small employers, or the dependents of such individuals or employees:
(A) demographic rating, including age and gender rating;
(B) geographic area rating;
(C) industry rating;
(D) medical underwriting and screening;
(E) experience rating;
(F) tier rating; or
(G) durational rating.
[Subdivision (f)(1) effective January 1, 2026; see also subdivision (f)(1) effective
until January 1, 2026 set out above.]
(1) A registered carrier shall use a community rating method acceptable to the Commissioner
of Financial Regulation for determining premiums for health benefit plans and shall
determine the premiums for the carrier’s individual market plans separately from the
premiums for its small group market plans. Except as provided in subdivision (2) of
this subsection, the following risk classification factors are prohibited from use
in rating individuals, small employers, or employees of small employers, or the dependents
of such individuals or employees:
(A) demographic rating, including age and gender rating;
(B) geographic area rating;
(C) industry rating;
(D) medical underwriting and screening;
(E) experience rating;
(F) tier rating; or
(G) durational rating.
(2)(A) The Commissioner of Financial Regulation shall, by rule, adopt standards and a process
for permitting registered carriers to use one or more risk classifications in their
community rating method, provided that the premium charged shall not deviate above
or below the community rate filed by the carrier by more than 20 percent and provided
further that the Commissioner of Financial Regulation’s rules may not permit any medical
underwriting and screening and shall give due consideration to the need for affordability
and accessibility of health insurance.
(B) The Commissioner of Financial Regulation’s rules shall permit a carrier, including
a hospital or medical service corporation and a health maintenance organization, to
establish rewards, premium discounts, split benefit designs, rebates, or otherwise
waive or modify applicable co-payments, deductibles, or other cost-sharing amounts
in return for adherence by a member or subscriber to programs of health promotion
and disease prevention. The Commissioner of Financial Regulation shall consult with
the Commissioner of Health, the Director of the Blueprint for Health, and the Commissioner
of Vermont Health Access in the development of health promotion and disease prevention
rules that are consistent with the Blueprint for Health. Such rules shall:
(i) limit any reward, discount, rebate, or waiver or modification of cost-sharing amounts
to not more than a total of 15 percent of the cost of the premium for the applicable
coverage tier, provided that the sum of any rate deviations under subdivision (A)
of this subdivision (2) does not exceed 30 percent;
(ii) be designed to promote good health or prevent disease for individuals in the program
and not be used as a subterfuge for imposing higher costs on an individual based on
a health factor;
(iii) provide that the reward under the program is available to all similarly situated individuals
and shall comply with the nondiscrimination provisions of the federal Health Insurance
Portability and Accountability Act of 1996; and
(iv) provide a reasonable alternative standard to obtain the reward to any individual for
whom it is unreasonably difficult due to a medical condition or other reasonable mitigating
circumstance to satisfy the otherwise applicable standard for the discount and disclose
in all plan materials that describe the discount program the availability of a reasonable
alternative standard.
(C) The Commissioner of Financial Regulation’s rules shall include:
(i) standards and procedures for health promotion and disease prevention programs based
on the best scientific, evidence-based medical practices as recommended by the Commissioner
of Health;
(ii) standards and procedures for evaluating an individual’s adherence to programs of health
promotion and disease prevention; and
(iii) any other standards and procedures necessary or desirable to carry out the purposes
of this subdivision (2).
(D) The Commissioner of Financial Regulation may require a registered carrier to identify
that percentage of a requested premium increase that is attributed to the following
categories: hospital inpatient costs, hospital outpatient costs, pharmacy costs, primary
care, other medical costs, administrative costs, and projected reserves or profit.
Reporting of this information shall occur at the time a rate increase is sought and
shall be in the manner and form directed by the Commissioner of Financial Regulation.
Such information shall be made available to the public in a manner that is easy to
understand.
(g) A registered carrier shall file with the Commissioner of Financial Regulation an annual
certification by a member of the American Academy of Actuaries of the carrier’s compliance
with this section. The requirements for certification shall be as the Commissioner
of Financial Regulation prescribes by rule.
(h) A registered carrier shall provide, on forms prescribed by the Commissioner of Financial
Regulation, full disclosure to a small employer of all premium rates and any risk
classification formulas or factors prior to acceptance of a plan by the small employer.
(i) A registered carrier shall guarantee the rates on a health benefit plan for a minimum
of 12 months.
(j) The Commissioner of Financial Regulation or the Green Mountain Care Board established
in 18 V.S.A. chapter 220, as appropriate, shall disapprove any rates filed by any registered carrier, whether
initial or revised, for insurance policies unless the anticipated medical loss ratios
for the entire period for which rates are computed are at least 80 percent, as required
by the Affordable Care Act.
[Subsection (k) effective until January 1, 2026; see also subsection (k) effective
January 1, 2026 set out below.]
(k) The guaranteed acceptance provision of subsection (d) of this section shall not be
construed to limit an employer’s discretion in contracting with his or her employees
for insurance coverage.
[Subsection (k) effective January 1, 2026; see also subsection (k) effective until
January 1, 2026 set out above.]
(k) The guaranteed acceptance provision of subsection (d) of this section shall not be
construed to limit an employer’s discretion in contracting with the employer’s employees
for insurance coverage.
(l)(1) A registered carrier shall allow for the enrollment of a pregnant individual, and
of any individual who is eligible for coverage under the terms of the health benefit
plan because of a relationship to the pregnant individual, at any time after the commencement
of the pregnancy. Coverage shall be effective as of the first of the month following
the individual’s selection of a health benefit plan.
(2) A registered carrier shall allow an individual who is eligible for advance payments
of federal premium tax credits under 26 U.S.C. § 36B and whose household income for the year is expected to be not greater than 200 percent
of the federal poverty level, and any individual who is eligible for coverage because
of a relationship to that individual, to enroll in a health benefit plan through the
Vermont Health Benefit Exchange at any time during the plan year. (Added 2011, No. 171 (Adj. Sess.), § 3, eff. Jan. 1, 2013; amended 2013, No. 79, § 5n, eff. Jan. 1, 2014; 2013, No. 79, § 30, eff. Oct. 1, 2013; 2013, No. 144 (Adj. Sess.), § 3, eff. May 27, 2014; 2015, No. 54, § 12, eff. June 5, 2015; 2015, No. 120 (Adj. Sess.), § 4; 2017, No. 85, § E.306.3; 2017, No. 88 (Adj. Sess.), § 3, eff. Feb. 20, 2018; 2017, No. 131 (Adj. Sess.), § 6, eff. May 16, 2018; 2019, No. 19, § 5, eff. Jan. 1, 2020; 2019, No. 63, § 6, eff. Jan. 1, 2020; 2025, No. 2, § 4, eff. January 1, 2026; 2025, No. 27, § E.306.3, eff. July 1, 2025.)
§ 1812. Financial assistance to individuals
(a)(1) An individual or family eligible for federal premium tax credits under 26 U.S.C. § 36B with income less than or equal to 300 percent of federal poverty level shall be eligible
for premium assistance from the State of Vermont.
(2) The Department of Vermont Health Access shall establish a premium schedule on a sliding
scale based on modified adjusted gross income for the individuals and families described
in subdivision (1) of this subsection. The Department shall reduce the premium contribution
for these individuals and families by 1.5 percent below the premium amount established
in 26 U.S.C. § 36B.
(3) Premium assistance shall be available for the same qualified health benefit plans
for which federal premium tax credits are available.
(b)(1) An individual or family with income at or below 300 percent of the federal poverty
level shall be eligible for cost-sharing assistance, including a reduction in the
out-of-pocket maximums established under Section 1402 of the Affordable Care Act.
(2) The Department of Vermont Health Access shall establish cost-sharing assistance on
a sliding scale based on modified adjusted gross income for the individuals and families
described in subdivision (1) of this subsection. Cost-sharing assistance shall be
established as follows:
(A) for households with income at or below 150 percent of the federal poverty level (FPL):
94 percent actuarial value;
(B) for households with income above 150 percent FPL and at or below 200 percent FPL:
87 percent actuarial value;
(C) for households with income above 200 percent FPL and at or below 250 percent FPL:
77 percent actuarial value;
(D) for households with income above 250 percent FPL and at or below 300 percent FPL:
73 percent actuarial value.
(3) Cost-sharing assistance shall be available for silver-level qualified health benefit
plans purchased through the Vermont Health Benefit Exchange and shall be administered
using the same methods as set forth in Section 1402 of the Affordable Care Act to
the extent practicable.
(c) To the extent feasible, the Department shall use the same mechanisms provided in the
Affordable Care Act to establish financial assistance under this section in order
to minimize confusion and complication for individuals, families, and health insurers. (Added 2013, No. 50, § E.307.1, eff. Oct. 1, 2013; amended 2015, No. 23, § 54; 2017, No. 88 (Adj. Sess.), § 4, eff. Feb. 20, 2018.)
§ 1813. Reflective health benefit plans
(a)(1) In the event that federal cost-sharing reduction payments to insurers are suspended
or discontinued, registered carriers may offer to individuals and employees of small
employers nonqualified reflective health benefit plans that do not include funding
to offset the loss of the federal cost-sharing reduction payments. These plans shall
be similar to, but contain at least one variation from, qualified health benefit plans
offered through the Vermont Health Benefit Exchange that include funding to offset
the loss of the federal cost-sharing reduction payments.
(2) In its review and approval of premium rates pursuant to 8 V.S.A. § 4026, the Green Mountain Care Board shall ensure that:
(A) the rates for some or all qualified health benefit plans offered through the Vermont
Health Benefit Exchange include funding to offset the loss of the federal cost-sharing
reduction payments; and
(B) the rates for the reflective health benefit plans described in subdivision (1) of
this subsection (a) do not include funding to offset the loss of the federal cost-sharing
reduction payments.
(3) To the extent not expressly prohibited under federal law, the Green Mountain Care
Board shall ensure that funding to offset the loss of the federal cost-sharing reduction
payments is included exclusively in silver-level qualified health benefit plans offered
through the Vermont Health Benefit Exchange.
(b) A reflective health benefit plan shall comply with the requirements of section 1806 of this title except that the plan shall not be offered through the Vermont Health Benefit Exchange. (Added 2017, No. 88 (Adj. Sess.), § 5, eff. Feb. 20, 2018; amended 2019, No. 19, § 6, eff. Jan. 1, 2020; 2025, No. 11, § 28, eff. September 1, 2025.)
§ 1814. Maximum out-of-pocket limit for prescription drugs in bronze plans
(a)(1) Notwithstanding any provision of 8 V.S.A. § 4092 to the contrary, the Green Mountain Care Board may approve modifications to the out-of-pocket
prescription drug limit established in 8 V.S.A. § 4092 for one or more bronze-level plans, as long as the Board finds that the offering
of such plans will not adversely impact the plan options available to consumers with
high prescription drug needs who benefit from the out-of-pocket prescription drug
limit established in 8 V.S.A. § 4092.
(2) The Department of Vermont Health Access shall certify at least two standard bronze-level
plans that include the out-of-pocket prescription drug limit established in 8 V.S.A. § 4092, as long as the plans comply with federal requirements. Notwithstanding any provision
of 8 V.S.A. § 4092 to the contrary, the Department may certify one or more bronze-level qualified health
benefit plans with modifications to the out-of-pocket prescription drug limit established
in 8 V.S.A. § 4092.
(b)(1) For each individual enrolled in a bronze-level qualified health benefit plan for the
previous two plan years who had out-of-pocket prescription drug expenditures that
met the out-of-pocket prescription drug limit established in 8 V.S.A. § 4092 for the most recent plan year for which information is available, the health insurer
shall, absent an alternative plan selection or plan cancellation by the individual,
automatically reenroll the individual in a bronze-level qualified health plan for
the forthcoming plan year with an out-of-pocket prescription drug limit at or below
the limit established in 8 V.S.A. § 4092.
(2) Prior to reenrolling an individual in a plan pursuant to subdivision (1) of this subsection,
the health insurer shall notify the individual of the insurer’s intent to reenroll
the individual automatically in a bronze-level qualified health plan for the forthcoming
plan year with an out-of-pocket prescription drug limit at or below the limit established
in 8 V.S.A. § 4092 unless the individual contacts the insurer to select a different plan and of the
availability of bronze-level plans with higher out-of-pocket prescription drug limits.
The health insurer shall collaborate with the Department of Vermont Health Access
and the Office of the Health Care Advocate as to the notification’s form and content. (Added 2017, No. 210 (Adj. Sess.), § 12, eff. June 1, 2018; amended 2025, No. 11, § 29, eff. September 1, 2025.)
-
Subchapter 002: GREEN MOUNTAIN CARE
§ 1821. Purpose
The purpose of Green Mountain Care is to provide, as a public good, comprehensive,
affordable, high-quality, publicly financed health care coverage for all Vermont residents
in a seamless and equitable manner regardless of income, assets, health status, or
availability of other health coverage. Green Mountain Care shall contain costs by:
(1) providing incentives to residents to avoid preventable health conditions, promote
health, and avoid unnecessary emergency room visits;
(2) establishing innovative payment mechanisms to health care professionals, such as global
payments;
(3) encouraging the management of health services through the Blueprint for Health; and
(4) reducing unnecessary administrative expenditures. (Added 2011, No. 48, § 4.)
§ 1822. Implementation; waiver
(a) Green Mountain Care shall be implemented 90 days following the last to occur of:
(1) Receipt of a waiver under Section 1332 of the Affordable Care Act pursuant to subsection
(b) of this section.
(2) Enactment of a law establishing the financing for Green Mountain Care.
(3) Approval by the Green Mountain Care Board of the initial Green Mountain Care benefit
package pursuant to 18 V.S.A. § 9375.
(4) Enactment of the appropriations for the initial Green Mountain Care benefit package
proposed by the Green Mountain Care Board pursuant to 18 V.S.A. § 9375.
(5) A determination by the Green Mountain Care Board, as the result of a detailed and
transparent analysis, that each of the following conditions will be met:
(A) Each Vermont resident covered by Green Mountain Care will receive benefits with an
actuarial value of 80 percent or greater.
(B) When implemented, Green Mountain Care will not have a negative aggregate impact on
Vermont’s economy. This determination shall include an analysis of the impact of implementation
on economic growth.
(C) The financing for Green Mountain Care is sustainable. In this analysis, the Board
shall consider at least a five-year revenue forecast using the consensus process established
in 32 V.S.A. § 305a, projections of federal and other funds available to support Green Mountain Care,
and estimated expenses for Green Mountain Care for an equivalent time period.
(D) Administrative expenses in Vermont’s health care system for which data are available
will be reduced below 2011 levels, adjusted for inflation and other factors as necessary
to reflect the present value of 2011 dollars at the time of the analysis.
(E) Cost-containment efforts will result in a reduction in the rate of growth in Vermont’s
per-capita health care spending without reducing access to necessary care or resulting
in excessive wait times for services.
(F) Health care professionals will be reimbursed at levels sufficient to allow Vermont
to recruit and retain high-quality health care professionals.
(b) As soon as allowed under federal law, the Secretary of Administration shall seek a
waiver to allow the State to suspend operation of the Vermont Health Benefit Exchange
and to enable Vermont to receive the appropriate federal fund contribution in lieu
of the federal premium tax credits, cost-sharing subsidies, and small business tax
credits provided in the Affordable Care Act. The Secretary may seek a waiver from
other provisions of the Affordable Care Act as necessary to ensure the operation of
Green Mountain Care.
(c) The Green Mountain Care Board’s analysis prepared pursuant to subdivision (a)(5) of
this section shall be made available to the General Assembly and the public and shall
include:
(1) a complete fiscal projection of revenues and expenses, as described in subdivision
(a)(5) of this section, including reserves, if recommended, and other costs in addition
to the cost of services, over at least a five-year period for a public-private universal
health care system providing benefits with an actuarial value of 80 percent or greater;
(2) the financing plans provided to the General Assembly in January 2013 pursuant to 2011
Acts and Resolves No. 48, Sec. 9;
(3) an analysis of how implementing Green Mountain Care will further the principles of
health care reform expressed in 18 V.S.A. § 9371 beyond the reforms established through the Blueprint for Health; and
(4) a comparison of best practices for reducing health care costs in self-funded plans,
if available. (Added 2011, No. 48, § 4; amended 2011, No. 171 (Adj. Sess.), § 36a, eff. May 16, 2012.)
§ 1823. Definitions
As used in this subchapter:
(1) “Agency” means the Agency of Human Services.
(2) “Board” means the Green Mountain Care Board established in 18 V.S.A. chapter 220.
(3) “CHIP funds” means federal funds available under Title XXI of the Social Security
Act.
(4) “Chronic care” means health services provided by a health care professional for an
established clinical condition that is expected to last a year or more and that requires
ongoing clinical management attempting to restore the individual to highest function,
minimize the negative effects of the condition, prevent complications related to chronic
conditions, engage in advanced care planning, and promote appropriate access to palliative
care. Examples of chronic conditions include diabetes, hypertension, cardiovascular
disease, cancer, asthma, pulmonary disease, substance abuse, mental condition or psychiatric
disability, spinal cord injury, and hyperlipidemia.
(5) “Chronic care management” means a system of coordinated health care interventions
and communications for individuals with chronic conditions, including significant
patient self-care efforts, systemic supports for licensed health care practitioners
and their patients, and a plan of care emphasizing prevention of complications utilizing
evidence-based practice guidelines, patient empowerment strategies, and evaluation
of clinical, humanistic, and economic outcomes on an ongoing basis with the goal of
improving overall health.
(6) “Health care professional” means an individual, partnership, corporation, facility,
or institution licensed, certified, or otherwise authorized by Vermont law to provide
professional health services.
(7) “Health service” means any treatment or procedure delivered by a health care professional
to maintain an individual’s physical or mental health or to diagnose or treat an individual’s
physical or mental condition, including services ordered by a health care professional,
chronic care management, preventive care, wellness services, and medically necessary
services to assist in activities of daily living.
(8) “Hospital” shall have the same meaning as in 18 V.S.A. § 1902 and may include hospitals located outside the State.
(9) “Preventive care” means health services provided by health care professionals to identify
and treat asymptomatic individuals who have risk factors or preclinical disease, but
in whom the disease is not clinically apparent, including immunizations and screening,
counseling, treatment, and medication determined by scientific evidence to be effective
in preventing or detecting a condition.
(10) “Primary care” means health services provided by health care professionals, including
naturopathic physicians licensed pursuant to 26 V.S.A. chapter 81, who are specifically
trained for and skilled in first-contact and continuing care for individuals with
signs, symptoms, or health concerns, not limited by problem origin, organ system,
or diagnosis, and shall include family planning, prenatal care, and mental health
and substance abuse treatment.
(11) “Secretary” means the Secretary of Human Services.
(12) “Vermont resident” means an individual domiciled in Vermont as evidenced by an intent
to maintain a principal dwelling place in Vermont indefinitely and to return to Vermont
if temporarily absent, coupled with an act or acts consistent with that intent. An
individual shall not be considered to be a Vermont resident if he or she is 18 years
of age or older and is claimed as a dependent on the tax return of a resident of another
State.
(13) “Wellness services” means health services, programs, or activities that focus on the
promotion or maintenance of good health. (Added 2011, No. 48, § 4; amended 2011, No. 96 (Adj. Sess.), § 6, eff. May 2, 2012; 2013, No. 96 (Adj. Sess.), § 203.)
§ 1824. Eligibility
(a)(1) Upon implementation, all Vermont residents shall be eligible for Green Mountain Care,
regardless of whether an employer offers health insurance for which they are eligible.
The Agency shall establish standards by rule for proof and verification of residency.
(2)(A) Except as otherwise provided in subdivision (C) of this subdivision (2), if an individual
is determined to be eligible for Green Mountain Care based on information later found
to be false, the Agency shall make reasonable efforts to recover from the individual
the amounts expended for his or her care. In addition, if the individual knowingly
provided the false information, he or she shall be assessed an administrative penalty
of not more than $5,000.00.
(B) The Agency shall include information on the Green Mountain Care application to provide
notice to applicants of the penalty for knowingly providing false information as established
in subdivision (A) of this subdivision (2).
(C) An individual determined to be eligible for Green Mountain Care whose health services
are paid in whole or in part by Medicaid funds who commits fraud shall be subject
to the provisions of chapter 1, subchapter 5 of this title in lieu of the administrative
penalty described in subdivision (A) of this subdivision (2).
(D) Nothing in this section shall be construed to limit or restrict prosecutions under
any applicable provision of law.
(3)(A) Except as otherwise provided in this section, a person who is not a Vermont resident
shall not be eligible for Green Mountain Care.
(B) Except as otherwise provided in subdivision (C) of this subdivision (3), an individual
covered under Green Mountain Care shall inform the Agency within 60 days of becoming
a resident of another state. An individual who obtains or attempts to obtain health
services through Green Mountain Care more than 60 days after becoming a resident of
another state shall reimburse the Agency for the amounts expended for his or her care
and shall be assessed an administrative penalty of not more than $1,000.00 for a first
violation and not more than $2,000.00 for any subsequent violation.
(C) An individual whose health services are paid in whole or in part by Medicaid funds
who obtains or attempts to obtain health services through Green Mountain Care more
than 60 days after becoming a resident of another state shall be subject to the provisions
of chapter 1, subchapter 5 of this title in lieu of the administrative penalty described
in subdivision (B) of this subdivision (3).
(D) Nothing in this section shall be construed to limit or restrict prosecutions under
any applicable provision of law.
(b) The Agency shall establish a procedure to enroll residents in Green Mountain Care.
(c)(1) The Agency shall establish by rule a process to allow health care professionals to
presume an individual is eligible based on the information provided on a simplified
application.
(2) After submission of the application, the Agency shall collect additional information
as necessary to determine whether Medicaid, Medicare, CHIP, or other federal funds
may be applied toward the cost of the health services provided, but shall provide
payment for any health services received by the individual from the time the application
is submitted.
(3) If an individual presumed eligible for Green Mountain Care pursuant to subdivision
(1) of this subsection is later determined not to be eligible for the program, the
Agency shall make reasonable efforts to recover from the individual the amounts expended
for his or her care.
(d) The Agency shall adopt rules pursuant to 3 V.S.A. chapter 25 to ensure that Vermont residents who are temporarily out of the State and who intend
to return and reside in Vermont remain eligible for Green Mountain Care while outside
Vermont.
(e) A nonresident visiting Vermont, or his or her insurer, shall be billed for all services
received. The Agency may enter into intergovernmental arrangements or contracts with
other states and countries to provide reciprocal coverage for temporary visitors and
shall adopt rules pursuant to 3 V.S.A. chapter 25 to carry out the purposes of this subsection. (Added 2011, No. 48, § 4.)
§ 1825. Health benefits
(a)(1) Green Mountain Care shall include primary care, preventive care, chronic care, acute
episodic care, and hospital services and shall include at least the same covered services
as those included in the benefit package in effect for the lowest cost Catamount Health
plan offered on January 1, 2011.
(2) It is the intent of the General Assembly that Green Mountain Care provide a level
of coverage that includes benefits that are actuarially equivalent to at least 87
percent of the full actuarial value of the covered health services.
(3) The Green Mountain Care Board shall consider whether to impose cost-sharing requirements;
if so, whether to make the cost-sharing requirements income-sensitized; and the impact
of any cost-sharing requirements on an individual’s ability to access care. The Board
shall consider waiving any cost-sharing requirement for evidence-based primary and
preventive care; for palliative care; and for chronic care for individuals participating
in chronic care management and, where circumstances warrant, for individuals with
chronic conditions who are not participating in a chronic care management program.
(4)(A) The Green Mountain Care Board established in 18 V.S.A. chapter 220 shall consider
whether to include dental, vision, and hearing benefits in the Green Mountain Care
benefit package.
(B) The Green Mountain Care Board shall consider whether to include long-term care benefits
in the Green Mountain Care benefit package.
(5) Green Mountain Care shall not limit coverage of preexisting conditions.
(6) The Green Mountain Care Board shall approve the benefit package and present it to
the General Assembly as part of its recommendations for the Green Mountain Care budget.
(b)(1)(A) For individuals eligible for Medicaid or CHIP, the benefit package shall include the
benefits required by federal law, as well as any additional benefits provided as part
of the Green Mountain Care benefit package.
(B) Upon implementation of Green Mountain Care, the benefit package for individuals eligible
for Medicaid or CHIP shall also include any optional Medicaid benefits pursuant to
42 U.S.C. § 1396d or services covered under the State plan for CHIP as provided in 42 U.S.C. § 1397cc for which these individuals are eligible on January 1, 2014. Beginning with the second
year of Green Mountain Care and going forward, the Green Mountain Care Board may,
consistent with federal law, modify these optional benefits, as long as at all times
the benefit package for these individuals contains at least the benefits described
in subdivision (A) of this subdivision (b)(1).
(2) For children eligible for benefits paid for with Medicaid funds, the benefit package
shall include early and periodic screening, diagnosis, and treatment services as defined
under federal law.
(3) For individuals eligible for Medicare, the benefit package shall include the benefits
provided to these individuals under federal law, as well as any additional benefits
provided as part of the Green Mountain Care benefit package. (Added 2011, No. 48, § 4.)
§ 1826. Blueprint for Health
(a) It is the intent of the General Assembly that within five years following the implementation
of Green Mountain Care, each individual enrolled in Green Mountain Care will have
a primary health care professional who is involved with the Blueprint for Health established
in 18 V.S.A. chapter 13.
(b) Consistent with the provisions of 18 V.S.A. chapter 13, if an individual enrolled
in Green Mountain Care does not have a medical home through the Blueprint for Health,
the individual may choose a primary health care professional who is not participating
in the Blueprint to serve as the individual’s primary care point of contact.
(c) The Agency shall determine a method to approve a specialist as a patient’s primary
health care professional for the purposes of establishing a medical home or primary
care point of contact for the patient. The Agency shall approve a specialist as a
patient’s medical home or primary care point of contact on a case-by-case basis and
only for a patient who receives the majority of his or her health care from that specialist.
(d) Green Mountain Care shall be integrated with the Blueprint for Health established
in 18 V.S.A. chapter 13. (Added 2011, No. 48, § 4.)
§ 1827. Administration; enrollment
(a)(1) The Agency shall, under an open bidding process, solicit bids from and award contracts
to public or private entities for administration of certain elements of Green Mountain
Care, such as claims administration and provider relations.
(2) The Agency shall ensure that entities awarded contracts pursuant to this subsection
do not have a financial incentive to restrict individuals’ access to health services.
The Agency may establish performance measures that provide incentives for contractors
to provide timely, accurate, transparent, and courteous services to individuals enrolled
in Green Mountain Care and to health care professionals.
(3) When considering contract bids pursuant to this subsection, the Agency shall consider
the interests of the State relating to the economy, the location of the entity, and
the need to maintain and create jobs in Vermont. The Agency may utilize an econometric
model to evaluate the net costs of each contract bid.
(b) Nothing in this subchapter shall require an individual with health coverage other
than Green Mountain Care to terminate that coverage.
(c) An individual enrolled in Green Mountain Care may elect to maintain supplemental health
insurance if the individual so chooses.
(d) Except for cost-sharing, Vermonters shall not be billed any additional amount for
health services covered by Green Mountain Care.
(e) [Repealed.]
(f) Green Mountain Care shall be the payer of last resort with respect to any health service
that may be covered in whole or in part by any other health benefit plan, including
Medicare, private health insurance, retiree health benefits, or federal health benefit
plans offered by the military or to federal employees.
(g) The Agency may seek a waiver under Section 1115 of the Social Security Act to include
Medicaid and under Section 2107(e)(2)(A) of the Social Security Act to include CHIP
in Green Mountain Care. If the Agency is unsuccessful in obtaining one or both of
these waivers, Green Mountain Care shall be the secondary payer with respect to any
health service that may be covered in whole or in part by Title XIX of the Social
Security Act (Medicaid) or Title XXI of the Social Security Act (CHIP), as applicable.
(h) Any prescription drug coverage offered by Green Mountain Care shall be consistent
with the standards and procedures applicable to the pharmacy best practices and cost
control program established in section 1998 of this title.
(i) Green Mountain Care shall maintain a robust and adequate network of health care professionals
located in Vermont or regularly serving Vermont residents, including mental health
and substance abuse professionals. The Agency shall contract with outside entities
as needed to allow for the appropriate portability of coverage under Green Mountain
Care for Vermont residents who are temporarily out of the State.
(j) The Agency shall make available the necessary information, forms, access to eligibility
or enrollment systems, and billing procedures to health care professionals to ensure
immediate enrollment for individuals in Green Mountain Care at the point of service
or treatment.
(k) An individual aggrieved by an adverse decision of the Agency or plan administrator
may appeal to the Human Services Board as provided in 3 V.S.A. § 3090.
(l) The Agency, in collaboration with the Department of Financial Regulation, shall monitor
the extent to which residents of other states move to Vermont for the purpose of receiving
health services and the impact, positive or negative, of any such migration on Vermont’s
health care system and on the State’s economy, and make appropriate recommendations
to the General Assembly based on its findings. (Added 2011, No. 48, § 4; amended 2013, No. 144 (Adj. Sess.), § 6, eff. May 27, 2014; 2015, No. 23, § 55.)
§ 1828. Budget proposal
The Green Mountain Care Board, in collaboration with the Agencies of Administration
and of Human Services, shall be responsible for developing each year a three-year
Green Mountain Care budget for proposal to the General Assembly and to the Governor,
to be adjusted annually in response to realized revenues and expenditures, that reflects
any modifications to the benefit package and includes recommended appropriations,
revenue estimates, and necessary modifications to tax rates and other assessments. (Added 2011, No. 48, § 4.)
§ 1829. Green Mountain Care Fund
(a) The Green Mountain Care Fund is established in the State Treasury as a special fund
to be the single source to finance health care coverage for Green Mountain Care.
(b) Into the Fund shall be deposited:
(1) transfers or appropriations from the General Fund, authorized by the General Assembly;
(2) if authorized by a waiver from federal law, federal funds for Medicaid, Medicare,
and the Vermont Health Benefit Exchange established in chapter 18, subchapter 1 of
this title; and
(3) the proceeds from grants, donations, contributions, taxes, and any other sources of
revenue as may be provided by statute or by rule.
(c) The Fund shall be administered pursuant to 32 V.S.A. chapter 7, subchapter 5, except that interest earned on the Fund and any remaining balance
shall be retained in the Fund. The Agency shall maintain records indicating the amount
of money in the Fund at any time.
(d) All monies received by or generated to the Fund shall be used only for:
(1) the administration and delivery of health services covered by Green Mountain Care
as provided in this subchapter; and
(2) expenses related to the duties and operation of the Green Mountain Care Board pursuant
to 18 V.S.A. chapter 220. (Added 2011, No. 48, § 4.)
§ 1830. Collective bargaining rights
Nothing in this subchapter shall be construed to limit the ability of collective bargaining
units to negotiate for coverage of health services pursuant to 3 V.S.A. § 904 or any other provision of law. (Added 2011, No. 48, § 4.)
§ 1831. Public process
The Agency of Human Services shall provide a process for soliciting public input on
the Green Mountain Care benefit package on an ongoing basis, including a mechanism
by which members of the public may request inclusion of particular benefits or services.
The process may include receiving written comments on proposed new or amended rules
or holding public hearings or both. (Added 2011, No. 48, § 4.)
§ 1832. Rulemaking
The Secretary of Human Services may adopt rules pursuant to 3 V.S.A. chapter 25 to carry out the purposes of this subchapter. When establishing rules relating to
the Green Mountain Care benefit package, the Secretary shall ensure that the rules
are consistent with the benefit package defined by the Green Mountain Care Board pursuant
to section 1825 of this title and to 18 V.S.A. chapter 220. (Added 2011, No. 48, § 4.)