The Vermont Statutes Online
The Statutes below include the actions of the 2024 session of the General Assembly.
NOTE: The Vermont Statutes Online is an unofficial copy of the Vermont Statutes Annotated that is provided as a convenience.
Title 33: Human Services
Chapter 018: Public-Private Universal Health Care System
- 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.
(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.]
(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.)
§ 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
(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.)
§ 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;
(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;
(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;
(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;
(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
(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. (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.)
§ 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:
(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.
(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.
(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.
(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.
(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.
(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.
(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) 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.
(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.
(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.
(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.
(l) 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. (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.)
§ 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. § 4062, 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.)
§ 1814. Maximum out-of-pocket limit for prescription drugs in bronze plans
(a)(1) Notwithstanding any provision of 8 V.S.A. § 4089i 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. § 4089i 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. § 4089i.
(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. § 4089i, as long as the plans comply with federal requirements. Notwithstanding any provision of 8 V.S.A. § 4089i 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. § 4089i.
(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. § 4089i 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. § 4089i.
(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. § 4089i 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.)
- 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.)
