The Vermont Statutes Online

Title 33: Human Services

Chapter 065: Medicare and General Assistance Beneficiaries; Balance Billing

• § 6501. Definitions

  As used in this chapter:

  (1) “Balance bill” means to charge to or collect from a Medicare or General Assistance beneficiary any amount in excess of the reasonable charge for that service as determined by the U.S. Secretary of Health and Human Services or the Commissioner of Vermont Health Access, as the case may be.

  (2) “General Assistance beneficiary” means a person who receives assistance under chapter 21 of this title.

  (3) “Medicare beneficiary” means a person who is a beneficiary of health insurance under Title XVIII of the Social Security Act.

  (4) “Physician” has the same meaning as in 42 U.S.C. § 1395x(r). (Added 1987, No. 51, § 1; amended 1999, No. 147 (Adj. Sess.), § 4; 2005, No. 174 (Adj. Sess.), § 124; 2009, No. 156 (Adj. Sess.), § I.76; 2021, No. 20, § 339.)

• § 6502. Balance billing prohibited

  A physician who agrees to treat a Medicare or General Assistance beneficiary shall not balance bill the beneficiary except as provided in section 6503 of this chapter. (Added 1987, No. 51, § 1; amended 2021, No. 20, § 340.)

• § 6503. Exceptions

  The provisions of section 6502 of this title shall not apply and the physician may balance bill a Medicare beneficiary if:

  (1) During the calendar year prior to treatment, the Medicare beneficiary (or his or her spouse with whom he or she lived at any time during that year):

  (A) received Social Security benefits or railroad retirement benefits (Tier I treated as Social Security) that were subject to federal income taxation; or

  (B) did not receive Social Security benefits or railroad retirement benefits (Tier I treated as Social Security) but, had such benefits been received, they would have been subject to federal income taxation.

  (2) The Medicare beneficiary refuses to sign the statement authorized by section 6504 of this title; or

  (3) The service for which the beneficiary is to be billed is either an office or home visit. Office or home visits are listed as procedure codes 90000 through 90170 in the Physicians’ Current Procedural Terminology, Fourth Edition (1986) published by the American Medical Association, as amended annually. Office or home visit codes for dentists, podiatrists, optometrists, and chiropractors shall be the same (or equivalent) procedure codes used for doctors of medicine or osteopathy. (Added 1987, No. 51, § 1.)

• § 6504. Medicare beneficiary to sign statement

  Annually and prior to treatment, a physician may request that a Medicare beneficiary sign a statement prepared in accordance with this section to determine whether or not the beneficiary may be balance billed. The exceptions contained in subdivision 6503(1) of this title shall not apply if the physician does not request that the beneficiary sign the statement. The statement shall be prepared by the Department of Disabilities, Aging, and Independent Living, and shall incorporate the exceptions contained in subdivision 6503(1) of this title. (Added 1987, No. 51, § 1; amended 1989, No. 219 (Adj. Sess.), § 9(a); 2005, No. 174 (Adj. Sess.), § 125.)

• § 6505. Assistance with claims required

  A physician who agrees to treat a Medicare beneficiary shall prepare the Medicare claim for the beneficiary. (Added 1987, No. 51, § 1.)

• § 6506. Posting

  A physician who treats Medicare or General Assistance beneficiaries shall post a summary of the provisions of this chapter in a conspicuous place in his or her office. The summary shall include the statement that any person aggrieved by a physician’s failure to comply with the provisions of this chapter may contact the Department of Disabilities, Aging, and Independent Living for assistance or file a complaint with the State Board of Medical Practice within the Department of Health and shall include toll-free telephone numbers to be used for these purposes. The summary shall be written by the Department of Disabilities, Aging, and Independent Living and distributed by the Secretary of State. (Added 1987, No. 51, § 1; amended 1989, No. 219 (Adj. Sess.) § 9(a); 2005, No. 174 (Adj. Sess.), § 126; 2013, No. 131 (Adj. Sess.), § 81.)

• § 6507. Administration; enforcement

  (a) A person aggrieved by a violation of the provisions of this chapter may file a complaint with the State Board of Medical Practice within the Department of Health. The matter shall be investigated by the Board and shall be subject to the provisions of 3 V.S.A. chapter 25, relating to contested cases.

  (b) The Board of Medical Practice may, after hearing, impose an administrative penalty of not more than $50.00 against any physician who violates the provisions of section 6505 or 6506 of this title relating to assistance and posting.

  (c) The Board of Medical Practice may, after hearing, order a physician who balance billed in violation of the provisions of this chapter to make restitution of any monies received from a Medicare or General Assistance beneficiary as a result of such billing. (Added 1987, No. 51, § 1; amended 2013, No. 131 (Adj. Sess.), § 82, eff. May 20, 2014.)

• § 6508. Repealed. 2013, No. 131 (Adj. Sess), § 83, eff. May 20, 2014; 2013, No. 142 (Adj. Sess.), § 100.