§ 4026. Filing and approval of policy forms and premiums
(a)(1) No policy of health insurance or certificate under a policy filed by a health insurer
and not exempted by subdivision 3368(a)(4) of this title shall be delivered or issued for delivery in this State, nor shall any endorsement,
rider, or application that becomes a part of any such policy be used, until a copy
of the form and of the rules for the classification of risks has been filed with the
Department of Financial Regulation and a copy of the premium rates has been filed
with the Green Mountain Care Board, and the Green Mountain Care Board has issued a
decision approving, modifying, or disapproving the proposed rate.
(2)(A) The Green Mountain Care Board shall review rate requests and shall approve, modify,
or disapprove a rate request within 90 calendar days after receipt of an initial rate
filing from a health insurer. If a health insurer fails to provide necessary materials
or other information to the Board in a timely manner, the Board may extend its review
for a reasonable additional period of time, not to exceed 30 calendar days.
(B) Prior to the Board’s decision on a rate request, the Department of Financial Regulation
shall provide the Board with an analysis and opinion on the impact of the proposed
rate on the insurer’s solvency and reserves.
(3) The Board shall determine whether a rate is affordable; promotes quality care; promotes
access to health care; protects insurer solvency; and is not unjust, unfair, inequitable,
misleading, or contrary to the laws of this State. In making this determination, the
Board shall consider the analysis and opinion provided by the Department of Financial
Regulation pursuant to subdivision (2)(B) of this subsection.
(b)(1) In conjunction with a rate filing required by subsection (a) of this section, a health
insurer shall file a plain language summary of the proposed rate. All summaries shall
include a brief justification of any rate increase requested, the information that
the Secretary of the U.S. Department of Health and Human Services (HHS) requires for
rate increases over 10 percent, and any other information required by the Board. The
plain language summary shall be in the format required by the Secretary of HHS pursuant
to the Patient Protection and Affordable Care Act of 2010, Pub. L. No. 111-148, as amended by the Health Care and Education Reconciliation Act of 2010, Pub. L. No. 111-152, and shall include notification of the public comment period established in subsection
(c) of this section. In addition, the insurer shall post the summaries on its website.
(2)(A) In conjunction with a rate filing required by subsection (a) of this section, a health
insurer shall disclose to the Board:
(i) for all covered prescription drugs, including generic drugs, brand-name drugs excluding
specialty drugs, and specialty drugs dispensed at a pharmacy, network pharmacy, or
mail-order pharmacy for outpatient use:
(I) the percentage of the premium rate attributable to prescription drug costs for the
prior year for each category of prescription drugs;
(II) the year-over-year increase or decrease, expressed as a percentage, in per-member,
per-month total health plan spending on each category of prescription drugs; and
(III) the year-over-year increase or decrease in per-member, per-month costs for prescription
drugs compared to other components of the premium rate; and
(ii) the specialty tier formulary list.
(B) The insurer shall provide, if available, the percentage of the premium rate attributable
to prescription drugs administered by a health care provider in an outpatient setting
that are part of the medical benefit as separate from the pharmacy benefit.
(C) The insurer shall include information on its use of a pharmacy benefit manager, if
any, including which components of the prescription drug coverage described in subdivisions
(A) and (B) of this subdivision (2) are managed by the pharmacy benefit manager, as
well as the name of the pharmacy benefit manager or managers used.
(3)(A) Upon request, in conjunction with a rate filing required by subsection (a) of this
section, a health insurer shall provide to the Board detailed information about the
insurer’s payments to specific providers, which may include fee schedules, payment
methodologies, and other payment information specified by the Board.
(B) Confidential business information and trade secrets received from a health insurer
pursuant to subdivision (A) of this subdivision (3) shall be exempt from public inspection
and copying under 1 V.S.A. § 317(c)(9) and shall be kept confidential, except that the Board may disclose or release information
publicly in summary or aggregate form if doing so would not disclose confidential
business information or trade secrets.
(C) Notwithstanding 1 V.S.A. chapter 5, subchapter 2 (Vermont Open Meeting Law), the Board may examine and discuss confidential
information outside a public hearing or meeting.
(c)(1) The Board shall provide information to the public on the Board’s website about the
public availability of the filings and summaries required under this section.
(2)(A) The Board shall post the rate filings pursuant to subsection (a) of this section and
summaries pursuant to subsection (b) of this section on the Board’s website within
five calendar days following filing. The Board shall also establish a mechanism by
which members of the public may request to be notified automatically each time a proposed
rate is filed with the Board.
(B) The Board shall provide an electronic mechanism for the public to comment on all rate
filings. The Board shall accept public comment on each rate filing from the date on
which the Board posts the rate filing on its website pursuant to subdivision (A) of
this subdivision (2) until 15 calendar days after the Board posts on its website the
analyses and opinions of the Department of Financial Regulation and of the Board’s
consulting actuary, if any, as required by subsection (d) of this section. The Board
shall review and consider the public comments prior to issuing its decision.
(3)(A) In addition to the public comment provisions set forth in this subsection (c), the
Office of the Health Care Advocate established in 18 V.S.A. chapter 229, acting on behalf of health insurance consumers in this State, may, within 30 calendar
days after the Board receives a health insurer’s rate request pursuant to this section,
submit to the Board, in writing, questions with a substantial relationship to the
rate filing and review criteria that the Board shall ask the insurer, either directly
or through its contracting actuary, if any.
(B) The Office of the Health Care Advocate may also submit to the Board written comments
on a health insurer’s rate request. The Board shall post the comments on its website
and shall consider the comments prior to issuing its decision.
(d) The Green Mountain Care Board shall post on its website or otherwise make available
to the public through a file-sharing platform all materials in the record of a rate
review proceeding after redacting any information or other material that the Board
determines to be confidential or otherwise subject to protection from disclosure by
law.
(e) Within the time period set forth in subdivision (a)(2)(A) of this section, the Board
shall:
(1) conduct a public hearing, at which the Board shall:
(A) call as witnesses the Commissioner of Financial Regulation or designee and the Board’s
contracting actuary, if any, unless all parties agree to waive such testimony; and
(B) provide an opportunity for testimony from the insurer, the Office of the Health Care
Advocate, and members of the public;
(2) at a public hearing, announce the Board’s decision of whether to approve, modify,
or disapprove the proposed rate; and
(3) issue its decision in writing.
(f)(1) The insurer shall notify its policyholders of the Board’s decision in a timely manner,
as defined by the Board by rule.
(2) Rates shall take effect on the date specified in the insurer’s rate filing.
(3) If the Board has not issued its decision by the effective date specified in the insurer’s
rate filing, the insurer shall notify its policyholders of its pending rate request
and of the effective date proposed by the insurer in its rate filing.
(g) A health insurer, the Office of the Health Care Advocate, and any member of the public
with party status, as defined by the Board by rule, may appeal a decision of the Board
approving, modifying, or disapproving the insurer’s proposed rate to the Vermont Supreme
Court.
(h)(1) The authority of the Board under this section shall apply only to the rate review
process for policies for major medical insurance coverage and shall not apply to the
policy forms for major medical insurance coverage or to the rate and policy form review
process for policies for specific disease, accident, injury, hospital indemnity, dental
care, vision care, disability income, long-term care, student health insurance coverage,
Medicare supplement insurance coverage, or other limited benefit coverage; to short-term,
limited-duration health insurance coverage; or to benefit plans that are paid directly
to an individual insured or to the individual’s assigns and for which the amount of
the benefit is not based on potential medical costs or actual costs incurred. Premium
rates and rules for the classification of risk for Medicare supplement insurance policies
shall be governed by section 4051 of this title.
(2) The policy forms for major medical insurance coverage, as well as the policy forms,
premium rates, and rules for the classification of risk for the other lines of insurance
described in subdivision (1) of this subsection shall be reviewed and approved or
disapproved by the Commissioner. In making a determination, the Commissioner shall
consider whether a policy form, premium rate, or rule is affordable and is not unjust,
unfair, inequitable, misleading, or contrary to the laws of this State; and, for a
policy form for major medical insurance coverage, whether it ensures equal access
to appropriate mental health care in a manner equivalent to other aspects of health
care as part of an integrated, holistic system of care. The Commissioner shall make
a determination within 30 days after the date the insurer filed the policy form, premium
rate, or rule with the Department. At the expiration of the 30-day period, the form,
premium rate, or rule shall be deemed approved unless prior to then it has been affirmatively
approved or disapproved by the Commissioner or found to be incomplete. The Commissioner
shall notify a health insurer in writing if the insurer files any form, premium rate,
or rule containing a provision that does not meet the standards expressed in this
subsection. In such notice, the Commissioner shall state that a hearing will be granted
within 20 days upon the insurer’s written request.
(i) Notwithstanding the procedures and timelines set forth in subsections (a) through
(e) of this section, the Board may establish, by rule, a streamlined rate review process
for certain rate decisions, including proposed rates affecting fewer than a minimum
number of covered lives and proposed rates for which a de minimis increase, as defined
by the Board by rule, is sought. (Recodified and amended 2025, No. 11, § 2, eff. September 1, 2025; amended 2025, No. 6, § 1.)