BILLASPASSEDBYTHEHOUSE H.31
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H.31
IntroducedbyRepresentativeBlackofEssex
ReferredtoCommitteeon
Date:
Subject:Health;healthinsurance;healthcareproviders;claimedits;placeof
service;priorauthorization;primarycareproviders
Statementofpurposeofbillasintroduced:Thisbillproposestospecifythat
otherwiseapplicablehealthinsuranceclaimeditstandardsdonotapplywhena
healthcareserviceisdeliveredoutsideVermont,unlessotherwiseagreedtoby
thehealthinsurerandtheout-of-stateprovider.Itwouldalsomodifythe
definitionofaprimarycareproviderforpurposesofdeterminingwhichhealth
careproviders’ordersareexemptfrompriorauthorizationrequirements.
Anactrelatingtoclaimeditstandardsandpriorauthorizationrequirements
ItisherebyenactedbytheGeneralAssemblyoftheStateofVermont:
Sec.1.18V.S.A.§ 9418aisamendedtoread:
§9418a.PROCESSINGCLAIMS,DOWNCODING, ANDADHERENCE
TOCODINGRULES
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(c)Adherencetotheeditstandardsinsubsection(b)ofthissectionisnot
required:
(1)whennecessarytocomplywithStateorfederallaws,rules,
regulations,orcoveragemandates;or
(2)foreditsthatthepayerdeterminesaremorefavorabletoproviders
thantheeditstandardsinsubsection(b)ofthissectionortoaddressnewcodes
notyetincorporatedbyapayer’seditmanagementsoftware,providedtheedit
standardsare:
(A)developedwithinputfromtherelevantVermontprovider
communityandnationalproviderorganizations;
(B)clearlysupportedbynationallyrecognizedstandards,guidelines,
orconventionsapprovedbytheCommissionerofFinancialRegulation;and
(C)availabletoprovidersontheplan’swebsitesandinits
newslettersorequivalentelectroniccommunications;or
(3)whenadjudicatingclaimsforhealthcareservicesthatweredelivered
outsidetheStateofVermont,unlessthepayerandtheout-of-stateprovider
agreethatoneormoreoftheeditstandardssetforthinsubsection(b)ofthis
sectionwillapply.
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Sec.2.18V.S.A.§ 9418bisamendedtoread:
§9418b.PRIORAUTHORIZATION
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(c)(1)(A)Exceptasprovidedinsubdivision(B)ofthissubdivision(1),a
healthplanshallnotimposeanypriorauthorizationrequirementforany
admission,item,service,treatment,orprocedureorderedbyaprimarycare
provider.
(B)Theprohibitionsetforthinsubdivision(A)ofthissubdivision
(1)shallnotbeconstruedtoprohibitpriorauthorizationrequirementsfor
prescriptiondrugsorforanadmission,item,service,treatment,orprocedure
thatisprovidedout-of-network.
(2)Asusedinthissubsection,“primarycareprovider”hasthesame
meaningasisusedbytheVermontBlueprintforHealthmeansahealthcare
providerwhoiscontractedandenrolledwiththehealthplanasaprimarycare
provider.
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Sec.3.EFFECTIVEDATES
(a)Sec.1(18V.S.A.§9418a)shalltakeeffectonJanuary1,2026.
(b)Sec.2(18V.S.A.§ 9418b)shalltakeeffectonpassageandshallbe
implementedbyallhealthplansassoonasreasonablypracticableafterthat
date,butinnoeventlaterthanJanuary1,2026.
(c)Thissectionshalltakeeffectonpassage.
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