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S.30
IntroducedbySenatorsLyonsandCummings
ReferredtoCommitteeonFinance
Date:January29,2025
Subject:Health;healthinsurance;VermontStatutesAnnotated
Statementofpurposeofbillasintroduced:Thisbillproposestoupdateand
reorganizethehealthinsurancechapter,8V.S.A.chapter107,includingusing
consistentlanguageandterminologythroughoutthechapter.Thebillwould
alsoupdatecross-referencesinotherstatutesasneeded.
Anactrelatingtoupdatingandreorganizingthehealthinsurancestatutesin
8V.S.A.chapter107
ItisherebyenactedbytheGeneralAssemblyoftheStateofVermont:
***RepealofExisting8V.S.A.Chapter107***
Sec.1.REPEALOFEXISTING8V.S.A.CHAPTER107
8V.S.A.chapter107(healthinsurance)isrepealed.
***EnactmentofUpdatedandReorganized8V.S.A.Chapter107***
Sec.2.8V.S.A.chapter107isaddedtoread:
CHAPTER107.HEALTHINSURANCE
Subchapter1.GeneralProvisions
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§ 4011.DEFINITIONS
Asusedinthischapter:
(1)“Coveredindividual”meansanindividualwhoiscoveredbya
healthinsuranceplan,whetherastheprimarysubscriberorpolicyholderoras
adependent,employee,oremployee’sdependentundertheplan.
(2)“Healthcareservices”meansservicesforthediagnosis,prevention,
treatment,cure,orreliefofahealthcondition,illness,injury,ordisease.
(3)“Healthinsuranceplan”meansapolicyorcontractissuedbya
healthinsurer,includingthehealthbenefitplanorplansofferedbytheStateof
Vermonttoitsemployeesandanyhealthbenefitplanofferedbyanyagencyor
instrumentalityoftheStatetoitsemployees.Unlessotherwisespecified,
“healthinsurance”doesnotincludeVermontMedicaid.
(4)“Healthinsurer”meansaninsurancecompanythatprovideshealth
insuranceasdefinedinsubdivision3301(a)(2)ofthistitle,anonprofithospital
ormedicalservicecorporation,amanagedcareorganization,ahealth
maintenanceorganization,and,totheextentpermittedunderfederallaw,any
administratorofaninsured,self-insured,orpubliclyfundedhealthcarebenefit
planofferedbyapublicorprivateentity.
(5)“Majormedicalinsurance”meansacomprehensivehealthinsurance
planthatisnotspecificdisease,accident,hospitalindemnity,dentalcare,
visioncare,disabilityincome,long-termcare,Medicaresupplementinsurance,
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orotherlimited-benefitcoverage.Thetermdoesnotincludeshort-term,
limited-durationhealthinsurancecoverageoraplanunderwhichbenefitsare
paiddirectlytoacoveredindividualortheindividual’sassignsandforwhich
theamountofthebenefitisnotbasedonpotentialmedicalcostsoronactual
costsincurred.
§ 4012.COMPLIANCEWITHFEDERALLAW
(a)Exceptasotherwiseprovidedinthistitle,healthinsurers,hospitaland
medicalservicecorporations,andhealthmaintenanceorganizationsthatissue,
sell,renew,orofferhealthinsuranceplansinVermontshallcomplywiththe
requirementsoftheHealthInsurancePortabilityandAccountabilityActof
1996,asamendedfromtimetotime(42U.S.C.Chapter6A,Subchapter
XXV),andthePatientProtectionandAffordableCareActof2010,Pub.L.
No.111-148,asamendedbytheHealthCareandEducationReconciliationAct
of2010,Pub.L.No.111-152.TheCommissionershallenforcesuch
requirementspursuanttotheCommissioner’sauthorityunderthistitle.
(b)(1)Healthinsurers,hospitalandmedicalservicecorporations,health
maintenanceorganizations,andhealthcareproviders,asthattermisdefinedin
18V.S.A.§9432,shallcomplywiththerequirementsoftheNoSurprisesAct,
Pub.L.No.116-260,DivisionBB,TitleI,asamendedfromtimetotime.
(2)TheCommissionershallenforcetherequirementsoftheNo
SurprisesActastheyapplytohealthinsurers,hospitalandmedicalservice
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corporations,healthmaintenanceorganizations,andhealthcareproviders,to
theextentpermittedunderfederallaw,pursuanttotheCommissioner’s
authorityunderthistitle.TheCommissionermayalsorefercasesof
noncompliancetotheU.S.DepartmentofHealthandHumanServicesunder
thetermsofacollaborativeenforcementagreement,ortotheOfficeofthe
VermontAttorneyGeneral.
§ 4013.DISCRIMINATIONPROHIBITED
Nohealthinsurershallmakeorpermitanyunfairdiscriminationbetween
individualsofsubstantiallythesamehazardintheamountofpremiumrates
chargedforanyhealthinsuranceplanorinthebenefitspayableundertheplan;
provided,however,thatthissectionshallnotbeconstruedtoprohibitdifferent
premiumrates,differentbenefits,ordifferentunderwritingprocedurefor
individualsinsuredundergroup,familyexpense,orblanketplansofinsurance.
§ 4014.ADVERTISINGPRACTICES
(a)NocompanydoingbusinessinthisState,andnoinsuranceagentor
broker,shalluseinconnectionwiththesolicitationofhealthinsuranceor
pharmacybenefitmanagementanyadvertisingcopyoradvertisingpracticeor
anyplanofsolicitationthatismateriallymisleadingordeceptive.An
advertisingcopyoradvertisingpracticeorplanofsolicitationshallbe
consideredtobemateriallymisleadingordeceptiveifbyimplicationor
otherwiseittransmitsinformationinsuchmannerorofsuchsubstancethata
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prospectiveapplicantforhealthinsurancemaybemisledbyittothe
applicant’smaterialdamage.
(b)(1)IftheCommissionerfindsthatanysuchadvertisingcopyor
advertisingpracticeorplanofsolicitationismateriallymisleadingor
deceptive,theCommissionershallorderthecompanyortheagentorbroker
usingsuchcopyorpracticeorplantoceaseanddesistfromsuchuse.
(2)Beforemakinganysuchfindingandorder,theCommissionershall
givenotice,notlessthan10daysinadvance,andahearingtothecompany,
agent,orbrokeraffected.
(3)IftheCommissionerfinds,afterduenoticeandhearing,thatany
authorizedinsurer,licensedpharmacybenefitmanager,licensedinsurance
agent,orlicensedinsurancebrokerhasintentionallyviolatedanysuchorderto
ceaseanddesist,theCommissionermaysuspendorrevokethelicenseofsuch
insurer,pharmacybenefitmanager,agent,orbroker.
§ 4015.PENALTIESFORVIOLATIONS
TheCommissionermayimposeanadministrativepenaltyofupto$750.00
onanypersonwhointentionallyviolatesanyprovisionofthischapterorany
orderoftheCommissionermadeinaccordancewiththischapter.The
Commissionermayalsosuspendorrevokethelicenseofahealthinsureror
agentforanysuchintentionalviolation.
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§ 4016.APPEAL
(a)AnypersonaggrievedbyanyactionoftheCommissionermayobtaina
reviewbyappealtotheSuperiorCourtofWashingtonCounty.Theappeal
shallbebasedontherecordoftheproceedingsbeforetheCommissionerand
shallnotbelimitedtoquestionsoflaw.Iftheappealisfromanorderofthe
Commissioner,theordershallnottakeeffectduringthependencyofthe
appealunlessthecourtdeterminesotherwise.
(b)Thecourtmayreviewallthefactsandindisposingofanyissuebefore
itmaymodify,affirm,orreverseanyorderoftheCommissionerinwholeorin
part.
(c)EitherpartymayappealfromthedecisionoftheSuperiorCourttothe
SupremeCourtinthemannerprovidedbylaw.
§ 4017.EXEMPTIONFROMATTACHMENTANDTRUSTEEPROCESS
Somuchofanybenefitsunderallpoliciesofhealthinsuranceasdoesnot
exceed$200.00foreachmonthduringanyperiodofdisabilitycoveredbythe
policyshallnotbeliabletoattachment,trusteeprocess,orotherprocess,orto
beseized,taken,appropriated,orappliedbyanylegalorequitableprocessor
byoperationoflaw,eitherbeforeorafterpaymentofsuchbenefits,topayany
debtorliabilitiesofthepersoninsuredunderthepolicy.However,this
exemptionshallnotapplywhereanactionisbroughttorecoverfornecessaries
contractedforduringtheperiodofdisabilityandthewritorbillofcomplaint
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containsastatementtothateffect.Whenapolicyprovidesforalumpsum
paymentbecauseofadismembermentorotherlossinsured,thepaymentshall
beexemptfromexecutionofthecoveredindividual’screditors.
§ 4018.THIRD-PARTYOWNERSHIP
Nothinginthischaptershallbeconstruedaspreventingapersonotherthan
thecoveredindividualwithproperinsurableinterestfrommakingapplication
forandowningapolicycoveringthecoveredindividualorfrombeingentitled
undersuchapolicytoanyindemnities,benefits,andrightsprovidedinthe
policy.
§ 4019.NOTICEASWAIVER
Ahealthinsurershallnotbedeemedtohavewaivedanyrightstodefenda
claimunderahealthinsuranceplanbasedsolelyonthehealthinsurer’s
acknowledgementofreceiptofnoticeundertheplan,furnishingoraccepting
formsforfilingproofoflossundertheplan,orinvestigatinganyclaimofloss
undertheplan.
§ 4020.AGELIMITS
(a)Ifahealthinsuranceplancontainsaprovisionestablishing,asanage
limitorotherwise,adateafterwhichthecoverageprovidedbytheplanwill
notbeeffective,andifthatdatefallswithinaperiodforwhichthehealth
insurerhasacceptedapremiumorifthehealthinsureracceptsapremiumafter
thatdate,thecoverageprovidedbytheplanshallcontinueinforcesubjectto
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anyrightofcancellationuntiltheendoftheperiodforwhichapremiumhas
beenaccepted.
(b)Notwithstandinganyprovisionofsubsection(a)ofthissectiontothe
contrary,iftheageofthecoveredindividualhasbeenmisstatedandif,
accordingtothecorrectageofthecoveredindividual,thecoverageprovided
bythepolicywouldnothavebecomeeffectiveorwouldhaveceasedpriorto
thehealthinsurer’sacceptanceofthepremiumorpremiums,thenthehealth
insurer’sliabilityshallbelimitedtotherefund,uponrequest,ofallpremiums
paidfortheperiodnotcoveredbytheplan.
§ 4021.TERMINATIONOFCOVERAGE
(a)(1)Amajormedicalinsurancepolicyissuedbyahealthinsurerthat
insuresemployees,members,orsubscribersforhospitalandmedicalinsurance
onanexpense-incurred,service,orprepaidbasisshall:
(A)providenoticetothepolicyholderorotherresponsiblepartyof
anypremiumpaymentdueonapolicyatleast21daysbeforetheduedate;and
(B)provideagraceperiodofatleastonemonthforthepaymentof
eachpremiumfallingdueafterthefirstpremium,duringwhichgraceperiod
theplanshallcontinueinforceandtheissueroftheplanshallbeliablefor
validclaimsforcoveredlossesincurredpriortotheendofthegraceperiod.
(2)Iftheissuerofaplandescribedsubdivision(1)ofthissubsection
doesnotreceivepaymentbytheduedate,theissuershallsendatermination
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noticetothepolicyholderatleast21dayspriortoterminationnotifyingthe
policyholderthattheissuermayterminatetheplanifpaymentisnotreceived
bytheterminationdate.
(3)Theterminationdateofaplandescribedinsubdivision(1)ofthis
subsectionshallnotbeearlierthanthedayfollowingthelastdayofthegrace
periodsetforthinsubdivision(1)(A)ofthissubsection.
(b)Forallhealthinsurancepoliciesotherthanmajormedicalinsurance
policies,ahealthinsurershallnotifyapolicyholderofanypremiumpayment
dueonapolicyatleast21daysbeforetheduedate.Ifahealthinsurerdoes
notreceivepaymentbytheduedate,thehealthinsurershallsendatermination
noticetothepolicyholdernotifyingthepolicyholderthatthehealthinsurer
willterminatethepolicyeffectiveontheduedateifpaymentisnotreceived
within14daysfromthedateofmailingoftheterminationnotice.Ifahealth
insurerdoesnotreceivepaymentwithin14daysfromthedateofmailingof
theterminationnotice,thehealthinsurermaycancelcoverageeffectiveonthe
duedate.
§4022.REBATESANDCOMMISSIONSPROHIBITEDFORNONGROUP
ANDSMALLGROUPPOLICIESANDPLANSOFFERED
THROUGHTHEVERMONTHEALTHBENEFITEXCHANGE
(a)NohealthinsurerdoingbusinessinthisStateandnoinsuranceagentor
brokershall:
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(1)offer,promise,allow,give,setoff,orpay,directlyorindirectly:
(A)anyrebateoforpartofthepremiumpayableonahealth
insuranceplanissuedpursuantto33V.S.A.§ 1811orearnings,profits,
dividends,orotherbenefitsfounded,arising,accruing,ortoaccrueonorfrom
thepremium;
(B)anyspecialadvantageindateofpolicyorageofissue;
(C)anypaidemploymentorcontractforservicesofanykind;
(D)anyothervaluableconsiderationorinducementtoorfor
insuranceonanyriskinthisState,orfororuponanyrenewalofanysuch
insurance,thatisnotspecifiedinthehealthinsuranceplan;or
(2)offer,promise,give,option,sell,orpurchaseanystocks,bonds,
securities,orproperty,oranydividendsorprofitsaccruingortoaccrueon
them,orotherthingofvalueasinducementtoinsuranceorinconnectionwith
insurance,oranyrenewalthereof,thatisnotspecifiedinthehealthinsurance
plan.
(b)Nopersoninsuredunderahealthinsuranceplanissuedpursuantto
33 V.S.A.§1811orpartyorapplicantforsuchplanshalldirectlyorindirectly
receiveoracceptoragreetoreceiveoracceptanyrebateofpremiumorofany
partofthepremium,oranyfavororadvantage,orshareinanybenefitto
accrueunderanyhealthinsuranceplanissuedpursuant33V.S.A.§1811,or
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anyvaluableconsiderationorinducement,thatisnotspecifiedinthehealth
insuranceplan.
(c)Nothinginthissectionshallbeconstruedasprohibitinganyhealth
insurerfrom:
(1)allowingorreturningtoitsparticipatingpolicyholdersdividends,
savings,orunusedpremiumdeposits;
(2)returningorotherwiseabating,infullorinpart,thepremiumsofits
policyholdersoutofsurplusaccumulatedfromnonparticipatinginsurance;or
(3)takingabonafideobligation,withinterestnotexceedingsixpercent
perannum,inpaymentofanypremium.
(d)(1)Noinsurershallpayanycommission,fee,orothercompensation,
directlyorindirectly,toalicensedorunlicensedagent,broker,orother
individualinconnectionwiththesaleofahealthinsuranceplanissued
pursuantto33V.S.A.§1811,norshallahealthinsurerincludeinaninsurance
rateforahealthinsuranceplanissuedpursuantto33V.S.A.§1811anysums
relatedtoservicesprovidedbyanagent,broker,orotherindividual.Ahealth
insurermayprovidetoitsemployeeswages,salary,andotheremployment-
relatedcompensationinconnectionwiththesaleofhealthinsuranceplans,but
shallnotstructureanysuchcompensationinamannerthatpromotesthesale
ofparticularhealthinsuranceplansoverotherplansofferedbythatinsurer.
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(2)NothinginthissubsectionshallbeconstruedtoprohibittheVermont
HealthBenefitExchangeestablishedin33V.S.A.chapter18,subchapter1
fromstructuringcompensationforagentsorbrokersintheformofan
additionalcommission,fee,orothercompensationoutsideinsuranceratesor
fromcompensatingagents,brokers,orotherindividualsthroughthe
proceduresandpaymentmechanismsestablishedpursuantto33V.S.A.
§ 1805(17).
§4022a.REBATESPROHIBITEDFORGROUPINSURANCEPOLICIES
(a)Asusedinthissection,“groupinsurance”meansanypolicydescribed
insection4041ofthistitle,exceptthatitshallnotincludeanysmallgroup
policyissuedpursuantto33V.S.A.§1811.
(b)NohealthinsurerdoingbusinessinthisStateandnoinsuranceagentor
brokershall:
(1)offer,promise,allow,give,setoff,orpay,directlyorindirectly:
(A)anyrebateoforpartofthepremiumpayableonagroup
insurancepolicy,oronanygroupinsurancepolicyoragent’scommissionon
thepremiumorearnings,profits,dividends,orotherbenefitsfounded,arising,
accruing,ortoaccrueonorfromthepremium;
(B)anyspecialadvantageindateofpolicyorageofissue;
(C)anypaidemploymentorcontractforservicesofanykind;or
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(D)anyothervaluableconsiderationorinducementtoorfor
insuranceonanyriskinthisState,orfororuponanyrenewalofanysuch
insurance,thatisnotspecifiedinthehealthinsuranceplan;or
(2)offer,promise,give,option,sell,orpurchaseanystocks,bonds,
securities,orproperty,oranydividendsorprofitsaccruingortoaccrueon
them,orotherthingofvalueasinducementtoinsuranceorinconnectionwith
insurance,oranyrenewalthereof,thatisnotspecifiedinthehealthinsurance
plan.
(c)Nopersoninsuredunderagroupinsurancepolicyorpartyorapplicant
forgroupinsuranceshalldirectlyorindirectlyreceiveoracceptoragreeto
receiveoracceptanyrebateofpremiumorofanypartofthepremium,orall
oranypartofanyagent’sorbroker’scommissiononthepremium,orany
favororadvantage,orshareinanybenefittoaccrueunderanyhealth
insuranceplan,oranyvaluableconsiderationorinducement,thatisnot
specifiedinthehealthinsuranceplan.
(d)Nothinginthissectionshallbeconstruedasprohibiting:
(1)thepaymentofcommissionorothercompensationtoanyduly
licensedagentorbroker;
(2)anyhealthinsurerfromallowingorreturningtoitsparticipating
policyholdersdividends,savings,orunusedpremiumdeposits;
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(3)anyhealthinsurerfromreturningorotherwiseabating,infullorin
part,thepremiumsofitspolicyholdersoutofsurplusaccumulatedfrom
nonparticipatinginsurance;or
(4)thehealthinsurerfromtakingabonafideobligation,withinterest
notexceedingsixpercentperannum,inpaymentofanypremium.
(e)Ahealthinsurerthatpaysacommission,fee,orothercompensation,
directlyorindirectly,toalicensedorunlicensedagent,broker,orother
individualotherthanabonafideemployeeofthehealthinsurerinconnection
withthesaleofagroupinsurancepolicyshallclearlydisclosetothepurchaser
ofthepolicytheamountofanysuchcommission,fee,orcompensationpaidor
tobepaid.
§ 4023.PROVISIONSAPPLYINGTOPOLICIESDELIVEREDIN
ANOTHERSTATE
IfanypolicyisissuedbyahealthinsurerdomiciledinthisStatefor
deliverytoapersonresidinginanotherstate,andiftheofficialhaving
responsibilityfortheadministrationoftheinsurancelawsoftheotherstate
informstheCommissionerthatthepolicyisnotsubjecttoapprovalor
disapprovalbytheofficial,theCommissionermayissueanorderrequiring
thatthepolicymeetthestandardssetforthinsections4029,4030,and4031of
thistitle.
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§ 4024.COORDINATIONOFINSURANCECOVERAGEWITH
MEDICAIDANDCOMPLIANCEWITHMEDICAIDRECOVERY
PROVISIONS
(a)Nohealthinsurershallconsidertheavailabilityoforeligibilityfor
medicalassistanceinthisoranyotherstateunderTitleXIXoftheSocial
SecurityAct(Medicaid)whenconsideringeligibilityforcoverageormaking
paymentsunderitsplanforeligibleenrollees,subscribers,policyholders,or
certificateholders.
(b)Ahealthinsurerthatissues,sells,renews,oroffershealthinsurance
coverageinVermontorwhoisrequiredtobelicensedorregisteredwiththe
Departmentshallcomplywiththerequirementsof33V.S.A.§§1907,1908,
1909,and1910.TheCommissionershallenforcesuchrequirementspursuant
totheCommissioner’sauthorityunderthistitle.
§ 4025.HEALTHINSURANCEANDTHEBLUEPRINTFORHEALTH
(a)Allmajormedicalinsuranceplansshallbeoffered,issued,and
administeredconsistentwiththeBlueprintforHealthestablishedin18V.S.A.
chapter13.
(b)Healthinsurersofferingmajormedicalinsuranceplansshallparticipate
intheBlueprintforHealthasspecifiedin18V.S.A.§706.
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Subchapter2.PolicyFormsandFilingRequirements
§ 4026.FILINGANDAPPROVALOFPOLICYFORMSANDPREMIUMS
(a)(1)Nopolicyofhealthinsuranceorcertificateunderapolicyfiledbya
healthinsurerandnotexemptedbysubdivision3368(a)(4)ofthistitleshallbe
deliveredorissuedfordeliveryinthisState,norshallanyendorsement,rider,
orapplicationthatbecomesapartofanysuchpolicybeused,untilacopyof
theformandoftherulesfortheclassificationofriskshasbeenfiledwiththe
DepartmentofFinancialRegulationandacopyofthepremiumrateshasbeen
filedwiththeGreenMountainCareBoard,andtheGreenMountainCare
Boardhasissuedadecisionapproving,modifying,ordisapprovingthe
proposedrate.
(2)(A)TheGreenMountainCareBoardshallreviewraterequestsand
shallapprove,modify,ordisapprovearaterequestwithin90calendardays
afterreceiptofaninitialratefilingfromahealthinsurer.Ifahealthinsurer
failstoprovidenecessarymaterialsorotherinformationtotheBoardina
timelymanner,theBoardmayextenditsreviewforareasonableadditional
periodoftime,nottoexceed30calendardays.
(B)PriortotheBoard’sdecisiononaraterequest,theDepartmentof
FinancialRegulationshallprovidetheBoardwithananalysisandopinionon
theimpactoftheproposedrateontheinsurer’ssolvencyandreserves.
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(3)TheBoardshalldeterminewhetherarateisaffordable;promotes
qualitycare;promotesaccesstohealthcare;protectsinsurersolvency;andis
notunjust,unfair,inequitable,misleading,orcontrarytothelawsofthisState.
Inmakingthisdetermination,theBoardshallconsidertheanalysisandopinion
providedbytheDepartmentofFinancialRegulationpursuanttosubdivision
(2)(B)ofthissubsection.
(b)(1)Inconjunctionwitharatefilingrequiredbysubsection(a)ofthis
section,ahealthinsurershallfileaplainlanguagesummaryoftheproposed
rate.Allsummariesshallincludeabriefjustificationofanyrateincrease
requested,theinformationthattheSecretaryoftheU.S.DepartmentofHealth
andHumanServices(HHS)requiresforrateincreasesover10percent,and
anyotherinformationrequiredbytheBoard.Theplainlanguagesummary
shallbeintheformatrequiredbytheSecretaryofHHSpursuanttothePatient
ProtectionandAffordableCareActof2010,Pub.L.No.111-148,asamended
bytheHealthCareandEducationReconciliationActof2010,Pub.L.No.
111-152,andshallincludenotificationofthepubliccommentperiod
establishedinsubsection(c)ofthissection.Inaddition,theinsurershallpost
thesummariesonitswebsite.
(2)(A)Inconjunctionwitharatefilingrequiredbysubsection(a)ofthis
section,ahealthinsurershalldisclosetotheBoard:
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(i)forallcoveredprescriptiondrugs,includinggenericdrugs,
brand-namedrugsexcludingspecialtydrugs,andspecialtydrugsdispensedata
pharmacy,networkpharmacy,ormail-orderpharmacyforoutpatientuse:
(I)thepercentageofthepremiumrateattributableto
prescriptiondrugcostsfortheprioryearforeachcategoryofprescription
drugs;
(II)theyear-over-yearincreaseordecrease,expressedasa
percentage,inper-member,per-monthtotalhealthplanspendingoneach
categoryofprescriptiondrugs;and
(III)theyear-over-yearincreaseordecreaseinper-member,
per-monthcostsforprescriptiondrugscomparedtoothercomponentsofthe
premiumrate;and
(ii)thespecialtytierformularylist.
(B)Theinsurershallprovide,ifavailable,thepercentageofthe
premiumrateattributabletoprescriptiondrugsadministeredbyahealthcare
providerinanoutpatientsettingthatarepartofthemedicalbenefitasseparate
fromthepharmacybenefit.
(C)Theinsurershallincludeinformationonitsuseofapharmacy
benefitmanager,ifany,includingwhichcomponentsoftheprescriptiondrug
coveragedescribedinsubdivisions(A)and(B)ofthissubdivision(2)are
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managedbythepharmacybenefitmanager,aswellasthenameofthe
pharmacybenefitmanagerormanagersused.
(3)(A)Uponrequest,inconjunctionwitharatefilingrequiredby
subsection(a)ofthissection,ahealthinsurershallprovidetotheBoard
detailedinformationabouttheinsurer’spaymentstospecificproviders,which
mayincludefeeschedules,paymentmethodologies,andotherpayment
informationspecifiedbytheBoard.
(B)Confidentialbusinessinformationandtradesecretsreceived
fromahealthinsurerpursuanttosubdivision(A)ofthissubdivision(3)shall
beexemptfrompublicinspectionandcopyingunder1V.S.A.§317(c)(9)and
shallbekeptconfidential,exceptthattheBoardmaydiscloseorrelease
informationpubliclyinsummaryoraggregateformifdoingsowouldnot
discloseconfidentialbusinessinformationortradesecrets.
(C)Notwithstanding1V.S.A.chapter5,subchapter2(Vermont
OpenMeetingLaw),theBoardmayexamineanddiscussconfidential
informationoutsideapublichearingormeeting.
(c)(1)TheBoardshallprovideinformationtothepublicontheBoard’s
websiteaboutthepublicavailabilityofthefilingsandsummariesrequired
underthissection.
(2)(A)TheBoardshallposttheratefilingspursuanttosubsection(a)of
thissectionandsummariespursuanttosubsection(b)ofthissectiononthe
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Board’swebsitewithinfivecalendardaysfollowingfiling.TheBoardshall
alsoestablishamechanismbywhichmembersofthepublicmayrequesttobe
notifiedautomaticallyeachtimeaproposedrateisfiledwiththeBoard.
(B)TheBoardshallprovideanelectronicmechanismforthepublic
tocommentonallratefilings.TheBoardshallacceptpubliccommenton
eachratefilingfromthedateonwhichtheBoardpoststheratefilingonits
websitepursuanttosubdivision(A)ofthissubdivision(2)until15calendar
daysaftertheBoardpostsonitswebsitetheanalysesandopinionsofthe
DepartmentofFinancialRegulationandoftheBoard’sconsultingactuary,if
any,asrequiredbysubsection(d)ofthissection.TheBoardshallreviewand
considerthepubliccommentspriortoissuingitsdecision.
(3)(A)Inadditiontothepubliccommentprovisionssetforthinthis
subsection,theOfficeoftheHealthCareAdvocateestablishedin18V.S.A.
chapter229,actingonbehalfofhealthinsuranceconsumersinthisState,may,
within30calendardaysaftertheBoardreceivesahealthinsurer’sraterequest
pursuanttothissection,submittotheBoard,inwriting,suggestedquestions
regardingthefilingfortheBoardtoprovidetoitscontractingactuary,ifany.
(B)TheOfficeoftheHealthCareAdvocatemayalsosubmittothe
Boardwrittencommentsonahealthinsurer’sraterequest.TheBoardshall
postthecommentsonitswebsiteandshallconsiderthecommentspriorto
issuingitsdecision.
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(d)(1)Notlaterthan60calendardaysafterreceivingahealthinsurer’srate
requestpursuanttothissection,theGreenMountainCareBoardshallmake
availabletothepublictheinsurer’sratefiling,theDepartment’sanalysisand
opinionoftheeffectoftheproposedrateontheinsurer’ssolvency,andthe
analysisandopinionoftheratefilingbytheBoard’scontractingactuary,if
any.
(2)TheBoardshallpostonitswebsite,afterredactinganyconfidential
orproprietaryinformationrelatingtotheinsurerortotheinsurer’sratefiling:
(A)allquestionstheBoardposestoitscontractingactuary,ifany,
andtheactuary’sresponsestotheBoard’squestions;and
(B)allquestionstheBoard;theBoard’scontractingactuary,ifany;
ortheDepartmentposestotheinsurerandtheinsurer’sresponsestothose
questions.
(e)Withinthetimeperiodsetforthinsubdivision(a)(2)(A)ofthissection,
theBoardshall:
(1)conductapublichearing,atwhichtheBoardshall:
(A)callaswitnessestheCommissionerofFinancialRegulationor
designeeandtheBoard’scontractingactuary,ifany,unlessallpartiesagreeto
waivesuchtestimony;and
(B)provideanopportunityfortestimonyfromtheinsurer,theOffice
oftheHealthCareAdvocate,andmembersofthepublic;
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(2)atapublichearing,announcetheBoard’sdecisionofwhetherto
approve,modify,ordisapprovetheproposedrate;and
(3)issueitsdecisioninwriting.
(f)(1)TheinsurershallnotifyitspolicyholdersoftheBoard’sdecisionina
timelymanner,asdefinedbytheBoardbyrule.
(2)Ratesshalltakeeffectonthedatespecifiedintheinsurer’srate
filing.
(3)IftheBoardhasnotissueditsdecisionbytheeffectivedate
specifiedintheinsurer’sratefiling,theinsurershallnotifyitspolicyholdersof
itspendingraterequestandoftheeffectivedateproposedbytheinsurerinits
ratefiling.
(g)Ahealthinsurer,theOfficeoftheHealthCareAdvocate,andany
memberofthepublicwithpartystatus,asdefinedbytheBoardbyrule,may
appealadecisionoftheBoardapproving,modifying,ordisapprovingthe
insurer’sproposedratetotheVermontSupremeCourt.
(h)(1)TheauthorityoftheBoardunderthissectionshallapplyonlytothe
ratereviewprocessforpoliciesformajormedicalinsurancecoverageandshall
notapplytothepolicyformsformajormedicalinsurancecoverageortothe
rateandpolicyformreviewprocessforpoliciesforspecificdisease,accident,
injury,hospitalindemnity,dentalcare,visioncare,disabilityincome,long-
termcare,studenthealthinsurancecoverage,Medicaresupplementinsurance
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coverage,orotherlimitedbenefitcoverage;toshort-term,limited-duration
healthinsurancecoverage;ortobenefitplansthatarepaiddirectlytoan
individualinsuredortotheindividual’sassignsandforwhichtheamountof
thebenefitisnotbasedonpotentialmedicalcostsoractualcostsincurred.
PremiumratesandrulesfortheclassificationofriskforMedicaresupplement
insurancepoliciesshallbegovernedbysection4051ofthistitle.
(2)Thepolicyformsformajormedicalinsurancecoverage,aswellas
thepolicyforms,premiumrates,andrulesfortheclassificationofriskforthe
otherlinesofinsurancedescribedinsubdivision(1)ofthissubsectionshallbe
reviewedandapprovedordisapprovedbytheCommissioner.Inmakinga
determination,theCommissionershallconsiderwhetherapolicyform,
premiumrate,orruleisaffordableandisnotunjust,unfair,inequitable,
misleading,orcontrarytothelawsofthisState;and,forapolicyformfor
majormedicalinsurancecoverage,whetheritensuresequalaccessto
appropriatementalhealthcareinamannerequivalenttootheraspectsof
healthcareaspartofanintegrated,holisticsystemofcare.TheCommissioner
shallmakeadeterminationwithin30daysafterthedatetheinsurerfiledthe
policyform,premiumrate,orrulewiththeDepartment.Attheexpirationof
the30-dayperiod,theform,premiumrate,orruleshallbedeemedapproved
unlesspriortothenithasbeenaffirmativelyapprovedordisapprovedbythe
Commissionerorfoundtobeincomplete.TheCommissionershallnotifya
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healthinsurerinwritingiftheinsurerfilesanyform,premiumrate,orrule
containingaprovisionthatdoesnotmeetthestandardsexpressedinthis
subsection.Insuchnotice,theCommissionershallstatethatahearingwillbe
grantedwithin20daysupontheinsurer’swrittenrequest.
(i)Notwithstandingtheproceduresandtimelinessetforthinsubsections
(a)through(e)ofthissection,theBoardmayestablish,byrule,astreamlined
ratereviewprocessforcertainratedecisions,includingproposedrates
affectingfewerthanaminimumnumberofcoveredlivesandproposedrates
forwhichademinimisincrease,asdefinedbytheBoardbyrule,issought.
§ 4027.FILINGFEES
Eachfilingofapolicy,contract,ordocumentformorpremiumratesor
rules,submittedpursuanttosection4026ofthistitle,shallbeaccompaniedby
paymenttotheCommissionerortheGreenMountainCareBoard,as
appropriate,ofanonrefundablefeeof$150.00.
§ 4028.FORMANDCONTENTSOFPOLICY
Nopolicyofindividualhealthinsuranceshallbedeliveredorissuedfor
deliverytoanypersoninthisStateunlessallofthefollowingconditionsare
met:
(1)Thepolicysetsforthallofthemonetaryandotherconsiderationsfor
thepolicy.
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(2)Thepolicysetsforththetimeatwhichtheinsurancetakeseffectand
terminates.
(3)Thepolicypurportstoinsureonlyoneperson,exceptthatapolicy
mayinsure,originallyorbysubsequentamendment,upontheapplicationofan
adultmemberofafamilywhoshallbedeemedthepolicyholder,anytwoor
moreeligiblemembersofthatfamily,includingaspouseorcivilunion
partner,dependentchildrenoranychildrenunderaspecifiedagethatshallnot
exceed26yearsofage,andanyotherpersondependentuponthepolicyholder.
(4)Thestyle,arrangement,andoverallappearanceofthepolicygiveno
undueprominencetoanyportionofthetext,andeveryprintedportionofthe
textofthepolicyandofanyendorsementsorattachedpapersisplainlyprinted
inlight-facedtypeofastyleingeneraluse,thesizeofwhichshallbeuniform
andnotlessthan10-pointwithalowercaseunspacedalphabetlengthnotless
than120-point.Asusedinthissubdivision,the“text”includesallprinted
matterexceptthenameandaddressoftheinsurer;thenameortitleofthe
policy;thebriefdescription,ifany;andthecaptionsandsubcaptions.
(5)Theexceptionsandreductionsofindemnityaresetforthinthe
policyand,exceptthosethataresetforthinsections4029and4030ofthis
title,areprinted,attheinsurer’soption,eitherwiththebenefitprovisionto
whichtheyapplyorunderanappropriatecaptionsuchas“EXCEPTIONS”or
“EXCEPTIONSANDREDUCTIONS”;provided,however,thatifan
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exceptionorreductionspecificallyappliesonlytoaparticularbenefitofthe
policy,thestatementoftheexceptionorreductionshallbeincludedwiththe
benefitprovisiontowhichitapplies.
(6)Eachpolicyform,includingridersandendorsements,isidentified
byaformnumberinthelowerleft-handcornerofthefirstpageoftheform.
(7)Thepolicydoesnotcontainanyprovisionpurportingtomakeany
portionofthecharter,rules,constitution,orbylawsofthehealthinsurerapart
ofthepolicyunlessthatportionissetforthinfullinthepolicy,exceptinthe
caseoftheincorporationof,orreferenceto,astatementofratesor
classificationofrisksorashort-ratetablefiledwiththeCommissioner.
(8)Eitherprominentlyprintedonorattachedtothefirstpageofthe
policyisanoticetotheeffectthatduringaperiodof30daysfollowingthe
datethepolicyisdeliveredtopersonseligibleforMedicarebyreasonofage,
and10daysfollowingthedateofdeliverytoallotherpersons,thepolicymay
besurrenderedtotheinsurertogetherwithawrittenrequestforcancellationof
thepolicy,andthatinsuchevent,theinsurerwillrefundanypremiumpaid,
includinganypolicyfeesorothercharges;provided,however,thatthis
subdivisionshallnotapplytosinglepremiumnonrenewablepoliciesinsuring
againstaccidentonlyormedicalcostsoraccidentalbodilyinjuryonly.
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§ 4029.REQUIREDSTANDARDPOLICYPROVISIONS
Exceptasprovidedinsection4031ofthistitle,eachhealthinsurancepolicy
deliveredorissuedfordeliverytoanypersoninthisStateshallcontainthe
provisionsspecifiedinthissectionusingthelanguagesetforthinthissection;
provided,however,thatahealthinsurermay,atitsoption,substitutedifferent
languageapprovedbytheCommissionerforoneormoreprovisions,provided
thesubstitutedlanguageisnotlessfavorableinanyrespecttotheinsuredor
coveredindividualthanthelanguageusedinthissection.Theprovisions
specifiedinthissectionshallbeprecededindividuallybythecaption
appearinginthissectionor,attheoptionofthehealthinsurer,bysuch
appropriatecaptionsorsubcaptionsastheCommissionermayapprove:
(1)ENTIRECONTRACT;CHANGES:Thispolicy,includingthe
endorsementsandtheattachedpapers,ifany,constitutestheentirecontractof
insurance.Nochangeinthispolicyshallbevaliduntilapprovedbyan
executiveofficeroftheinsurerandunlesssuchapprovalbeendorsedhereonor
attachedhereto.Noagenthasauthoritytochangethispolicyortowaiveany
ofitsprovisions.
(2)TIMELIMITONCERTAINDEFENSES:(a)Afterthreeyears
fromthedateofissueofthispolicynomisstatements,exceptfraudulent
misstatements,madebytheapplicantintheapplicationforsuchpolicy,shall
beusedtovoidthepolicyortodenyaclaimforlossincurredordisability(as
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definedinthepolicy)commencingaftertheexpirationofsuchthreeyear
period.
Afterthispolicyhasbeeninforceforaperiodofthreeyearsduringthe
lifetimeoftheinsured(excludinganyperiodduringwhichtheinsuredis
disabled),itshallbecomeincontestableastothestatementscontainedinthe
application.)
(b)Noclaimforlossincurredordisability(asdefinedinthepolicy)
commencingafterthreeyearsfromthedateofissueofthispolicyshallbe
reducedordeniedonthegroundthatadiseaseorphysicalconditionnot
excludedfromcoveragebynameorspecificdescriptioneffectiveonthedate
oflosshadexistedpriortotheeffectivedateofcoverageofthispolicy.
(3)GRACEPERIOD:Agraceperiodof....(insertanumbernotless
than“7”forweeklypremiumpolicies,“10”formonthlypremiumpoliciesand
“31”forallotherpolicies)dayswillbegrantedforthepaymentofeach
premiumfallingdueafterthefirstpremium,duringwhichgraceperiodthe
policyshallcontinueinforce.
(Apolicywhichcontainsacancellationprovisionmayadd,attheendof
theaboveprovision,
subjecttotherightoftheinsurertocancelinaccordancewiththe
cancellationprovisionhereof,
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Apolicyinwhichtheinsurerreservestherighttorefuseanyrenewal
shallhave,atthebeginningoftheaboveprovision,
Unlessnotlessthanfivedayspriortothepremiumduedatetheinsurerhas
deliveredtotheinsuredorhasmailedtohisorherlastaddressasshownbythe
recordsoftheinsurerwrittennoticeofitsintentionnottorenewthispolicy
beyondtheperiodforwhichthepremiumhasbeenaccepted.)
(4)REINSTATEMENT:Ifanyrenewalpremiumbenotpaidwithinthe
timegrantedtheinsuredforpayment,asubsequentacceptanceofpremiumby
theinsurerorbyanyagentdulyauthorizedbytheinsurertoacceptsuch
premium,withoutrequiringinconnectiontherewithanapplicationfor
reinstatement,shallreinstatethepolicy;provided,however,thatiftheinsurer
orsuchagentrequiresanapplicationforreinstatementandissuesaconditional
receiptforthepremiumtendered,thepolicywillbereinstateduponapproval
ofsuchapplicationbytheinsureror,lackingsuchapproval,uponthe45thday
followingthedateofsuchconditionalreceiptunlesstheinsurerhaspreviously
notifiedtheinsuredinwritingofitsdisapprovalofsuchapplication.The
reinstatedpolicyshallcoveronlylossresultingfromsuchaccidentalinjuryas
maybesustainedafterthedateofreinstatementandlossduetosuchsickness
asmaybeginmorethantendaysaftersuchdate.Inallotherrespectsthe
insuredandinsurershallhavethesamerightsthereunderastheyhadunderthe
policyimmediatelybeforetheduedateofthedefaultedpremium,subjectto
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anyprovisionsendorsedhereonorattachedheretoinconnectionwiththe
reinstatement.Anypremiumacceptedinconnectionwithareinstatementshall
beappliedtoaperiodforwhichpremiumhasnotbeenpreviouslypaid,butnot
toanyperiodmorethansixtydayspriortothedateofreinstatement.
(Thelastsentenceoftheaboveprovisionmaybeomittedfromany
policywhichtheinsuredhastherighttocontinueinforcesubjecttoitsterms
bythetimelypaymentofpremiums(1)untilatleastage50,or(2)inthecase
ofapolicyissuedafterage44,foratleastfiveyearsfromitsdateofissue.)
(5)NOTICEOFCLAIM:Writtennoticeofclaimmustbegiventothe
insurerwithin20daysaftertheoccurrenceorcommencementofanyloss
coveredbythepolicy,orassoonthereafterasisreasonablypossible.Notice
givenbyoronbehalfoftheinsuredorthebeneficiarytotheinsurerat....
(insertthelocationofsuchofficeastheinsurermaydesignateforthe
purpose),ortoanyauthorizedagentoftheinsurer,withinformationsufficient
toidentifytheinsured,shallbedeemednoticetotheinsurer.
(Inapolicyprovidingaloss-of-timebenefitwhichmaybepayableforat
leasttwoyears,aninsurermayatitsoptioninsertthefollowingbetweenthe
firstandsecondsentencesoftheaboveprovision:
Subjecttothequalificationssetforthbelow,iftheinsuredsufferslossof
timeonaccountofdisabilityforwhichindemnitymaybepayableforatleast
twoyears,heorsheshall,atleastonceineverysixmonthsafterhavinggiven
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noticeofclaim,givetotheinsurernoticeofcontinuanceofsaiddisability,
exceptintheeventoflegalincapacity.Theperiodofsixmonthsfollowing
anyfilingofproofbytheinsuredoranypaymentbytheinsureronaccountof
suchclaimoranydenialofliabilityinwholeorinpartbytheinsurershallbe
excludedinapplyingthisprovision.Delayinthegivingofsuchnoticeshall
notimpairtheinsured’srighttoanyindemnitywhichwouldotherwisehave
accruedduringtheperiodofsixmonthsprecedingthedateonwhichsuch
noticeisactuallygiven.)
(6)CLAIMFORMS:Theinsurer,uponreceiptofanoticeofclaim,will
furnishtotheclaimantsuchformsasareusuallyfurnishedbyitforfiling
proofsofloss.Ifsuchformsarenotfurnishedwithin15daysafterthegiving
ofsuchnoticetheclaimantshallbedeemedtohavecompliedwiththe
requirementsofthispolicyastoproofoflossuponsubmitting,withinthetime
fixedinthepolicyforfilingproofsofloss,writtenproofcoveringthe
occurrence,thecharacterandtheextentofthelossforwhichclaimismade.
(7)PROOFSOFLOSS:Writtenproofoflossmustbefurnishedtothe
insureratitssaidofficeincaseofclaimforlossforwhichthispolicyprovides
anyperiodicpaymentcontingentuponcontinuinglosswithin90daysafterthe
terminationoftheperiodforwhichtheinsurerisliableandincaseofclaimfor
anyotherlosswithin90daysafterthedateofsuchloss.Failuretofurnish
suchproofwithinthetimerequiredshallnotinvalidatenorreduceanyclaimif
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itwasnotreasonablypossibletogiveproofwithinsuchtime,providedsuch
proofisfurnishedassoonasreasonablypossibleandinnoevent,exceptinthe
absenceoflegalcapacity,laterthanoneyearfromthetimeproofisotherwise
required.
(8)TIMEOFPAYMENTOFCLAIMS:Indemnitiespayableunderthis
policyforanylossotherthanlossforwhichthispolicyprovidesanyperiodic
paymentwillbepaidimmediatelyuponreceiptofduewrittenproofofsuch
loss.Subjecttoduewrittenproofofloss,allaccruedindemnitiesforlossfor
whichthispolicyprovidesperiodicpaymentwillbepaid....(insertperiod
forpaymentwhichmustnotbelessfrequentlythanmonthly)andanybalance
remainingunpaidupontheterminationofliabilitywillbepaidimmediately
uponreceiptofduewrittenproof.
(9)PAYMENTOFCLAIMS:Indemnityforlossoflifewillbepayablein
accordancewiththebeneficiarydesignationandtheprovisionsrespectingsuch
paymentwhichmaybeprescribedhereinandeffectiveatthetimeofpayment.
Ifnosuchdesignationorprovisionistheneffective,suchindemnityshallbe
payabletotheestateoftheinsured.Anyotheraccruedindemnitiesunpaidat
theinsured’sdeathmay,attheoptionoftheinsurer,bepaideithertosuch
beneficiaryortosuchestate.Allotherindemnitieswillbepayabletothe
insured.
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(Thefollowingprovisions,oreitherofthem,maybeincludedwiththe
foregoingprovisionattheoptionoftheinsurer:
Ifanyindemnityofthispolicyshallbepayabletotheestateoftheinsured,
ortoaninsuredorbeneficiarywhoisaminororotherwisenotcompetentto
giveavalidrelease,theinsurermaypaysuchindemnity,uptoanamountnot
exceeding$......(insertanamountwhichshallnotexceed$1,000.00),to
anyrelativebybloodorconnectionbycivilmarriageoftheinsuredor
beneficiarywhoisdeemedbytheinsurertobeequitablyentitledthereto.Any
paymentmadebytheinsureringoodfaithpursuanttothisprovisionshall
fullydischargetheinsurertotheextentofsuchpayment.
Subjecttoanywrittendirectionoftheinsuredintheapplicationor
otherwisealloraportionofanyindemnitiesprovidedbythispolicyon
accountofhospital,nursing,medical,orsurgicalservicesmay,attheinsurer’s
optionandunlesstheinsuredrequestsotherwiseinwritingnotlaterthanthe
timeoffilingproofsofsuchloss,bepaiddirectlytothehospitalorperson
renderingsuchservices;butitisnotrequiredthattheserviceberenderedbya
particularhospitalorperson.)
(10)PHYSICALEXAMINATIONSANDAUTOPSY:Theinsureratits
ownexpenseshallhavetherightandtheopportunitytoexaminethepersonof
theinsuredwhenandasoftenasitmayreasonablyrequireduringthe
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pendencyofaclaimhereunderandtomakeanautopsyincaseofdeathwhere
itisnotforbiddenbylaw.
(11)LEGALACTIONS:Noactionatlaworinequityshallbebroughtto
recoveronthispolicypriortotheexpirationof60daysafterwrittenproofof
losshasbeenfurnishedinaccordancewiththerequirementsofthispolicy.No
suchactionshallbebroughtaftertheexpirationofthreeyearsafterthetime
writtenproofoflossisrequiredtobefurnished.
(12)CHANGEOFBENEFICIARY:Unlesstheinsuredmakesan
irrevocabledesignationofbeneficiary,therighttochangeofbeneficiaryis
reservedtotheinsuredandtheconsentofthebeneficiaryorbeneficiariesshall
notberequisitetosurrenderorassignmentofthispolicyortoanychangeof
beneficiaryorbeneficiaries,ortoanyotherchangesinthispolicy.
(Thefirstclauseofthisprovision,relativetotheirrevocabledesignation
ofbeneficiary,maybeomittedattheinsurer’soption.)
§ 4030.OPTIONALSTANDARDPOLICYPROVISIONS
Exceptasprovidedinsection4031ofthistitle,nohealthinsurancepolicy
deliveredorissuedfordeliverytoanypersoninthisStateshallcontain
provisionsrespectingthematterssetforthinthissectionunlesstheprovisions
usethelanguagesetforthinthissection;provided,however,thatahealth
insurermay,atitsoption,substitutedifferentlanguageapprovedbythe
Commissionerforoneormoreprovisions,providedthesubstitutedlanguageis
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notlessfavorableinanyrespecttotheinsuredorcoveredindividualthanthe
languageusedinthissection.Anyprovisionsetforthinthissectionthatis
containedinthepolicyshallbeprecededindividuallybytheappropriate
captionappearinginthissectionor,attheoptionofthehealthinsurer,bysuch
appropriatecaptionsorsubcaptionsastheCommissionermayapprove:
(1)CHANGEOFOCCUPATION:Iftheinsuredbeinjuredorcontract
sicknessafterhavingchangedhisorheroccupationtooneclassifiedbythe
insurerasmorehazardousthanthatstatedinthispolicyorwhiledoingfor
compensationanythingpertainingtoanoccupationsoclassified,theinsurer
willpayonlysuchportionoftheindemnitiesprovidedinthispolicyasthe
premiumpaidwouldhavepurchasedattheratesandwithinthelimitsfixedby
theinsurerforsuchmorehazardousoccupation.Iftheinsuredchangeshisor
heroccupationtooneclassifiedbytheinsureraslesshazardousthanthat
statedinthispolicy,theinsurer,uponreceiptofproofofsuchchangeof
occupation,willreducethepremiumrateaccordingly,andwillreturnthe
excessprorataunearnedpremiumfromthedateofchangeofoccupationor
fromthepolicyanniversarydateimmediatelyprecedingreceiptofsuchproof,
whicheveristhemorerecent.Inapplyingthisprovision,theclassificationof
occupationalriskandthepremiumratesshallbesuchashavebeenlastfiled
bytheinsurerpriortotheoccurrenceofthelossforwhichtheinsurerisliable
orpriortodateofproofofchangeinoccupationwiththestateofficialhaving
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supervisionofinsuranceinthestatewheretheinsuredresidedatthetimethis
policywasissued;butifsuchfilingwasnotrequired,thentheclassificationof
occupationalriskandthepremiumratesshallbethoselastmadeeffectiveby
theinsurerinsuchstatepriortotheoccurrenceofthelossorpriortothedate
ofproofofchangeinoccupation.
(2)MISSTATEMENTOFAGE:Iftheageoftheinsuredhasbeen
misstated,allamountspayableunderthispolicyshallbesuchasthepremium
paidwouldhavepurchasedatthecorrectage.
(3)OTHERINSURANCEINTHISINSURER:Ifanaccidentor
sicknessoraccidentandsicknesspolicyorpoliciespreviouslyissuedbythe
insurertotheinsuredbeinforceconcurrentlyherewith,makingtheaggregate
indemnityfor....(inserttypeofcoverageorcoverages)inexcessof$
....................(insertmaximumlimitofindemnityorindemnities)theexcess
insuranceshallbevoidandallpremiumspaidforsuchexcessshallbereturned
totheinsuredortohisorherestate.
Insuranceeffectiveatanyonetimeontheinsuredunderalikepolicyor
policiesinthisinsurerislimitedtotheonesuchpolicyelectedbytheinsured,
hisorherbeneficiaryorhisorherestate,asthecasemaybe,andtheinsurer
willreturnallpremiumspaidforallothersuchpolicies.
(4)INSURANCEWITHOTHERINSURERS:Iftherebeothervalid
coverage,notwiththisinsurer,providingbenefitsforthesamelossona
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provisionofservicebasisoronanexpenseincurredbasisandofwhichthis
insurerhasnotbeengivenwrittennoticepriortotheoccurrenceor
commencementofloss,theonlyliabilityunderanyexpenseincurredcoverage
ofthispolicyshallbeforsuchproportionofthelossastheamountwhich
wouldotherwisehavebeenpayablehereunderplusthetotalofthelike
amountsunderallsuchothervalidcoveragesforthesamelossofwhichthis
insurerhadnoticebearstothetotallikeamountsunderallvalidcoveragesfor
suchloss,andforthereturnofsuchportionofthepremiumspaidasshall
exceedtheprorataportionfortheamountsodetermined.Forthepurposeof
applyingthisprovisionwhenothercoverageisonaprovisionofservicebasis,
the“likeamount”ofsuchothercoverageshallbetakenastheamountwhich
theservicesrenderedwouldhavecostintheabsenceofsuchcoverage.
(Iftheforegoingpolicyprovisionisincludedinapolicywhichalso
containsthenextfollowingpolicyprovisionthereshallbeaddedtothecaption
oftheforegoingprovisionthephrase“—EXPENSEINCURRED
BENEFITS.”Theinsurermay,atitsoption,includeinthisprovisiona
definitionof“othervalidcoverage,”approvedastoformbythe
Commissioner,whichdefinitionshallbelimitedinsubjectmattertocoverage
providedbyorganizationssubjecttoregulationbyinsurancelaworby
insuranceauthoritiesofthisoranyotherstateoftheUnitedStatesorany
provinceofCanada,andbyhospitalormedicalserviceorganizations,andto
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anyothercoveragetheinclusionofwhichmaybeapprovedbythe
Commissioner.Intheabsenceofsuchdefinitionsuchtermshallnotinclude
groupinsurance,automobilemedicalpaymentsinsurance,orcoverage
providedbyhospitalormedicalserviceorganizationsorbyunionwelfare
plansoremployeroremployeebenefitorganizations.Forthepurposeof
applyingtheforegoingpolicyprovisionwithrespecttoanyinsured,any
amountofbenefitprovidedforsuchinsuredpursuanttoanycompulsory
benefitstatute(includinganyworkers’compensationoremployer’sliability
statute)whetherprovidedbyagovernmentalagencyorotherwiseshallinall
casesbedeemedtobe“othervalidcoverage”ofwhichtheinsurerhashad
notice.Inapplyingtheforegoingpolicyprovisionnothirdpartyliability
coverageshallbeincludedas“othervalidcoverage.”)
(5)INSURANCEWITHOTHERINSURERS:Iftherebeothervalid
coverage,notwiththisinsurer,providingbenefitsforthesamelossonother
thananexpenseincurredbasisandofwhichthisinsurerhasnotbeengiven
writtennoticepriortotheoccurrenceorcommencementofloss,theonly
liabilityforsuchbenefitsunderthispolicyshallbeforsuchproportionofthe
indemnitiesotherwiseprovidedhereunderforsuchlossasthelikeindemnities
ofwhichtheinsurerhadnotice(includingtheindemnitiesunderthispolicy)
beartothetotalamountofalllikeindemnitiesforsuchloss,andforthereturn
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ofsuchportionofthepremiumpaidasshallexceedtheprorataportionforthe
indemnitiesthusdetermined.
(Iftheforegoingpolicyprovisionisincludedinapolicywhichalso
containsthenextprecedingpolicyprovisionthereshallbeaddedtothecaption
oftheforegoingprovisionthephrase“—OTHERBENEFITS.”Theinsurer
may,atitsoption,includeinthisprovisionadefinitionof“othervalid
coverage,”approvedastoformbytheCommissioner,whichdefinitionshall
belimitedinsubjectmattertocoverageprovidedbyorganizationssubjectto
regulationbyinsurancelaworbyinsuranceauthoritiesofthisoranyother
stateoftheUnitedStatesoranyprovinceofCanada,andtoanyothercoverage
theinclusionofwhichmaybeapprovedbytheCommissioner.Intheabsence
ofsuchdefinitionsuchtermshallnotincludegroupinsurance,orbenefits
providedbyunionwelfareplansorbyemployeroremployeebenefit
organizations.Forthepurposeofapplyingtheforegoingpolicyprovisionwith
respecttoanyinsured,anyamountofbenefitprovidedforsuchinsured
pursuanttoanycompulsorybenefitstatute(includinganyworkers’
compensationoremployer’sliabilitystatute)whetherprovidedbya
governmentalagencyorotherwiseshallinallcasesbedeemedtobe“other
validcoverage”ofwhichtheinsurerhashadnotice.Inapplyingtheforegoing
policyprovisionnothirdpartyliabilitycoverageshallbeincludedas“other
validcoverage.”)
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(6)RELATIONOFEARNINGSTOINSURANCE:Ifthetotalmonthly
amountoflossoftimebenefitspromisedforthesamelossunderallvalidloss
oftimecoverageupontheinsured,whetherpayableonaweeklyormonthly
basis,shallexceedthemonthlyearningsoftheinsuredatthetimedisability
commencedorhisorheraveragemonthlyearningsfortheperiodoftwoyears
immediatelyprecedingadisabilityforwhichclaimismade,whicheveristhe
greater,theinsurerwillbeliableonlyforsuchproportionateamountofsuch
benefitsunderthispolicyastheamountofsuchmonthlyearningsorsuch
averagemonthlyearningsoftheinsuredbearstothetotalamountofmonthly
benefitsforthesamelossunderallsuchcoverageupontheinsuredatthetime
suchdisabilitycommencesandforthereturnofsuchpartofthepremiums
paidduringsuchtwoyearsasshallexceedtheprorataamountofthe
premiumsforthebenefitsactuallypaidhereunder;butthisshallnotoperateto
reducethetotalmonthlyamountofbenefitspayableunderallsuchcoverage
upontheinsuredbelowthesumof$200.00orthesumofthemonthlybenefits
specifiedinsuchcoverages,whicheveristhelesser,norshallitoperateto
reducebenefitsotherthanthosepayableforlossoftime.
(Theforegoingpolicyprovisionmaybeinsertedonlyinapolicywhich
theinsuredhastherighttocontinueinforcesubjecttoitstermsbythetimely
paymentofpremiums(1)untilatleastage50;or(2)inthecaseofapolicy
issuedafterage44,foratleastfiveyearsfromitsdateofissue.Theinsurer
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may,atitsoption,includeinthisprovisionadefinitionof“validlossoftime
coverage,”approvedastoformbytheCommissioner,whichdefinitionshall
belimitedinsubjectmattertocoverageprovidedbygovernmentalagenciesor
byorganizationssubjecttoregulationbyinsurancelaworbyinsurance
authoritiesofthisoranyotherstateoftheUnitedStatesoranyprovinceof
Canada,ortoanyothercoveragetheinclusionofwhichmaybeapprovedby
theCommissioneroranycombinationofsuchcoverages.Intheabsenceof
suchdefinitionsuchtermshallnotincludeanycoverageprovidedforsuch
insuredpursuanttoanycompulsorybenefitstatute(includinganyworkers’
compensationoremployer’sliabilitystatute),orbenefitsprovidedbyunion
welfareplansorbyemployeroremployeebenefitorganizations.)
(7)UNPAIDPREMIUM:Uponthepaymentofaclaimunderthispolicy,
anypremiumthendueandunpaidorcoveredbyanynoteorwrittenordermay
bedeductedtherefrom.
(8)CANCELLATION:Theinsurermaycancelthispolicyatanytimeby
writtennoticedeliveredtotheinsured,ormailedtohisorherlastaddressas
shownbytherecordsoftheinsurer,statingwhen,notlessthanfivedays
thereafter,suchcancellationshallbeeffective;andafterthepolicyhasbeen
continuedbeyonditsoriginaltermtheinsuredmaycancelthispolicyatany
timebywrittennoticedeliveredormailedtotheinsurer,effectiveuponreceipt
oronsuchlaterdateasmaybespecifiedinsuchnotice.Intheeventof
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cancellation,theinsurerwillreturnpromptlytheunearnedportionofany
premiumpaid.Iftheinsuredcancels,theearnedpremiumshallbecomputed
bytheuseoftheshort-ratetablelastfiledwiththestateofficialhaving
supervisionofinsuranceinthestatewheretheinsuredresidedwhenthepolicy
wasissued.Iftheinsurercancels,theearnedpremiumshallbecomputedpro
rata.Cancellationshallbewithoutprejudicetoanyclaimoriginatingpriorto
theeffectivedateofcancellation.
(9)CONFORMITYWITHSTATESTATUTES:Anyprovisionofthis
policywhich,onitseffectivedate,isinconflictwiththestatutesofthestatein
whichtheinsuredresidesonsuchdateisherebyamendedtoconformtothe
minimumrequirementsofsuchstatutes.
(10)ILLEGALOCCUPATION:Theinsurershallnotbeliableforanyloss
towhichacontributingcausewastheinsured’scommissionoforattemptto
commitafelonyortowhichacontributingcausewastheinsured’sbeing
engagedinanillegaloccupation.
§ 4031.OMISSIONOFINAPPLICABLEORINCONSISTENT
STANDARDPROVISIONS
Ifanyprovisionofsections4029and4030ofthistitleisinwholeorinpart
inapplicabletoorinconsistentwiththecoverageprovidedbyaparticularform
ofpolicy,thehealthinsurer,withtheapprovaloftheCommissioner,shallomit
fromsuchpolicyanyinapplicableprovisionorpartofaprovision,andshall
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modifyanyinconsistentprovisionorpartoftheprovisioninsuchmannerasto
maketheprovisionascontainedinthepolicyconsistentwiththecoverage
providedbythepolicy.
§ 4032.ORDEROFSTANDARDPOLICYPROVISIONS
Theprovisionsspecifiedinsections4029and4030ofthistitle,orany
correspondingprovisionsusedinlieuofthoseprovisionsaspermittedbythose
sections,shalleitherbeprintedinthesameorderastheprovisionsaresetforth
inthosesectionsor,attheoptionofthehealthinsurer,anysuchprovisionmay
appearasaunitinanypartofthepolicy,withotherprovisionstowhichitmay
belogicallyrelated,providedtheresultingpolicyshallnotbeinwholeorin
partunintelligible,uncertain,ambiguous,abstruse,orlikelytomisleada
persontowhomthepolicyisoffered,delivered,orissued.
§ 4033.DISCRETIONARYCLAUSESPROHIBITED
(a)Thepurposeofthissectionistoensurethathealthinsurancebenefits,
disabilityincomeprotectioncoverage,andlifeinsurancebenefitsare
contractuallyguaranteedandtoavoidtheconflictofinterestthatmayoccur
whenthecarrierresponsibleforprovidingbenefitshasdiscretionaryauthority
todecidewhatbenefitsaredue.Nothinginthissectionshallbeconstruedto
imposeanyrequirementordutyonanypersonotherthanahealthinsurerora
healthinsurerofferingdisabilityincomeprotectioncoverageorlifeinsurance.
(b)Asusedinthissection:
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(1)“Disabilityincomeprotectioncoverage”meansapolicy,contract,
certificate,oragreementthatprovidesforweekly,monthly,orotherperiodic
paymentsforaspecifiedperiodduringthecontinuanceofdisabilityresulting
fromillness,injury,oracombinationofillnessandinjury.
(2)“Healthinsurer”hasthesamemeaningasinsection4021ofthis
chapterand,asusedinthissection,alsoincludesentitiesofferingpoliciesfor
specificdisease,accident,injury,hospitalindemnity,dentalcare,disability
income,long-termcare,andotherlimitedbenefitcoverage.
(3)“Lifeinsurance”meansapolicy,contract,certificate,oragreement
thatprovideslifeinsuranceasdefinedinsubdivision3301(a)(1)ofthistitle.
(c)Nopolicy,contract,certificate,oragreementofferedorissuedinthis
Statebyahealthinsurertoprovide,deliver,arrangefor,payfor,orreimburse
anyofthecostsofhealthcareservicesmaycontainaprovisionpurportingto
reservediscretiontothehealthinsurertointerpretthetermsofthecontractor
toprovidestandardsofinterpretationorreviewthatareinconsistentwiththe
lawsofthisState,andanysuchprovisioninapolicy,contract,certificate,or
agreementshallbenullandvoid.
(d)Nopolicy,contract,certificate,oragreementofferedorissuedinthis
Stateprovidingfordisabilityincomeprotectioncoveragemaycontaina
provisionpurportingtoreservediscretiontotheinsurertointerprettheterms
ofthecontractortoprovidestandardsofinterpretationorreviewthatare
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inconsistentwiththelawsofthisState,andanysuchprovisioninapolicy,
contract,certificate,oragreementshallbenullandvoid.
(e)Nopolicy,contract,certificate,oragreementoflifeinsuranceoffered
orissuedinthisStateshallcontainaprovisionpurportingtoreservediscretion
totheinsurertointerpretthetermsofthecontractortoprovidestandardsof
interpretationorreviewthatareinconsistentwiththelawsofthisState,and
anysuchprovisioninapolicy,contract,certificate,oragreementshallbenull
andvoid.
§ 4034.REQUIREMENTS OFOTHERJURISDICTIONS
(a)Anypolicyofaforeignoralieninsurer,whendeliveredorissuedfor
deliverytoanypersoninthisState,maycontainanyprovisionthatisnotless
favorabletothecoveredindividualthantheprovisionsofthischapterandthat
isprescribedorrequiredbythelawofthestateunderwhichtheinsureris
organized.
(b)Anypolicyofadomestichealthinsurer,whenissuedfordeliveryin
anyotherstateorcountry,maycontainanyprovisionpermittedorrequiredby
thelawsofsuchotherstateorcountry.
§ 4035.POLICIESNOTAFFECTED
Nothinginsections4018–4020,4023,4028–4032,4034,4036,and4037of
thistitleshallapplytooraffect:
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(1)anypolicyofworkers’compensationinsuranceoranypolicyof
liabilityinsurance,withorwithoutsupplementarycoverage;
(2)anypolicyorcontractofreinsurance;
(3)anyblanketorgrouppolicyofinsuranceenumeratedinsections
4041–4043and4052ofthistitle,exceptasotherwiseprovidedinthose
sections;or
(4)lifeinsurance,endowment,orannuitycontracts,orcontracts
supplementaltothosecontracts,thatcontainonlysuchprovisionsrelatingto
accidentandsicknessinsuranceas:
(A)provideadditionalbenefitsincaseofdeathordismembermentor
lossofsightbyaccident;or
(B)operatetosafeguardthecontractsagainstlapseortogivea
specialsurrendervalueorspecialbenefitoranannuityintheeventthatthe
insuredorannuitantbecomestotallyandpermanentlydisabled,asdefinedby
thecontractorsupplementalcontract.
§ 4036.NONCONFORMING POLICIES
(a)Ahealthinsurancepolicyshallnotcontainanyprovisionthatmakesthe
policyoranyportionofthepolicylessfavorableinanyrespecttothecovered
individualthantheprovisionsofthepolicythatareregulatedbysections4029
and4030ofthistitle.
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(b)ApolicydeliveredorissuedfordeliverytoanypersoninthisStatein
violationofsections4029and4030ofthistitleshallbeheldvalidbutshallbe
construedasprovidedinthischapter.Whenanyprovisioninapolicy
regulatedbysections4029and4030isinconflictwithanyprovisionofthose
sections,therights,duties,andobligationsofthehealthinsurerandthe
coveredindividualshallbegovernedbytheprovisionsofthosesections.
§ 4037.APPLICATIONSFORINSURANCE
(a)(1)Acoveredindividualshallnotbeboundbyanystatementmadein
anapplicationforapolicyunlessacopyoftheapplicationisattachedtoor
endorsedonthepolicyasapartofthepolicywhenissued.
(2)IfapolicydeliveredorissuedfordeliverytoanypersoninthisState
isreinstatedorrenewedandthecoveredindividualorassigneeofthepolicy
makesawrittenrequesttothehealthinsurerforacopyoftheapplication,if
any,forsuchreinstatementorrenewal,thehealthinsurershalldeliverormail
acopyoftheapplicationtotheindividualmakingtherequestwithin15days
afterthereceiptoftherequest.Ifthehealthinsurerdoesnotdeliverormail
thecopywithin15days,thehealthinsurershallbeprecludedfromintroducing
theapplicationasevidenceinanyactionorproceedingbasedonorinvolving
thepolicyoritsreinstatementorrenewal.
(b)Noalterationofawrittenapplicationforapolicyshallbemadebyany
personotherthantheapplicantwithouttheapplicant’swrittenconsent,except
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thatinsertionsmaybemadebythehealthinsurer,foradministrativepurposes
only,inamannerthatindicatesclearlythattheinsertionsarenottobeascribed
totheapplicant.
(c)Thefalsityofanystatementinanapplicationforapolicyshallnotbar
therighttorecoveryunderthepolicyunlessthefalsestatementmaterially
affectedeithertheacceptanceoftheriskorthehazardassumedbythehealth
insurer.
§ 4038.RULEMAKINGONPOLICYFILINGS
TheCommissionermayadoptsuchreasonablerulesconcerningthe
procedureforthefilingorsubmissionofpoliciessubjecttosections4023and
4028–4030ofthistitleasarenecessary,proper,oradvisableforthe
administrationofthesesections.Thisprovisionshallnotabridgeanyother
authoritygrantedtotheCommissionerbylaw.
Subchapter3.GroupCoverage
§ 4041.GROUPHEALTHINSURANCEPOLICIES;DEFINITIONS
(a)Asusedinthissection:
(1)“Employees”includestheofficers,managers,andemployeesofthe
employer;thepartners,iftheemployerisapartnership;theofficers,managers,
andemployeesofsubsidiaryoraffiliatedcorporationsofacorporation
employer;andtheindividualproprietors,partners,andemployeesof
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individualsandfirms,thebusinessofwhichiscontrolledbytheinsured
employerthroughstockownership,contract,orotherwise.
(2)“Employer”maybedeemedtoincludeanymunicipalor
governmentalentityorofficer,ortheappropriateofficerforanunincorporated
townorgoreorfortheUnifiedTownsandGoresofEssexCounty,aswellas
privateindividuals,partnerships,andcorporations.
(b)Grouphealthinsuranceisaformofhealthinsurancethatcoversoneor
morepersons,withorwithouttheirdependents,thatisissueduponthe
followingbasis:
(1)(A)Underapolicyissuedtoanemployer,whoisdeemedthe
policyholder,insuringatleastoneemployeeoftheemployer,forthebenefitof
personsotherthantheemployer.
(B)Inaccordancewithsection3368ofthistitle,anemployer
domiciledinajurisdictionotherthanVermontthathasmorethan25
certificate-holderemployeeswhoseprincipalworksiteanddomicileisin
Vermontandthatisdefinedasalargegroupinitsownjurisdictionandunder
thePatientProtectionandAffordableCareAct,Pub.L.No.111-148,§1304,
asamendedbytheHealthCareandEducationReconciliationActof2010,
Pub.L.No.111-152,maypurchaseinsuranceinthelargegrouphealth
insurancemarketforitsVermont-domiciledcertificate-holderemployees.
(2)(A)Underapolicyissued:
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(i)toanassociation,atrust,oroneormoretrusteesofafund
establishedbyoneormoreassociationsotherwiseeligiblefortheissuanceofa
policyunderthissubdivision(2)andmaintained,directlyorindirectly,byone
ormoreassociationsforthebenefitofitsmembersoracontractorplanissued
bysuchanassociationortrust;or
(ii)byamultipleemployerwelfarearrangementasdefinedinthe
EmployeeRetirementIncomeSecurityActof1974,asamended.
(B)(i)Theassociationorassociationsshallhave:
(I)aminimumof100personsatthetimeofincorporationor
formation;
(II)beenorganizedandmaintainedingoodfaithforpurposes
otherthanthatofobtaininginsurance;
(III)beeninactiveexistenceforatleastoneyear;and
(IV)aconstitutionandbylawsthatprovidethat:
(aa)theassociationorassociationsholdregularmeetings
notlessthanannuallytofurtherpurposesofthemembers;
(bb)exceptforcreditunions,theassociationorassociations
collectduesorsolicitcontributionsfrommembers;and
(cc)themembersconstituteamajorityofthevotingpower
oftheassociationforallpurposesandhaverepresentationonthegoverning
boardandcommittees.
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(ii)(I)Theassociationorassociationsshallnotbecontrolledbya
healthinsurer,asevidencedbytheoperationoftheassociationorassociations.
(II)Thefollowingfactorsmaybeusedasevidenceto
determinewhetheranassociationisahealthinsurer-operatedassociation;
provided,however,thatthepresenceorabsenceofoneormoreofthese
factorsshallnotservetolimitorbedispositiveofsuchadetermination:
(aa)commonboardmembers,officers,executives,or
employees;
(bb)commonownershipofthehealthinsurerandthe
association,oroftheassociationandanothereligiblegroup;and
(cc)commonuseofofficespaceorequipmentusedbythe
healthinsurertotransactinsurance.
(C)Anassociation’smembersshallhaveasharedorcommon
purposethatisnotprimarilyabusinessorcustomerrelationship.
(D)(i)Apolicyissuedbyanassociationshallnotinsurepersons
otherthanthemembersoremployeesoftheassociationorassociations,or
employeesofmembers,orallofanyclassorclassesofemployeesofthe
association,associations,ormembers,together,ineachcase,withthe
employees’ormembers’dependents,asapplicable,forthebenefitofpersons
otherthantheemployee’semployer.
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(ii)Apolicyissuedbyanassociationshallinsurealleligible
persons,exceptthosewhorejectcoverageinwriting.
(E)Anassociationshallnotusethesolicitationofinsuranceasthe
primarymethodofobtainingnewmembers.
(F)Ifahealthinsurercollectsmembershipfeesorduesonbehalfof
anassociation,thehealthinsurershalldisclosetothemembersofthe
associationthatthehealthinsurerisbillingandcollectingmembershipfees
andduesonbehalfoftheassociation.
(3)(A)Underapolicyissuedtoatrust,ortooneormoretrusteesofa
fundestablishedandmaintained,directlyorindirectly,by:
(i)twoormoreemployers;
(ii)oneormorelaborunionsorsimilaremployeeorganizations;
or
(iii)oneormoreemployersandoneormorelaborunionsor
similaremployeeorganizations.
(B)(i)Apolicyunderthissubdivision(3)mustbeissuedtothetrust
ortrusteesforthepurposeofinsuringalloftheemployeesoftheemployersor
allofthemembersoftheunionsororganizations,orallofanyclassorclasses
ofemployeesormembers,together,ineachcase,withtheemployees’or
members’dependents,asapplicable,forthebenefitofpersonsotherthanthe
employersortheunionsororganizations.
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(ii)Apolicyissuedtoatrustshallinsurealleligiblepersons,
exceptthosewhorejectcoverageinwriting.
(4)Underapolicyissuedtoanyothersubstantiallysimilargroupthat,
inthediscretionoftheCommissioner,maybesubjecttotheissuanceofa
groupaccidentandsicknesspolicyorcontract.
§ 4042.GROUPINSURANCEPOLICIES;REQUIREDPOLICY
PROVISIONS
(a)Termsandconditions.Nogrouphealthinsurancepolicyshallcontain
anyprovisionrelatingtonoticeofclaim,proofsofloss,timeofpaymentof
claims,ortimewithinwhichlegalactionmustbebroughtuponthepolicythat,
intheopinionoftheCommissioner,islessfavorabletothepersonsinsured
thanwouldbepermittedbytheprovisionssetforthinsection4029ofthistitle.
Inaddition,eachsuchpolicyshallcontaininsubstancethefollowing
provisions:
(1)Aprovisionthatthepolicy;theapplicationofthepolicyholder,ifan
applicationorcopyisattachedtothepolicy;andtheindividualapplications,if
any,submittedbytheemployeesormembersinconnectionwiththepolicy
shallconstitutetheentirecontractbetweentheparties,andthatallstatements,
intheabsenceoffraud,madebyanyapplicantorapplicantsshallbedeemed
representationsandnotwarranties,andthatnosuchstatementshallavoidthe
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insuranceorreducebenefitsunderthepolicyunlesscontainedinawritten
application,ofwhichacopyisattachedtothepolicy.
(2)Aprovisionthatthehealthinsurerwillfurnishtothepolicyholder,
fordeliverytoeachemployeeormemberoftheinsuredgroup,anindividual
certificatesettingforthinsummaryformastatementoftheessentialfeatures
oftheinsurancecoverageoftheemployeeormemberandtowhombenefits
arepayableunderthepolicy.Ifdependentsareincludedinthecoverage,only
onecertificateneedbeissuedforeachfamilyunit.
(3)Aprovisionthattothegrouporiginallyinsuredmaybeaddedfrom
timetotimeeligiblenewemployeesormembersordependents,asthecase
maybe,inaccordancewiththetermsofthepolicy.
(4)Aprovisionthatthehealthinsurershallnotexcludepart-time
employeesandshallofferthesamegrouphealthbenefitstopart-time
employeesasitofferstotheemployeegroupsofwhichthepart-time
employeeswouldbemembersiftheywerefull-timeemployees.Thehealth
insurershalloffertoincludethepart-timeemployeesaspartoftheemployer’s
employeegroup,atthefullratetobepaidbytheemployerandtheemployee,
atarateproratedbetweentheemployerandtheemployee,oratthe
employee’sexpense.Asusedinthissubdivision,“part-timeemployee”means
anyemployeewhoworksaminimumofatleast17.5hoursperweek.
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(b)Protectionsforcoveredindividuals.
(1)Preexistingconditionexclusions.Agroupinsurancepolicyshallnot
containanyprovisionthatexcludes,restricts,orotherwiselimitscoverage
underthepolicyforoneormorepreexistinghealthconditions.
(2)Annuallimitationsoncostsharing.
(A)(i)Theannuallimitationoncostsharingforself-onlycoverage
foranyyearshallbethesameasthedollarlimitestablishedbythefederal
governmentforself-onlycoverageforthatyearinaccordancewith45C.F.R.
§ 156.130.
(ii)Theannuallimitationoncostsharingforotherthanself-only
coverageforanyyearshallbetwicethedollarlimitforself-onlycoverage
describedinsubdivision(i)ofthissubdivision(A).
(B)(i)Intheeventthatthefederalgovernmentdoesnotestablishan
annuallimitationoncostsharingforanyplanyear,theannuallimitationon
costsharingforself-onlycoverageforthatyearshallbethedollarlimitfor
self-onlycoverageintheprecedingcalendaryear,increasedbyanypercentage
bywhichtheaveragepercapitapremiumforhealthinsurancecoveragein
Vermontfortheprecedingcalendaryearexceedstheaveragepercapita
premiumfortheyearbeforethat.
(ii)Theannuallimitationoncostsharingforotherthanself-only
coverageforanyyearinwhichthefederalgovernmentdoesnotestablishan
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annuallimitationoncostsharingshallbetwicethedollarlimitforself-only
coveragedescribedinsubdivision(i)ofthissubdivision(B).
(3)Banonannualandlifetimelimits.Agroupinsurancepolicyshall
notestablishanyannualorlifetimelimitonthedollaramountofessential
healthbenefits,asdefinedinSection1302(b)ofthePatientProtectionand
AffordableCareActof2010,Pub.L.No.111-148,asamendedbytheHealth
CareandEducationReconciliationActof2010,Pub.L.No.111-152,and
applicableregulationsandfederalguidance,foranyindividualinsuredunder
thepolicy,regardlessofwhethertheservicesareprovidedin-networkorout-
of-network.
(4)Nocostsharingforpreventiveservices.
(A)Agroupinsurancepolicyshallnotimposeanyco-payment,
coinsurance,ordeductiblerequirementsfor:
(i)preventiveservicesthathavean“A”or“B”ratinginthe
currentrecommendationsoftheU.S.PreventiveServicesTaskForce;
(ii)immunizationsforroutineuseinchildren,adolescents,and
adultsthathaveineffectarecommendationfromtheAdvisoryCommitteeon
ImmunizationPracticesoftheCentersforDiseaseControlandPreventionwith
respecttotheindividualinvolved;
(iii)withrespecttoinfants,children,andadolescents,evidence-
informedpreventivecareandscreeningsassetforthincomprehensive
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guidelinessupportedbythefederalHealthResourcesandServices
Administration;and
(iv)withrespecttowomen,totheextentnotincludedin
subdivision(i)ofthissubdivision(4)(A),evidence-informedpreventivecare
andscreeningssetforthinbindingcomprehensivehealthplancoverage
guidelinessupportedbythefederalHealthResourcesandServices
Administration.
(B)Subdivision(A)ofthissubdivision(4)shallapplytoahigh-
deductiblehealthplanonlytotheextentthatitwouldnotdisqualifytheplan
fromeligibilityforahealthsavingsaccountpursuantto26U.S.C.§223.
(5)Definitionof“groupinsurancepolicy.”Asusedinthissubsection,
“groupinsurancepolicy”hasthesamemeaningas“grouphealthplan”and
shallbesubjecttothesameexceptedbenefits,ineachcase,assetforthin
45 C.F.R.§146.145,asineffectasofDecember31,2017.
§ 4043.ASSOCIATIONHEALTHPLANS
(a)(1)Asusedinthissection,“associationhealthplan”meansapolicy
issuedtoanassociation;toatrust;ortooneormoretrusteesofafund
established,created,ormaintainedforthebenefitofthemembersofoneor
moreassociationsoracontractorplanissuedbyanassociationortrustorbya
multipleemployerwelfarearrangementasdefinedintheEmployeeRetirement
IncomeSecurityActof1974,29U.S.C.§1001etseq.
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(2)Noassociationhealthplanshallbeissued,offered,orrenewedin
thisStatetoanypersonotherthananassociationthatwasformedorcould
havebeenformedundertheEmployeeRetirementIncomeSecurityActof
1974,29U.S.C.§1001et.seq.,andaccompanyingU.S.DepartmentofLabor
regulationsandguidance,ineachcase,asineffectasofJanuary19,2017.
(b)TheCommissionershalladoptrulespursuantto3V.S.A.chapter25
regulatingassociationhealthplansinordertoprotectVermontconsumersand
promotethestabilityofVermont’shealthinsurancemarkets,totheextent
permittedunderfederallaw,includingrulesregardinglicensure,solvencyand
reserverequirements,andratingrequirements.
(c)Theprovisionsofsection3661ofthistitleshallapplytoassociation
healthplans.
Subchapter4.ContinuationandConversionof
GroupHealthInsurancePolicies
§ 4047a.CONTINUATIONOFGROUP
(a)Allgroupmajormedicalinsuranceanddentalinsurancepoliciesshall
providethatanypersonwhoseinsuranceunderthegrouppolicywould
terminatebecauseoftheoccurrenceofaqualifyingeventasdefinedin
subsection(b)ofthissectionshallbeentitledtocontinuetheperson’shealth
insuranceunderthatgrouppolicy.
(b)Forpurposesofthissubchapter,“qualifyingevent”means:
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(1)lossofemployment,includingareductioninhoursthatresultsin
ineligibilityforemployer-sponsoredcoverage;
(2)divorce,dissolution,orlegalseparationofthecoveredemployee
fromtheemployee’sspouseorcivilunionpartner;
(3)adependentchildceasingtoqualifyasadependentchildunderthe
generallyapplicablerequirementsofthepolicy;or
(4)deathofthecoveredemployeeormember.
(c)Theprovisionsofthissectionshallnotapplyifoneormoreofthe
followingconditionsapplies:
(1)Thedeceasedpersonoremployeewasnotinsuredunderthegroup
policyonthedateofthequalifyingevent.
(2)ThepersoniscoveredbyMedicare.
(3)Thepersoniscoveredbyanyothergroupinsuredoruninsured
arrangementthatprovidesdentalcoverageorhospitalandmedicalcoverage
forindividualsinagroupandunderwhichthepersonwasnotcovered
immediatelypriortothequalifyingevent,andnopreexistingcondition
exclusionapplies;provided,however,thatthepersonshallremaineligiblefor
continuationcoveragesthatarenotavailableundertheinsuredoruninsured
arrangement.
(4)Thepersonhasalossofemploymentduetomisconductasdefined
in21V.S.A.§1344.
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(d)Thecontinuationrequiredbythissectiononlyappliestomajormedical
insuranceanddentalinsurancebenefits.
(e)Noticeofthecontinuationprivilegeshallbeincludedineachcertificate
ofcoverageandshallbeprovidedbytheemployertotheemployeewithin30
daysfollowingtheoccurrenceofanyqualifyingevent.
§ 4047b.CONTINUATION;NOTICE;TERMS
(a)Apersonelectingcontinuationshallnotifythehealthinsurer,orthe
policyholder,orthecontractor,oragentforthegroupifthepolicyholderdid
notcontractforthepolicydirectlywiththehealthinsurer,ofsuchelectionin
writingwithin60daysafterreceivingnoticefollowingtheoccurrenceofa
qualifyingeventpursuanttosubsection4047a(e)ofthistitle.Noticeof
electiontocontinueunderthegrouppolicyshallbeaccompaniedbytheinitial
contribution,whichshallincludepaymentfortheperiodfromthequalifying
eventthroughtheendofthemonthinwhichtheelectionismade.
(b)Contributionsshallbedueonamonthlybasisinadvancetothehealth
insurerorthehealthinsurer’sagent,andshallnotbemorethan102percentof
thegroupratefortheinsurancebeingcontinuedunderthegrouppolicyonthe
duedateofeachpayment.
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§ 4047c.TERMINATIONOFCOVERAGE
Continuationofinsuranceunderthegrouppolicyshallterminateuponthe
occurrenceofanyofthefollowing:
(1)Thedate18monthsafterthedatethatinsuranceunderthepolicy
wouldhaveterminatedduetoaqualifyingevent,asdefinedinsubsection
4047a(b)ofthistitle.
(2)Thepersonfailstomaketimelypaymentoftherequired
contribution.
(3)ThepersoniscoveredbyMedicare.
(4)Thepersoniscoveredbyanyothergroupinsuredoruninsured
arrangementthatprovidesdentalcoverageorhospitalandmedicalcoverage
forindividualsinagroup,underwhichthepersonwasnotcovered
immediatelypriortotheoccurrenceofaqualifyingevent,asdefinedin
subsection4047a(b)ofthistitle,andnopreexistingconditionexclusion
applies;provided,however,thatthepersonshallremaineligiblefor
continuationcoveragesthatarenotavailableundertheinsuredoruninsured
arrangement.
(5)Thedateonwhichthegrouppolicyisterminatedor,inthecaseof
anemployee,thedateonwhichthedecedent’sorterminatedemployee’s
employerterminatesparticipationunderthegrouppolicy.Ifsuchcoverageis
replacedbysimilarcoverageunderanothergrouppolicy:
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(A)thepersonshallhavetherighttobecomecoveredunderthat
replacementpolicyforthebalanceoftheperiodthatthepersonwouldhave
remainedcoveredunderthepriorgrouppolicy;
(B)theminimumlevelofbenefitstobeprovidedbythereplacement
policyshallbetheapplicablelevelofbenefitsofthepriorgrouppolicy
reducedbyanybenefitspayableunderthatpriorgrouppolicy;and
(C)thepriorgrouppolicyshallcontinuetoprovidebenefitstothe
extentofitsaccruedliabilitiesandextensionsofbenefitsasifthereplacement
hasnotoccurred.
Subchapter5.GroupHealthInsuranceTerminationandReplacement
§ 4048a.DEFINITIONS;POLICIESANDCONTRACTSCOVERED
(a)Asusedinthissubchapter,“grouphealthinsurancepolicyorsubscriber
contract”meansapolicyorcontractthatmeetsthefollowingconditions:
(1)coverageisprovidedthroughinsurancepoliciesorsubscriber
contractstoclassesofemployeesormembersofanorganizationorgroup;
(2)thecoverageisnotavailabletothegeneralpublicandcanbe
obtainedandmaintainedonlybecauseofthecoveredindividual’semployment
ormembershipinanorganizationorgroup;
(3)therearearrangementsforbulkpaymentofpremiumsor
subscriptionchargestothehealthinsurer;and
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(4)thereissponsorshipoftheplanbytheemployer,organization,or
group.
(b)Agrouphealthinsurancepolicyorsubscribercontractshallnotbe
issuedorprovidedbyahealthinsurerunlessthepolicyorcontractcomplies
withtheprovisionsofthissubchapterandtherulesadoptedpursuanttothis
subchapter.
§ 4048b.TERMINATIONFORNONPAYMENT OFPREMIUMOR
SUBSCRIPTIONCHARGES
(a)Ifagrouphealthinsurancepolicyorsubscribercontractprovidesfor
automaticterminationofthepolicyorcontractafterapremiumorsubscription
chargehasremainedunpaidthroughthegraceperiodallowedforsuch
payment,thehealthinsurershallbeliableforvalidclaimsforcoveredlosses
incurredpriortotheendofthegraceperiod.
(b)Iftheactionsofthehealthinsureraftertheendofthegraceperiod
indicatethatitconsidersthepolicyorcontracttobecontinuinginforce
beyondtheendofthegraceperiod,includingactionssuchascontinuingto
recognizeclaimssubsequentlyincurred,thehealthinsurershallbeliablefor
validclaimsforlossesincurredpriortotheeffectivedateofwrittennoticeof
terminationtothepolicyholderorotherentityresponsibleformaking
paymentsorsubmittingsubscriptionchargestothehealthinsurer.
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(c)Thehealthinsurershallnotifyapolicyholderorotherresponsibleentity
ofanypremiumpaymentdueonapolicyatleast21daysbeforetheduedate.
Theeffectivedateofterminationofapolicyorcontractshallnotbepriorto
midnightattheendofthe14thdayfollowingmailingofnoticeoftermination.
§ 4048c.NOTICEOFTERMINATION
(a)Anoticeofterminationofahealthinsurer’sgrouphealthinsurance
policyorsubscribercontractshall:
(1)requestthegrouppolicyholderorotherentityinvolvedtonotify
employeesormemberscoveredunderthepolicyorsubscribercontractofthe
dateofterminationofthepolicyorcontractandtoadvisetheemployeesor
membersthat,unlessotherwiseprovidedinthepolicyorcontract,thehealth
insurershallnotbeliableforclaimsforlossesincurredaftersuchdate;and
(2)advise,inanyinstanceinwhichtheplaninvolvesemployee
contributions,thatifthepolicyholderorotherentitycontinuestocollect
contributionsforthecoveragebeyondthedateoftermination,thepolicyholder
orotherentitymaybeheldsolelyliableforthebenefitswithrespecttowhich
thecontributionshavebeencollected.
(b)Thehealthinsurergivingnoticeofterminationshallprepareand
furnishtothepolicyholderorotherentityatthetimeofnoticeasupplyofa
noticeformtobedistributedtocoveredemployeesormembers.Theform
shallstatethefactofterminationandtheeffectivedateoftermination.The
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formshallcontainastatementdirectingemployeesormemberstorefertotheir
certificatesorcontractsinordertodeterminetheirrights.
§ 4048d.EXTENSIONOFBENEFITS
(a)Eachgrouphealthinsurancepolicyorsubscribercontractshallprovide
areasonableextensionofbenefitsintheeventthattheemployerormemberis
inaconditionoftotaldisabilityonthedateofterminationofthegrouppolicy
orcontractinaccordancewiththeprovisionsofthissection.
(b)Apolicyorcontractprovidingbenefitsforlossoftimefromworkor
specificindemnityduringhospitalconfinementshallprovidethattermination
ofthepolicyorcontractduringalossoftimeorconfinementshallhaveno
effectonbenefitspayableforthelossoftimeorconfinement.
(c)Apolicyorcontractprovidinghospitalormedicalexpensecoverage
benefitsshallprovideanextensionofbenefitsofatleast12monthsunder
majormedicalinsurancecoverageandatleast90daysunderothertypesof
hospitalormedicalexpensecoverage.
(d)Theprovisionsofapolicyorcontractrelatingtoextensionofbenefits
oraccruedliabilityshallbedescribedinthepolicyorcontractaswellasin
groupinsurancecertificates.Thebenefitspayableduringaperiodofextension
oraccruedliabilitymaybesubjecttothepolicy’sorcontract’sregularbenefit
limits.
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(e)Nothinginthissectionshallbeconstruedtorequireanextensionof
dentalbenefits.
§ 4048e.REPLACEMENT COVERAGE
(a)General.Whenthegrouphealthinsurancepolicyorsubscribercontract
ofahealthinsurerreplacesapolicyorcontractprovidingsimilarbenefitsof
anotherhealthinsurer,theliabilityofbothhealthinsurersshallbeasprovided
inthissectionandrulesadoptedpursuanttothissection.
(b)Liabilityofpriorhealthinsurer.Apriorhealthinsurerremainsliable
afterterminationofitspolicyorcontractonlytotheextentofitsaccrued
liabilitiesandextensionsofbenefits.
(c)Liabilityofsucceedinghealthinsurer.
(1)Asucceedinghealthinsurershallofferagrouphealthinsurance
policyorsubscribercontracttoreplaceapriorhealthinsurer’spolicyor
contractinaccordancewiththeprovisionsofthissubsection.
(2)Asucceedinghealthinsurershallofferapolicyorcontracttocover
allpersonswho:
(A)arecoveredorareamemberofaclasseligibleforcoverage
underthepriorhealthinsurer’spolicyorcontractonthedateofterminationof
thepriorhealthinsurer’spolicyorcontract;or
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(B)areamemberofaclasseligibleforcoverageunderthe
succeedinghealthinsurer’spolicyorcontractonthedateofterminationofthe
priorhealthinsurer’spolicyorcontract.
(3)Thesucceedinghealthinsurerisnotliableunderthissubsectionfor
benefitsrequiredtobepaidbythepriorhealthinsurer.
(4)Whenreplacingapriorhealthinsurer’splanthatisnotsubjectto
section4048dofthistitle,thesucceedinghealthinsurershall,inadditionto
thecoveragerequiredtobeofferedundersubdivision(2)ofthissubsection,
offerapolicyorcontractthatprovidesalevelofbenefitequaltothelesserof:
(A)theextensionofbenefitsthatwouldhavebeenrequiredifthe
priorhealthinsurer’spolicyorcontractwassubjecttosection4048dofthis
title;or
(B)theextensionofbenefitsrequiredforthesucceedinghealth
insurer’spolicyorcontract,exceptthatanysuchbenefitsmaybereducedby
benefitsactuallypayableunderthepriorhealthinsurer’splan.
(5)Thepreexistingconditionlimitationofasucceedinghealthinsurer’s
policyorcontractshallprovidealevelofbenefitsequaltothelesserof:
(A)thebenefitsofthesucceedinghealthinsurer’spolicyorcontract
determinedwithoutapplicationofthepreexistingconditionslimitation;or
(B)thebenefitsofthepriorhealthinsurer’spolicyorcontract.
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(6)Thesucceedinghealthinsurer,inapplyingadeductibleorwaiting-
periodprovisioninitspolicyorcontract,shallgivecreditforthesatisfaction
ofthesameorsimilarprovisionsunderthepriorhealthinsurer’spolicyor
contract.
(7)Atthesucceedinghealthinsurer’srequest,thepriorhealthinsurer
shallfurnishallinformationneededtodeterminethebenefitsavailableunder
thepriorhealthinsurer’spolicyorcontract.
(d)Rules.TheCommissionershalladoptrulesnecessarytocarryoutthe
purposesofthissection.
Subchapter6.OtherFormsofHealthCoverage
§ 4051.MEDICARESUPPLEMENTINSURANCEPOLICIES
(a)Communityrating.
(1)Ahealthinsurershalluseacommunityratingmethodacceptableto
theCommissionerfordeterminingpremiumsforMedicaresupplement
insurancepolicies.
(2)TheCommissionershalladoptrulesforstandardsandprocedurefor
permittinghealthinsurersthatissueMedicaresupplementinsurancepoliciesto
useoneormoreriskclassificationsintheircommunityratingmethod.The
premiumchargedshallnotdeviatefromthecommunityrateandtherulesshall
notpermitmedicalunderwritingandscreening,exceptthatahealthinsurer
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maysetdifferentcommunityratesforpersonseligibleforMedicarebyreason
ofageandpersonseligibleforMedicarebyreasonofdisability.
(b)Premiumincreases.
(1)Withinfivedaysafterreceivingarequestforapprovalofany
compositeaveragerateincreaseinexcessofthreepercent,oranyother
coveragechangesthattheCommissionerdetermineswillhaveacomparable
impactoncostoravailabilityofcoverageforaMedicaresupplementinsurance
policyissuedbyanyhealthinsurerwith5,000ormoretotallivesinthe
VermontMedicaresupplementinsurancemarket,theCommissionershall
notifytheDepartmentofDisabilities,Aging,andIndependentLivingofthe
proposedpremiumincrease.Acompositeaveragerateistheenrollment-
weightedaveragerateincreaseofallplansofferedbyahealthinsurer.
(2)Withinfivedaysafterreceivingnotificationpursuanttosubdivision
(1)ofthissubsection,theDepartmentofDisabilities,Aging,andIndependent
LivingshallinformthemembersoftheAdvisoryBoardestablishedpursuant
to33V.S.A.§505oftheproposedpremiumincrease.
(3)(A)TheCommissionershallnotapproveanyrequesttoincrease
Medicaresupplementinsurancepremiumratesunlesstheamountoftherate
increasecomplieswiththestatutorystandardsforapprovalundersections
4026,4513,4584,and5104ofthistitle.Anyapprovedrateincreaseshallnot
bebasedonanunreasonablechangeinlossratiofromthepreviousyear,unless
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theCommissionermakeswrittenfindingsthatsuchchangeisnecessaryto
preventasubstantialadverseimpactonthefinancialconditionofthehealth
insurer.Inactingonsuchrateincreaserequests,theCommissionermaydeny
therequest,approvetherateincreaseasrequested,orapprovearateincrease
inanamountdifferentfromtheincreaserequested.Adecisionbythe
Commissionerotherthananapprovaloftheraterequestedmaybeappealedby
thehealthinsurer,providedthattheburdenofproofshallbeonthehealth
insurertoshowthattheapprovedratedoesnotmeetthestatutorystandards
establishedunderthissubsection.
(B)Beforeactingontherateincreaserequested,theCommissioner
maymakesuchexaminationorinvestigationastheCommissionerdeems
necessary,includingwhereapplicablethereviewprocesssetforthin
subdivision(C)ofthissubdivision(3).
(C)(i)InreviewinganyMedicaresupplementinsurancerateincrease
forwhichanindependentanalysishasbeenperformedpursuantto33V.S.A.
§ 6706andinwhichthehealthinsurer’srequestedcompositeaverageincrease,
theindependentexpert’srecommendedcompositeaveragerateincrease,orthe
Departmentactuary’srecommendedcompositeaveragerateincreasedifferby
twopercentagepointsormore,theCommissionershallholdapublichearing
atwhichthehealthinsurer,theDepartment’sactuary,theindependentexpert,
anyintervenor,andthepublicwillhavetheopportunitytopresentwrittenand
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oraltestimonyandwillbeavailabletoanswerquestionsoftheCommissioner
andthosepresent.
(ii)Thehearingshallbenoticedandheldatatimeandplacesoas
tofacilitatepublicparticipation,andshallberecordedandbecomepartofthe
recordbeforetheCommissioner.AttheCommissioner’sdiscretion,the
hearingmaybeconductedremotely.
(iii)Ifthecarrier’srequestedcompositeaverageincrease,the
independentexpert’srecommendedcompositeaverageincrease,orthe
Departmentactuary’srecommendedcompositeaverageincreasediffersbyless
thantwopercentagepoints,theDepartmentandthepartiesshallconferby
conferencecall,orbyanyotheravailablemedia,toreviewtheraterequests
andrecommendations.However,apublichearingmaybeheldatthe
Commissioner’sdiscretionforgoodcauseshown.
(D)(i)Inanyreviewheldinaccordancewiththissubdivision(3),the
Commissionershallpermitinterventionbyanypersonwhomthe
Commissionerdetermineswillmateriallyadvancetheinterestsofthecovered
individuals.Theintervenorshallhaveaccesstoandmayusetheinformation
oftheindependentexpertappointedunder33V.S.A.§6706.
(ii)Thereasonableandnecessarycostofinterventionas
determinedbytheCommissionershallbepaidbytheaffectedpolicyholdersor
certificateholders.Themaximumpaymentshallbe$2,500.00exceptwhen
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waivedbytheCommissionerforgoodcauseshown.The$2,500.00maximum
amountmaybeadjustedtoreflect,attheCommissioner’sdiscretion,
appropriateinflationfactors.
(E)Nonproprietary,relevantinformationinanyMedicare
supplementinsuranceratefiling,includinganyanalysisbytheDepartment’s
actuaryandtheindependentexpert,shallbemadeavailabletothepublicupon
request.
(c)Disability.
(1)AhealthinsurerthatissuesMedicaresupplementinsurancepolicies
orcertificatestoapersoneligibleforMedicarebyreasonofageshallmake
available,topersonseligibleforMedicarebyreasonofdisability,thesame
policiesorcertificatesthatareofferedandsoldtopersonseligiblefor
Medicarebyreasonofage.Theinitialenrollmentperiodforanysuchpolicies
orcertificatesshallbeatleastsixmonthsfollowingthedatetheindividual
becomeseligibleforMedicarebyreasonofdisability.Anyadditional
enrollmentperiodsasrequiredbylawandofferedtoindividualseligibleby
reasonofageshallbeofferedtoindividualseligiblebyreasonofdisability.
(2)ThissubsectiondoesnotapplytopersonseligibleforMedicareby
reasonofendstagerenaldisease.
(d)Outreachandeducation.TheDepartmentofFinancialRegulationshall
collaboratewithhealthinsurers,advocatesforolderVermontersandforother
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Medicare-eligibleadults,andtheOfficeoftheHealthCareAdvocateto
educatethepublicaboutthebenefitsandlimitationsofMedicaresupplement
insurancepoliciesandMedicareAdvantageplans,includinginformationto
helpthepublicunderstandissuesrelatingtocoverage,costs,andprovider
networks.
§ 4052.BLANKETHEALTHINSURANCE
(a)Blankethealthinsuranceisaformofhealthinsurancethat,totheextent
permittedunderfederallaw,issupplementaltomajormedicalhealthinsurance
orprovidescoverageotherthanthepaymentofalloraportionofthecostof
healthcareservicesorproducts,andthatcoversspecialgroupsofpersonsas
follows:
(1)underapolicyorcontractissuedtoanycommoncarrier,whichshall
bedeemedthepolicyholder,coveringagroupdefinedasallpersonswhomay
becomepassengersonsuchcommoncarrier;
(2)underapolicyorcontractissuedtoanemployer,whoshallbe
deemedthepolicyholder,coveringanygroupofemployeesdefinedby
referencetoexceptionalhazardsincidenttosuchemployment;
(3)underapolicyorcontractissuedtoapublicschool,independent
school,orapprovededucationprogram,asthosetermsaredefinedin
16 V.S.A.§ 11;toapostsecondaryschool,asdefinedin16V.S.A.§ 176(b)(1);
ortoaprequalifiedprivateprekindergartenprovider,asdefinedin16V.S.A.
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§ 829(a)(3),ortotheheadorprincipaloftheschool,program,orprovider,
whoorwhichshallbedeemedthepolicyholder,coveringstudentsorteachers,
orboth;
(4)underapolicyorcontractissuedinthenameofanyvolunteerfire
department,emergencymedicalservicesprovider,orothersuchvolunteer
group,whichshallbedeemedthepolicyholder,coveringallofthemembersof
thedepartmentorgroupinconnectionwiththeirdepartmentorgroup
activities;or
(5)underapolicyorcontractissuedtoanyothersubstantiallysimilar
groupthat,inthediscretionoftheCommissionerandafterthepriorapproval
bytheCommissionerofthegroup,maybesubjecttotheissuanceofablanket
healthpolicyorcontract.
(b)(1)Noblankethealthinsurancepolicyshallcontainanyprovision
relatingtonoticeofclaim,proofsofloss,timeofpaymentofclaims,ortime
withinwhichlegalactionmustbebroughtuponthepolicythat,intheopinion
oftheCommissioner,islessfavorabletothepersonsinsuredthanwouldbe
permittedbytheprovisionssetforthinsection4029ofthistitle.
(2)Anindividualapplicationshallnotberequiredfromaperson
coveredunderablankethealthpolicyorcontract,norshallitbenecessaryfor
theinsurertofurnisheachpersonacertificate.
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(3)Allbenefitsunderanyblankethealthpolicyshall,unlessforhospital
andphysicianserviceorsurgicalbenefits,bepayabletothepersoninsured,or
totheperson’sdesignatedbeneficiaryorbeneficiaries,ortotheperson’s
estate,exceptthatifthepersoninsuredisaminor,thebenefitsmaybemade
payabletotheminor’sparent,guardian,orotherpersonactuallysupporting
theminor.
(4)Nothinginthissectionshallbedeemedtoaffectthelegalliabilityof
policyholdersforthedeathof,orinjuryto,anymembersofthegroup.
(c)Noblankethealthinsurancepolicythatprovidescoverageforthe
paymentofalloraportionofthecostofhealthcareservicesorproductsshall
containanyprovisionthatdoesnotcomplywitharequirementofthistitle,or
aruleadoptedpursuanttothistitleapplicabletohealthinsurance,otherthan
thoserequirementsapplicabletonongrouphealthinsuranceorsmallgroup
healthinsurance.TheCommissionermaywaivetheapplicationtoablanket
insurancepolicyofoneormoreofthehealthinsurancerequirementsofthis
title,oraruleadoptedpursuanttothistitle,iftherequirementisnotrelevant
tothetypesofrisksanddurationofrisksinsuredagainstintheblanket
insurancepolicy.
§ 4053.SHORT-TERM,LIMITED-DURATIONHEALTHINSURANCE
(a)Asusedinthissection,“short-term,limited-durationhealthinsurance”
meanshealthinsurancethatprovidesmedical,hospital,ormajormedical
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expensebenefitscoveragepursuanttoapolicyorcontractwithahealthinsurer
andthathasanexpirationdatespecifiedinthepolicyorcontractthatisthree
monthsorlessaftertheoriginaleffectivedateofthepolicyorcontract.
(b)Nopersonshallprovideshort-term,limited-durationhealthinsurance
coveragewithoutacertificateofauthorityfromtheCommissionertooffer
healthinsuranceinthisStateunlessthepersonisexemptedbysubdivision
3368(a)(4)ofthistitle.
(c)Ashort-term,limited-durationhealthinsurancepolicyorcontractshall
benonrenewable,andahealthinsurershallnotissueashort-term,limited-
durationhealthinsurancepolicyorcontracttoanypersoniftheissuance
wouldresultinthepersonbeingcoveredbyshort-term,limited-durationhealth
insurancecoverageformorethanthreemonthsinany12-monthperiod.
(d)Apolicyorcontractforshort-term,limited-durationhealthinsurance
coverageshalldisplayprominentlyinthepolicyorcontractandinany
applicationmaterialsprovidedinconnectionwithenrollmentinthatcoverage,
inatleast14-pointtype,certaindisclosuresregardingthescopeofshort-term,
limited-durationhealthinsurancecoverage,includingthetypesofbenefitsand
consumerprotectionsthatareandarenotincluded.TheCommissionershall
determinethespecificdisclosurelanguagethatshallbeusedinallshort-term,
limited-durationhealthinsurancepolicies,contracts,andapplicationmaterials
andshallprovidethelanguagetothehealthinsurersofferingthatcoverage.
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(e)TheCommissionershalladoptrulespursuantto3V.S.A.chapter25:
(1)establishingtheminimumfinancial,marketing,service,andother
requirementsforregistrationofahealthinsurertoprovideshort-term,limited-
durationhealthinsurancecoveragetoindividualsinthisState;
(2)requiringahealthinsurerseekingtoprovideshort-term,limited-
durationhealthinsurancecoveragetoindividualsinthisStatetofileitsrates
andformswiththeCommissionerfortheCommissioner’sapproval;
(3)requiringahealthinsurerseekingtoprovideshort-term,limited-
durationhealthinsurancecoveragetoindividualsinthisStatetofileits
advertisingmaterialswiththeCommissionerfortheCommissioner’sapproval;
and
(4)establishingsuchotherrequirementsastheCommissionerdeems
necessarytoprotectVermontconsumersandpromotethestabilityof
Vermont’shealthinsurancemarkets.
(f)Theprovisionsofsection4063ofthistitle,andanyrulesadoptedunder
thatsection,shallapplytoshort-term,limited-durationhealthinsurance
coverage.
Subchapter7.ChildandDependentCoverage
§ 4057.COVERAGEOFCHILDREN
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(a)Definition.“Healthinsuranceplan”hasthesamemeaningasinsection
4011ofthischapterandshallbesubjecttothesameexceptedbenefits,ineach
case,assetforthin45C.F.R.§146.145,asineffectasofDecember31,2017.
(b)Newborncoverage.
(1)Ahealthinsuranceplanthatprovidesdependentcoverageof
childrenshallalsoprovidethathealthinsurancebenefitsapplicabletochildren
arepayablewithrespecttoanewlybornchildoftheinsuredorsubscriber
fromthemomentofbirth.Coverageforanewlybornchildshallinclude
coverageofinjury,sickness,andnecessarycareandtreatmentofmedically
diagnosedcongenitaldefectorbirthabnormality.
(2)Coverageforanewlybornchildshallbeprovidedwithoutnoticeor
additionalpremiumfornotlessthan60daysafterthedateofbirth.If
paymentofaspecificpremiumorsubscriptionfeeisrequiredinordertohave
thecoveragecontinuebeyondsuch60-dayperiod,thepolicymayrequirethat
notificationofthebirthofthenewlybornchildandpaymentoftherequired
premiumorfeesbefurnishedtothehealthinsurerwithinaperiodofnotless
than60daysafterthedateofbirth.
(c)Adoptedchildcoverage.
(1)Asusedinthissection:
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(A)“Child”means,inconnectionwithanyadoptionorplacementfor
adoptionofthechild,anindividualwhohasnotattained18yearsofageasof
thedateoftheadoptionorplacementforadoption.
(B)“Placementforadoption”meanstheassumptionandretentionby
apersonofalegalobligationfortotalorpartialsupportofachildin
anticipationoftheadoptionofthechild.Thechild’splacementwithaperson
terminatesupontheterminationofsuchlegalobligations.
(2)Inanycaseinwhichahealthinsuranceplanprovidescoveragefor
dependentchildrenofcoveredindividuals,theplanshallprovidebenefitsto
dependentchildrenplacedwithcoveredindividualsforadoptionunderthe
sametermsandconditionsasapplytothenatural,dependentchildrenofthe
coveredindividuals,irrespectiveofwhethertheadoptionhasbecomefinal.
(3)Ahealthinsuranceplanshallnotrestrictcoverageundertheplanof
anydependentchildadoptedbyacoveredindividual,orplacedwithacovered
individualforadoption,solelyonthebasisofapreexistingconditionofthe
childatthetimethatthechildwouldotherwisebecomeeligibleforcoverage
undertheplan,iftheadoptionorplacementforadoptionoccurswhilethe
coveredindividualiseligibleforcoverageundertheplan.
(d)Coveragerequireduntil26yearsofage.Ahealthinsuranceplanthat
providesdependentcoverageofchildrenshallcontinuetomakethatcoverage
availableforanadultchilduntilthechildattains26yearsofage,providedthat
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thissubsectionshallnotapplytoaplanprovidingcoverageforaspecified
diseaseorotherlimitedbenefitcoverage,andfurtherprovidedthatnothingin
thissubsectionshallrequireaplantomakecoverageavailableforthechildof
achildreceivingdependentcoverage.
(e)Coverageofadultchildwithadisability.
(1)Ahealthinsuranceplanthatprovidesforterminatingthecoverageof
adependentchilduponattainmentofthelimitingagefordependentchildren
specifiedinthepolicyshallnotlimitorrestrictcoveragewithrespecttoan
unmarriedchildwhomeetsallofthefollowingcriteria:
(A)isincapableofself-sustainingemploymentbyreasonofamental
orphysicaldisabilitythathasbeenfoundtobeadisabilitythatqualifiesor
wouldqualifythechildforbenefitsusingthedefinitions,standards,and
methodologyin20C.F.R.Part404,SubpartP;
(B)becamesoincapablepriortoattainmentofthelimitingage;and
(C)ischieflydependentupontheemployee,member,subscriber,or
policyholderforsupportandmaintenance.
(2)Coverageundersubdivision(1)ofthissubsectionshallnotbe
deniedanypersonbasedupontheexistenceofsuchacondition;provided,
however,thatahealthinsuranceplanmayrequirereasonableperiodicproofof
acontinuingconditionnotmorefrequentlythanonceeveryyear.
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(f)Coverageofleaveofabsencefromcollege.Ahealthinsuranceplan
thatcoversdependentchildrenwhoarefull-timecollegestudentsbeyond18
yearsofageshallincludecoverageforadependent’smedicallynecessary
leaveofabsencefromschoolforaperiodnottoexceed24monthsorthedate
onwhichcoveragewouldotherwiseendpursuanttothetermsandconditions
ofthepolicyorcoverage,whichevercomesfirst,exceptthatcoveragemay
continueundersubsection(b)ofthissectionasappropriate.Toestablish
entitlementtocoverageunderthissubsection,documentationandcertification
bythestudent’streatinghealthcareprofessionalofthemedicalnecessityofa
leaveofabsenceshallbesubmittedtothehealthinsureror,forself-insured
plans,thehealthplanadministrator.Thehealthinsuranceplanmayrequire
reasonableperiodicprooffromthestudent’streatinghealthcareprofessional
thattheleaveofabsencecontinuestobemedicallynecessary.
(g)Parentalrights.Whenachildhashealthcoveragethroughthehealth
insurerofaparent,thehealthinsurershall:
(1)providesuchinformationtoeitherparentasmaybenecessaryfor
thechildtoobtainbenefitsthroughthatcoverage;
(2)permiteitherparent,aproviderwithparentalauthorization,theState
Medicaidagencyasassignee,oranyStateagencyadministeringhealth
benefitsorahealthbenefitplanforwhichMedicaidisasourceoffundingto
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submitclaimsforcoveredservices,andtoappealthedenialofanybenefit,
withouttheapprovaloftheotherparent;and
(3)makepaymentsonclaimssubmittedinaccordancewithsubdivision
(2)ofthissubsectiondirectlytotheparentwhopaidtheprovider,theprovider
asassignee,theStateMedicaidagency,oranyStateagencyadministering
healthbenefitsorahealthbenefitplanforwhichMedicaidisasourceof
funding.
(h)Childvaccinecoverage.Nohealthinsurershallreduceitscoveragefor
pediatricvaccinesbelowthecoverageprovidedasofMay1,1993.
§ 4058.MEDICALSUPPORTORDERS
(a)Asusedinthissection:
(1)“Dependentcoverage”meansfamilycoverage,orcoverageforone
ormorepersonsaslongasthecoverageforoneormorepersonsisgreaterthan
orequaltothecoverageavailableunderfamilycoverage.
(2)“Healthinsuranceplan”hasthesamemeaningasinsection4011of
thischapterandshallbesubjecttothesameexceptedbenefits,ineachcase,as
setforthin45C.F.R.§146.145,asineffectasofDecember31,2017.
(b)Ahealthinsurershallnotdenyenrollmentofachildunderthehealth
insuranceplanofthechild’sparentwhoisorderedtoprovidemedicalsupport
onthegroundsthat:
(1)thechildwasborntounmarriedparents;
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(2)thechildisnotclaimedasadependentontheparent’sfederaltax
return;or
(3)thechilddoesnotresidewiththeparentorinthehealthinsurer’s
servicearea.
(c)Whenaparentisrequiredbyacourtoradministrativeordertoprovide
healthcoverageforachild,andtheparentiseligiblefordependenthealth
coverage,thehealthinsurershallberequired:
(1)Toenroll,underthedependentcoverage,achildwhoisotherwise
eligibleforthecoveragewithoutregardtoanyenrollmentseasonrestrictions
oranyseasonalrestrictionsonswitchingfromoneplantoanother,upon
applicationofeitherparent,theemployer,theStateagencyadministeringthe
Medicaidprogram,anyStateagencyadministeringhealthbenefitsorahealth
insuranceplanforwhichMedicaidisasourceoffunding,orthechildsupport
enforcementprogram.
(2)Nottodisenrolloreliminatecoverageofthechildunlessthehealth
insurerisprovidedsatisfactorywrittenevidencethat:
(A)thecourtoradministrativeorderisnolongerineffect;
(B)thechildisorwillbeenrolledincomparablehealthcoverage
throughanotherhealthinsurerthatwilltakeeffectnotlaterthantheeffective
dateofdisenrollment;or
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(C)theemployerhaseliminateddependenthealthcoverageforallof
itsemployeesifallowedbylaw.
(3)Toprovideenrollmentundersubdivision(1)ofthissubsectionwith
coverageeffectivethreedaysafterthemailingofnoticeofthecourtor
administrativeordertothehealthinsureroruponactualreceiptofnoticeby
thehealthinsurer,whicheverissooner.Thehealthinsurershallhave10days
fromnoticetoprocesstheenrollmentandshallbeentitledtopremiumsfrom
theeffectivedateofenrollment.
(d)AhealthinsurershallnotimposerequirementsonaStateagencythat
hasbeenassignedtherightsofanindividualeligibleformedicalassistance
underMedicaidandcoveredforhealthbenefitsfromthehealthinsurerthatare
differentfromrequirementsapplicabletoanagentorassigneeofanyother
individualsocovered.
(e)Anyhealthinsurerthatfailstoenrollachildafternoticeunder
15 V.S.A.§663(d)or33V.S.A.§4110(a)(4)shallbedirectlyliableforany
medicalexpensesofthechildthatwouldhavebeencoveredunderthehealth
insuranceplanhadthehealthinsurerenrolledthechilduponreceivingnotice.
(f)Noticebyfirstclassmail,postageprepaid,orbyanyothermethod
showingactualreceipt,shallbepresumptiveevidenceofitsreceiptbythe
healthinsurertowhomitisaddressed.Anyperiodoftimethatisdetermined
underthissectionbythegivingofnoticeshallcommencetorunfromthedate
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ofmailing,ifthenoticeismailed,orthedateofactualreceiptifanother
methodoftransmittingthenoticeisused.
(g)Ahealthinsurermaycancelanyhealthinsuranceplanthatisthe
subjectofamedicalsupportorderfornonpaymentofpremiumonlyifthe
healthinsurermailsordeliversnoticeofcancellationtobothparentsandall
otherpersonsoragenciesidentifiedinthemedicalsupportorder.Anyhealth
insurercancellingahealthinsuranceplanfornonpaymentofpremiumshall
reinstatethehealthinsuranceplaneffectivefromthedateofcancellationifthe
nonpaymentofpremiumiscuredwithin45daysofthecancellation.
§ 4059.COVERAGEFORCIVILUNIONS
(a)Asusedinthissection:
(1)“Dependentcoverage”meansfamilycoverageorcoverageforone
ormorepersons.
(2)“Partytoacivilunion”hasthesamemeaningasin15V.S.A.
§ 1201.
(b)Notwithstandinganyprovisionoflawtothecontrary,healthinsurers
shallprovidedependentcoveragetopartiestoacivilunionthatisequivalent
tothatprovidedtocoveredindividualswhoaremarried.Ahealthinsurance
policythatprovidescoverageforaspouseorfamilymemberofthecovered
individualshallalsoprovidetheequivalentcoverageforapartytoacivil
union.
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§ 4060.COVERAGEFOREMPLOYEESOFANEMPLOYER
DOMICILEDOUTSIDEVERMONT
(a)Asusedinthissection:
(1)“Marriage”hasthesamemeaningasin15V.S.A.§8.
(2)“Partytoacivilunion”hasthesamemeaningasin15V.S.A.§
1201.
(b)Totheextentpermittedunderfederallaw,healthinsurancecoverage
providedtoVermontresidentswhoworkforanemployerdomiciledoutside
Vermontshallnotdistinguishbetweenpartiestoacivilunion,marriedsame-
sexcouples,andmarriedopposite-sexcouples.
Subchapter8.InternalandExternalReviews
§ 4063.INDEPENDENTEXTERNALREVIEWOFHEALTHCARE
SERVICEDECISIONS
(a)Asusedinthissection,“coveredindividual”includesamemberofa
healthinsuranceplannototherwisesubjecttotheDepartment’sjurisdiction
thathasvoluntarilyagreedtousetheexternalreviewprocessprovidedunder
thissection.
(b)Acoveredindividualwhohasexhaustedallapplicableinternalreview
proceduresprovidedbythehealthinsuranceplanshallhavetherighttoan
independentexternalreviewofadecisionunderahealthinsuranceplanto
deny,reduce,orterminatehealthcarecoverageortodenypaymentfora
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healthcareservice.Theindependentreviewshallbeavailablewhenrequested
inwritingbytheaffectedcoveredindividual,providedthedecisiontobe
reviewedrequirestheplantoexpendatleast$100.00fortheserviceandthe
decisionbytheplanisbasedononeofthefollowingreasons:
(1)Thehealthcareserviceisacoveredbenefitthatthehealthinsurer
hasdeterminedtobenotmedicallynecessary.
(2)Alimitationisplacedontheselectionofahealthcareproviderthat
isclaimedbythecoveredindividualtobeinconsistentwithlimitsimposedby
thehealthinsuranceplanandanyapplicablelawsandrules.
(3)Thehealthcaretreatmenthasbeendeterminedtobeexperimentalor
investigationalorisanoff-labeldrug.Ahealthinsuranceplanthatdeniesuse
ofaprescriptiondrugforthetreatmentofcancerasnotmedicallynecessaryor
asanexperimentalorinvestigationaluseshalltreatanyinternalappealofsuch
denialasanemergencyorurgentappealandshalldecidetheappealwithinthe
timeframesapplicabletoemergencyandurgentinternalappealsunderrules
adoptedbytheCommissioner.
(4)Thehealthcareserviceinvolvesamedicallybaseddecisionthata
conditionispreexisting.
(5)Thedecisioninvolvesanadversedeterminationrelatedtosurprise
medicalbilling,asestablishedunderSection2799A-1or2799A-2ofthe
PublicHealthServiceAct,includingwithrespecttowhetheranitemorservice
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thatisthesubjectoftheadversedeterminationisanitemorservicetowhich
Section2799A-1or2799A-2ofthePublicHealthServiceAct,orboth,
applies.
(c)Therighttoreviewunderthissectionshallnotbeconstruedtochange
thetermsofcoverageunderahealthinsuranceplan.
(d)TheDepartmentshalladoptrulesnecessarytocarryoutthepurposesof
thissection.Therulesshallensurethattheindependentexternalreviewshave
thefollowingcharacteristics:
(1)Theindependentexternalreviewsshallbeconducted:
(A)byindependentrevieworganizationspursuanttoacontractwith
theDepartment,andthereviewersshallincludehealthcareproviders
credentialedwithrespecttothehealthcareserviceunderreviewandshallhave
noconflictofinterestrelatingtotheperformanceoftheirdutiesunderthis
section;and
(B)inaccordancewithstandardsofdecisionmakingbasedon
objectiveclinicalevidence,shallresolveallissuesinatimelymanner,and
shallprovideexpeditedresolutionwhenthedecisionrelatestoemergencyor
urgenthealthcareservices.
(2)Acoveredindividualshall:
(A)Beprovidedwithadequatenoticeofthecoveredindividual’s
reviewrightsunderthissection.
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(B)Havetherighttouseoutsideassistanceduringthereviewprocess
andtosubmitevidencerelatingtothehealthcareservice.
(C)Payanapplicationfeeof$25.00foreachrequestforan
independentexternalreviewofanappealabledecisionnottoexceedatotalof
$75.00annually.Theapplicationfeemaybewaivedorreducedbasedona
determinationbytheCommissionerthatthefinancialcircumstancesofthe
coveredindividualwarrantawaiverorreduction.Theapplicationfeeshallbe
paidbythehealthinsurer,notthecoveredindividual,iftheindependent
revieworganizationreversesthehealthinsurer’sdecisiontodenypaymentfor
ahealthcareservice.
(D)Beprotectedfromretaliationforexercisingthecovered
individual’srighttoanindependentexternalreviewunderthissection.
(3)Othercostsoftheindependentreviewshallbepaidbythehealth
insuranceplan.
(4)Theindependentrevieworganizationshallissuetobothpartiesa
writtenreviewdecisionthatisevidence-based.Thedecisionshallbebinding
onthehealthinsuranceplan.
(5)Theconfidentialityofanyhealthcareinformationacquiredor
providedtotheindependentrevieworganizationshallbemaintainedin
compliancewithanyapplicableStateorfederallaws.
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(6)Therecordsof,andinternalmaterialspreparedfor,specificreviews
byanyindependentrevieworganizationunderthissectionshallbeexempt
frompublicinspectionandcopyingunderthePublicRecordsAct.
(e)Decisionsrelatingtothefollowinghealthcareservicesshallnotbe
reviewedunderthissectionbutshallbereviewedbythereviewprocess
providedbylaw:
(1)healthcareservicesprovidedbytheVermontMedicaidprogramor
Medicaidbenefitsprovidedthroughacontractedhealthplan;and
(2)healthcareservicesprovidedtoincarceratedindividualsbythe
DepartmentofCorrections.
§ 4064.MENTALHEALTHSERVICESREVIEW
(a)Thepurposesofthissectionareto:
(1)promotethedeliveryofqualitymentalhealthservicesinacost-
effectivemanner;
(2)fosterthepracticeofmentalhealthservicesreviewasaprofessional
collaborativeprocess,theprimaryobjectiveofwhichistoenhancethe
effectivenessofclinicaltreatment;
(3)protectclientsandpatients,employers,andmentalhealthproviders
byensuringthatreviewagentsarequalifiedtoperformservicereview
activitiesandtomakeinformeddecisionsontheappropriatenessofmental
healthcare;and
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(4)ensuretheconfidentialityofclients’andpatients’mentalhealth
recordsintheperformanceofservicereviewactivitiesinaccordancewith
applicableStateandfederallaws.
(b)Definitions.Asusedinthissection:
(1)“License”meansareviewagent’slicensegrantedbythe
Commissioner.
(2)“Mentalhealthprovider”meansanyindividual,corporation,facility,
orinstitutioncertifiedorlicensedbythisStatetoprovidementalhealth
services,includingaphysician,nursewithrecognizedpsychiatricspecialties,
hospitalorotherhealthcarefacility,psychologist,clinicalsocialworker,
mentalhealthcounselor,alcoholordrugabusecounselor,oranemployeeor
agentofsuchmentalhealthprovideractinginthecourseandscopeof
employmentoranagencyrelatedtomentalhealthservices.
(3)“Mentalhealthservices”meanactsofdiagnosis,treatment,
evaluation,oradviceoranyotheractspermissibleunderthehealthcarelaws
ofVermont,whetherperformedinanoutpatientorinstitutionalsetting,and
includetreatmentforsubstanceusedisorder.
(4)“Reviewagent”meansapersonorentityperformingservicereview
activitieswithinoneyearfollowingthedateofsubmissionofafullycompliant
applicationforlicensurewhoisaffiliatedwith,undercontractwith,oracting
onbehalfofabusinessentityinthisStateandwhoprovidesoradministers
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mentalhealthbenefitstomembersofhealthinsuranceplanssubjecttothe
Department’sjurisdiction,includingahealthinsurer.
(5)“Servicereview”meansanysystemforreviewingtheappropriate
andefficientallocationofmentalhealthservicesgivenorproposedtobegiven
toaclientorpatient,ortoagroupofclientsorpatients,forthepurposeof
recommendingordeterminingwhethertheservicesshouldbecoveredand
includesactivitiesofutilizationreviewandmanagedcare,butdoesnotinclude
professionalpeerreviewthatdoesnotaffectreimbursementfororprovisionof
services.
(c)Anypersonwhoapprovesordeniespayment,orwhorecommends
approvalordenialofpayment,formentalhealthservices,orwhosereview
resultsinapprovalordenialofpaymentformentalhealthservicesonacase-
by-casebasis,shallnotreviewtheseservicesinthisStateunlessthe
Commissionerhasgrantedthepersonareviewagent’slicense.The
Commissionershalladoptrulestoimplementtheprovisionsofthissection,
includingtheproceduresandstandardsforlicensure.Therulesshall
differentiatebetweenhealthmaintenanceorganizationslicensedtodobusiness
withinthisStateandotherformsofutilizationreview.Therulesshall
establish:
(1)Arequirementthatwithin10businessdaysafterreceivingarequest
forthem,thereviewagentshallmakeavailableatnocosttotheclients,
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patients,andprovidersaffectedbyitsservicereviewactivitiesthespecific
reviewcriteriaandstandards,credentialsofthereviewingprofessionals,and
proceduresandmethodstobeusedinevaluatingproposedordeliveredmental
healthservices.
(2)Atimeperiodwithinwhichanydeterminationregardingthe
provisionorreimbursementofmentalhealthservicesshallbemade.
(3)Arequirementthatanydeterminationregardingmentalhealth
servicesrenderedortoberenderedtoaclientorpatientthatmayresultina
denialofthird-partyreimbursementoradenialofprecertificationforthat
serviceshallincludetheevaluation,findings,andconcurrenceofamental
healthprofessionalwhosetrainingandexpertiseisatleastcomparabletothat
ofthetreatingmentalhealthprovider.
(4)Thetype,qualifications,andnumberofpersonnelrequiredto
performservicereviewactivities.
(5)Arequirementthatadeterminationbyareviewagentthatcare
renderedortoberenderedisinappropriateshallnotbemadeuntilthereview
agenthascommunicatedwiththepatient’sattendingmentalhealthprovider
concerningthatcare.Thereviewshallbeprospectiveorconcurrentwiththe
treatment.
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(6)Arequirementthatanydeterminationthatcarerenderedortobe
renderedisinappropriateshallincludethewrittenevaluationandfindingsof
thereviewagent.
(7)Aprocedureforclients,patients,mentalhealthproviders,and
hospitalstoseekpromptreconsiderationbeforeanindependentreview
organizationpursuanttosection4063ofthistitleofanadversedecisionbya
reviewagent.Theexternalreviewerengagedbytheindependentreview
organizationshallhavetrainingandexpertiseatleastcomparabletothatofthe
treatinghealthcareprovider.
(8)PoliciesandprocedurestoensurethatallapplicableStateand
federallawstoprotecttheconfidentialityofindividualmentalhealthrecords
arefollowed.
(9)Policiesandproceduresthatensureappropriatenotificationand
concurrenceofprovidersandtheirclientsorpatientsbeforeclientorpatient
interviewsareconductedbythereviewagent.
(10)(A)Prohibitionofanagreementbetweenthereviewagentanda
businessentityorthird-partypayorinwhichpaymenttothereviewagent
includesanincentiveorcontingentfeearrangementbasedonthereductionof
mentalhealthservices,reductionoflengthofstay,reductionoftreatment,or
treatmentsettingselected.
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(B)Nothinginthissubdivision(10)shallprohibitcapitation
arrangementsforreimbursementformentalhealthservices.
(C)Aclinicaldecisionmadebytheattendingmentalhealthprovider
regardingcontinuedtreatmentshallnotbeconstruedasadenialofservices
subjecttotheprovisionsofthissection.
(d)Reviewingagentsshallbesubjecttotheprovisionsofchapter129of
thistitlegoverningunfairinsurancetradepractices.
(e)TheCommissionershallhavetheauthoritytoexamine,take
administrativeactionagainst,andpenalizereviewagentsasprovidedin
chapters3,101,and129ofthistitle.Apersonwhoviolatesanyprovisionof
thissectionorwhosubmitsanyfalseinformationinanapplicationrequiredby
thissectionmaybefinednotmorethan$5,000.00foreachviolation.
(f)Areviewagentshallpayalicensefeeof$200.00fortheyearof
registrationandarenewalfeeof$200.00foreachyearthereafter.Inaddition,
areviewagentshallpayanyadditionalexpensesincurredbythe
Commissionertoexamineandinvestigateanapplicationoranamendmentto
anapplication.
(g)Theconfidentialityofanyhealthcareinformationacquiredbyor
providedtoanindependentrevieworganizationpursuanttosection4063of
thistitleshallbemaintainedincompliancewithanyapplicableStateorfederal
laws.Recordsof,andinternalmaterialspreparedfor,specificreviewsunder
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thissectionshallbeexemptfrompublicinspectionandcopyingunderthe
PublicRecordsAct.
Subchapter9.RequiredCoveredBenefits
§ 4067.APPLICATIONOFSUBCHAPTER
(a)Unlessotherwisespecifiedandtotheextentnotinconsistentwith
federallaw,thebenefitsrequiredinthissubchapter:
(1)applyonlytomajormedicalinsuranceplans;
(2)maybesubjecttodeductibles,co-paymentandcoinsuranceamounts,
feeorbenefitlimits,practiceparameters,andutilizationreviewconsistentwith
anyapplicablerulesandguidanceadoptedbytheDepartmentofFinancial
Regulation;and
(3)donotapplytoVermontMedicaid.
(b)Ahealthinsurermayrequirebenefitsmandatedinthissubchaptertobe
providedbyalicensedhealthcareproviderundercontractwiththehealth
insurer;provided,however,thatthisprovisionshallnotbeconstruedtorelieve
ahealthinsuranceplanfromcomplyingwiththeapplicablenetworkadequacy
requirementsadoptedbytheCommissionerbyrule.
§ 4068.CHIROPRACTICSERVICES
(a)Ahealthinsuranceplanshallprovidecoverageforclinicallynecessary
healthcareservicesprovidedbyachiropracticphysicianlicensedinthisState
fortreatmentwithinthescopeofpracticedescribedin26V.S.A.chapter10,
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butlimitingadjunctivetherapiestophysiotherapymodalitiesandrehabilitative
exercises.Ahealthinsuranceplandoesnothavetoprovidecoverageforthe
treatmentofanyvisceralconditionarisingfromproblemsordysfunctionsof
theabdominalorthoracicorgans.
(b)Ahealthinsurermayrequirethatthechiropracticservicesbe
provideduponreferralfromahealthcareproviderundercontractwiththe
healthinsurer.
(c)Forsilver-andbronze-levelqualifiedhealthbenefitplansandany
reflectivehealthbenefitplansofferedatthesilverorbronzelevelpursuantto
33V.S.A.chapter18,subchapter1,healthcareservicesprovidedbya
chiropracticphysicianmaybesubjecttoaco-paymentrequirement,provided
thatanyrequiredco-paymentamountshallbebetween125and150percentof
theamountoftheco-paymentapplicabletocareandservicesprovidedbya
primarycareproviderundertheplan.
(d)Nothinginthissectionshallbeconstruedasimpedingorpreventing
eithertheprovisionorcoverageofhealthcareservicesbylicensedchiropractic
physicians,withinthelawfulscopeofchiropracticpractice,inhospital
facilitiesonastafforemployeebasis.
§ 4069.PROSTHETICDEVICES
(a)Asusedinthissection,“prostheticdevice”meansanartificiallimb
devicetoreplace,inwholeorinpart,anarmoraleg.
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(b)Ahealthinsuranceplanshallprovidecoverageforprostheticdevices
thatisatleastequivalenttothecoverageprovidedbythefederalMedicare
program.Coveragemaybelimitedtotheprostheticdevicethatisthemost
appropriatemodelthatismedicallynecessarytomeetthepatient’smedical
needs.Anydisputebetweenthecoveredindividualandthecarrierconcerning
coverageandtheapplicationofthissectionshallbesubjecttoindependent
externalreviewundersection4063ofthistitle.
(c)Ahealthinsuranceplanmayrequirepriorauthorizationforprosthetic
devicesinthesamemannerandtothesameextentaspriorauthorizationis
requiredforanyothercoveredbenefit.
(d)Ahealthinsuranceplanshallprovidecoverageunderthissectionfor
themedicallynecessaryrepairorreplacementofaprostheticdevice.
(e)Thecoverageforprostheticdevicesshallnotbesubjecttoadeductible,
co-payment,orcoinsuranceprovisionthatislessfavorabletoacovered
individualthanthedeductible,co-payment,orcoinsuranceprovisionsthat
applygenerallytoothernonprimarycareitemsandservicesunderthehealth
insuranceplan.
§ 4070.HEARINGAIDCOVERAGEINLARGEGROUPHEALTH
INSURANCEPLANS
(a)Asusedinthissection:
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(1)“Hearingaid”meansanysmall,wearableelectronicinstrumentor
devicedesignedandintendedfortheearforthepurposeofaidingor
compensatingforimpairedhumanhearingandanyrelatedparts,attachments,
oraccessories,includingearmoldsandassociatedremotemicrophonesthat
pairwithhearingaidstoimprovewordcomprehensionindifficultlistening
situationsinliveortelecommunicationsettings.Thetermdoesnotinclude
large-audienceassistedlisteningdevices,suchasthosedesignedfor
auditoriums,orstand-aloneassistedlisteningdevicesthatcanfunctionwithout
ahearingaid.
(2)“Hearingaidprofessionalservices”meansthepracticeoffitting,
selecting,dispensing,selling,orservicinghearingaids,oracombination,
including:
(A)evaluationforahearingaid;
(B)fittingofahearingaid;
(C)programmingofahearingaid;
(D)hearingaidrepairs;
(E)follow-upadjustments,servicing,andmaintenanceofahearing
aid;
(F)earmoldimpressions;and
(G)auditoryrehabilitationandtraining.
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(3)“Hearingcareprofessional”meansanaudiologistorhearingaid
dispenserlicensedunder26V.S.A.chapter67,aphysicianlicensedunder
26 V.S.A.chapter23or33,aphysicianassistantlicensedunder26V.S.A.
chapter31,oranadvancedpracticeregisterednurselicensedunder26V.S.A.
chapter28,workingwithinthatprofessional’sscopeofpractice.
(4)“Largegrouphealthinsuranceplan”meansamajormedical
insuranceplanthatmeetstherequirementsofsection4041ofthistitlebutthat
isnot:
(A)aqualifiedhealthbenefitplanorreflectivehealthbenefitplan
offeredinaccordancewith33V.S.A.chapter18,subchapter1;or
(B)ahealthbenefitplanofferedbyanintermunicipalinsurance
associationtooneormoreentitiesprovidingeducationalservicespursuantto
24V.S.A.chapter121,subchapter6.
(b)(1)Alargegrouphealthinsuranceplanshallcoverthecostofahearing
aidforeachearandtheassociatedhearingaidprofessionalserviceswhenthe
hearingaidoraidsareprescribed,fitted,anddispensedbyahearingcare
professional.Thecoverageshallincludehearingaidbatterieswhenprescribed
byahearingcareprofessional.
(2)Alargegrouphealthinsuranceplanmaylimitcoveragetonotmore
thanonehearingaidpereareverythreeyears,exceptthataplanshallcover
thecostofoneormorenewhearingaidsforacoveredindividualpriortothe
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expirationofthethree-yearperiodbasedonahearingcareprofessional’s
determinationthatanewhearingaidforoneorbothearsismedically
necessary.
(c)(1)Subjecttothelimitationssetforthinsubdivision(b)(2)ofthis
section,thecoverageprovidedbyalargegrouphealthinsuranceplanfor
hearingaidsandassociatedservicesshallbelimitedonlybymedicalnecessity.
(2)Acoveredindividualmayselectahearingaidthatexceedsthelimits
setforthinsubdivision(1)ofthissubsectionandpaytheadditionalcost.
(d)Thecoveragerequiredbythissectionshallnotbesubjecttoa
deductible,co-payment,orcoinsuranceprovisionthatislessfavorabletoa
coveredindividualthanthedeductible,co-payment,orcoinsuranceprovisions
thatapplygenerallytoothernonprimarycareitemsandservicesunderthe
largegrouphealthinsuranceplan.
§ 4071.GENDER-AFFIRMINGHEALTHCARESERVICES
(a)Asusedinthissection,“gender-affirminghealthcareservices”hasthe
samemeaningasin1V.S.A.§150.
(b)(1)Ahealthinsuranceplanshallprovidecoverageforgender-affirming
healthcareservicesthat:
(A)aremedicallynecessaryandclinicallyappropriateforthe
individual’sdiagnosisorhealthcondition;and
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(B)areincludedintheState’sessentialhealthbenefitsbenchmark
plan.
(2)Nothinginthissectionshallprohibitahealthinsuranceplanfrom
providinggreatercoverageforgender-affirminghealthcareservicesthanis
requiredunderthissection.
(c)Costsharing.Ahealthinsuranceplanshallnotimposegreater
coinsurance,co-payment,deductible,orothercost-sharingrequirementsfor
coverageofgender-affirminghealthcareservicesthanapplytothediagnosis
andtreatmentofanyotherphysicalormentalconditionundertheplan.
(d)ThissectionshallapplytoMedicaidandanyotherpublichealthcare
assistanceprogramofferedoradministeredbytheStateorbyanysubdivision
orinstrumentalityoftheState.Thecoverageprovidedpursuanttothissection
byMedicaidandotherpublichealthcareassistanceprogramsshallcomply
withanyrequirementsimposedonsuchcoveragebytheCentersforMedicare
andMedicaidServices.
§ 4072.MENTALHEALTHANDSUBSTANCEUSEDISORDER
SERVICES
(a)ItisthegoaloftheGeneralAssemblythattreatmentformental
conditionsberecognizedasanintegralcomponentofhealthcare,thathealth
insuranceplanscoverallnecessaryandappropriatemedicalserviceswithout
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imposingpracticesthatcreatebarrierstoreceivingappropriatecare,andthat
integrationofhealthcareberecognizedasthestandardforcareinthisState.
(b)Asusedinthissection:
(1)“Mentalcondition”meansanyconditionordisorderinvolving
psychiatricdisabilitiesorsubstanceusedisorderthatfallsunderanyofthe
diagnosticcategorieslistedinthementaldisorderssectionoftheInternational
ClassificationofDiseases,asperiodicallyrevised.
(2)“Mentalhealthprovider”meansanyindividual,corporation,facility,
orinstitutioncertifiedorlicensedbythisStatetoprovidementalhealth
services,includingaphysician,nursewithrecognizedpsychiatricspecialties,
hospitalorotherhealthcarefacility,psychologist,clinicalsocialworker,
mentalhealthcounselor,alcoholordrugabusecounselor,oranemployeeor
agentofsuchprovideractinginthecourseandscopeofemploymentoran
agencyrelatedtomentalhealthservices.
(3)“Rate,term,orcondition”meansanylifetimeorannualpayment
limits,deductibles,copayments,coinsurance,andanyothercost-sharing
requirements,out-of-pocketlimits,visitlimits,andanyotherfinancial
componentofhealthinsurancecoveragethataffectsthecoveredindividual.
(c)Ahealthinsuranceplanshallprovidecoveragefortreatmentofa
mentalconditionandshall:
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(1)notestablishanyrate,term,orconditionthatplacesagreaterburden
onacoveredindividualforaccesstotreatmentforamentalconditionthanfor
accesstotreatmentforotherhealthconditions,includingnogreaterco-
paymentforprimarymentalhealthcareorservicesthantheco-payment
applicabletocareorservicesprovidedbyaprimarycareproviderundera
coveredindividual’shealthinsuranceplanandnogreaterco-paymentfor
specialtymentalhealthcareorservicesthantheco-paymentapplicabletocare
orservicesprovidedbyaspecialistproviderunderacoveredindividual’s
healthinsuranceplan;
(2)notexcludefromitsnetworkorlistofauthorizedprovidersany
licensedmentalhealthorsubstanceusedisordertreatmentproviderlocated
withinthegeographiccoverageareaofthehealthinsuranceplanifthe
provideriswillingtomeetthetermsandconditionsforparticipation
establishedbythehealthinsurer;
(3)makeanydeductibleorout-of-pocketlimitsrequiredunderahealth
insuranceplancomprehensiveforcoverageofbothmentalandphysicalhealth
conditions;and
(4)ifthehealthinsuranceplanprovidesprescriptiondrugcoverage,
ensurethatatleastonemedicationineachtherapeuticclassapprovedbythe
U.S.FoodandDrugAdministrationforthetreatmentofsubstanceuse
disorder,includingforopioidusedisorder,methadone,buprenorphine,and
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naltrexone,isavailableonthelowestcost-sharingtieroftheplan’s
prescriptiondrugformulary.
(d)(1)(A)Ahealthinsuranceplanthatdoesnototherwiseprovidefor
managementofcareundertheplan,orthatdoesnotprovideforthesame
degreeofmanagementofcareforallhealthconditions,mayprovidecoverage
fortreatmentofmentalconditionsthroughamanagedcareorganization,
providedthatthemanagedcareorganizationisincompliancewithrules
adoptedbytheCommissionerthatensurethatthesystemfordeliveryof
treatmentformentalconditionsdoesnotdiminishornegatethepurposeofthis
section.Inreviewingpolicyratesandformspursuanttosection4026ofthis
title,theCommissionerortheGreenMountainCareBoardestablishedin
18 V.S.A.chapter220,asappropriate,shallconsiderthecomplianceofthe
policywiththeprovisionsofthissection.
(B)TherulesadoptedbytheCommissionershallensurethat:
(i)timelyandappropriateaccesstocareisavailable;
(ii)thequantity,location,andspecialtydistributionofhealthcare
providersisadequate;
(iii)administrativeorclinicalprotocolsdonotservetoreduce
accesstomedicallynecessarytreatmentforanycoveredindividual;
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(iv)utilizationreviewandotheradministrativeandclinical
protocolsdonotdetertimelyandappropriatecare,includingemergency
hospitaladmissions;
(v)inthecaseofamanagedcareorganizationthatcontractswith
ahealthinsurertoadministerthehealthinsurer’smentalhealthbenefits,the
portionofahealthinsurer’spremiumrateattributabletothecoverageof
mentalhealthbenefitsisreviewedundersection4026,4513,4584,or5104of
thistitletodeterminewhetheritisexcessive,inadequate,unfairly
discriminatory,unjust,unfair,inequitable,misleading,orcontrarytothelaws
ofthisState;
(vi)thehealthinsuranceplanisconsistentwiththeBlueprintfor
Healthwithrespecttomentalconditions;
(vii)aqualityimprovementprojectiscompletedannuallyasa
jointprojectbetweenthehealthinsuranceplananditsmentalhealthmanaged
careorganizationtoimplementpoliciesandincentivestoincrease
collaborationamongprovidersthatwillfacilitateclinicalintegrationof
servicesformedicalandmentalconditions,including:
(I)evidenceofhowdatacollectedfromthequality
improvementprojectarebeingusedtoinformthepractices,policies,and
futuredirectionofcaremanagementprogramsformentalconditions;and
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(II)demonstrationofhowthequalityimprovementprojectis
supportingtheincorporationofbestpracticesandevidence-basedguidelines
intotheutilizationreviewofmentalconditions;
(viii)anup-to-datelistofactivementalhealthprovidersinthe
plan’snetworkisavailableonthehealthinsurer’sandmanagedcare
organization’swebsitesandprovidedtoconsumersuponrequest;and
(ix)thehealthinsurersandmanagedcareorganizationsmake
accessibletoconsumersthetoll-freetelephonenumberfortheDepartmentof
FinancialRegulation’sconsumerprotectionhelpline.
(C)Priortotheadoptionofrulespursuanttothissubdivision(d)(1),
theCommissionershallconsultwiththeCommissionerofMentalHealthand
thetaskforceestablishedpursuanttosubsection(h)ofthissectionconcerning:
(i)developingincentivesandothermeasuresaddressingthe
availabilityofprovidersofcareandtreatmentformentalconditions,especially
inmedicallyunderservedareas;
(ii)incorporatingnationallyrecognizedbestpracticesand
evidence-basedguidelinesintotheutilizationreviewofmentalconditions;and
(iii)establishingbenefitdesign,infrastructuresupport,and
paymentmethodologystandardsforevaluatingthehealthinsuranceplan’s
consistencywiththeBlueprintforHealthwithrespecttothecareand
treatmentofmentalconditions.
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(2)Amanagedcareorganizationprovidingoradministeringcoverage
fortreatmentofmentalconditionsonbehalfofahealthinsuranceplanshall
complywiththissection,sections4064and4724ofthistitle,and18V.S.A.
§ 9414;withrulesadoptedpursuanttothoseprovisionsoflaw;andwithall
otherobligations,underTitle18andunderthistitle,ofthehealthinsurance
planandthehealthinsureronbehalfofwhichthemanagedcareorganization
isprovidingoradministeringcoverage.Aviolationofanyprovisionofthis
sectionshallconstituteanunfairactorpracticeinthebusinessofinsurancein
violationofsection4723ofthistitle.
(3)Ahealthinsurerthatcontractswithamanagedcareorganizationto
provideoradministercoveragefortreatmentofmentalconditionsisfully
responsiblefortheactsandomissionsofthemanagedcareorganization,
includinganyviolationsofthissectionoraruleadoptedpursuanttothis
section.
(4)Inadditiontoanyotherremedyorsanctionprovidedforbylaw,if
theCommissioner,afternoticeandanopportunitytobeheard,findsthata
healthinsuranceplanormanagedcareorganizationhasviolatedthissectionor
anyruleadoptedpursuanttothissection,theCommissionermay:
(A)assessapenaltyonthehealthinsurerormanagedcare
organizationundersection4726ofthistitle;
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(B)orderthehealthinsurerormanagedcareorganizationtocease
anddesistinfurtherviolations;
(C)orderthehealthinsurerormanagedcareorganizationto
remediatetheviolation,includingissuinganordertothehealthinsurerto
terminateitscontractwiththemanagedcareorganization;and
(D)revokeorsuspendthelicenseofahealthinsurerormanagedcare
organization,orpermitcontinuedlicensuresubjecttosuchconditionsasthe
Commissionerdeemsnecessarytocarryoutthepurposesofthissection.
(5)Asusedinthissubsection,theterm“managedcareorganization”
includesanyofthefollowingentitiesthatprovideoradministerthecoverage
ofmentalhealthbenefitsonbehalfofahealthinsuranceplan:
(A)amentalhealthreviewagentasdefinedinsection4064ofthis
title;
(B)ahealthinsureroritsdelegate;
(C)amanagedcareorganization,asdefinedin18V.S.A.§9402,or
itsdelegate;and
(D)anyotherpersonorentitythatmeetsthedefinitionofamanaged
careorganizationunder18V.S.A.§ 9402orunderrulesadoptedbythe
Commissioner.
(e)Tobeeligibleforcoverageunderthissection,theserviceshallbe
rendered:
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(1)Fortreatmentofamentalcondition,either:
(A)byalicensedorcertifiedmentalhealthprofessional;or
(B)inamentalhealthfacilityqualifiedpursuanttorulesadoptedby
theSecretaryofHumanServicesorinaninstitution,approvedbythe
SecretaryofHumanServices,thatprovidesaprogramforthetreatmentofa
mentalconditionpursuanttoawrittenplan.
(2)Fortreatmentofsubstanceabusedisorder,either:
(A)byalicensedalcoholanddrugabusecounselororotherperson
approvedbytheSecretaryofHumanServicesbasedonrulesadoptedbythe
Secretarythatestablishstandardsandcriteriafordeterminingeligibilityunder
thissubdivision;or
(B)inaninstitution,approvedbytheSecretaryofHumanServices,
thatprovidesaprogramforthetreatmentofsubstanceusedisorderpursuantto
awrittenplan.
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§ 4073.DIABETESTREATMENT
(a)Ahealthinsuranceplanshallprovidecoveragefortheequipment,
supplies,andoutpatientself-managementtrainingandeducation,including
medicalnutritiontherapy,forthetreatmentofinsulin-dependentdiabetes,
insulin-usingdiabetes,gestationaldiabetes,andnoninsulin-usingdiabetesif
prescribedbyahealthcareprofessional.
(b)Diabetesoutpatientself-managementtrainingandeducationrequiredto
becoveredbythissectionshallbeprovidedbyacertified,registered,or
licensedhealthcareprofessionalwithspecializedtrainingintheeducationand
managementofdiabetes.
§ 4074.TREATMENTOFINHERITEDMETABOLICDISORDERS
(a)Asusedinthissection:
(1)“Inheritedmetabolicdisorder”meansadisordercausedbyan
inheritedabnormalityofbodychemistryforwhichtheStatescreensnewborn
infants.
(2)“Lowproteinmodifiedfoodproduct”meansafoodproductthatis
specificallyformulatedtohavelessthanonegramofproteinperservingandis
intendedtobeusedunderthedirectionofahealthcareprofessionalforthe
dietarytreatmentofametabolicdisorder.
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(3)“Medicalfood”meansanaminoacidmodifiedpreparationthatis
intendedtobeusedunderthedirectionofahealthcareprofessionalforthe
dietarytreatmentofaninheritedmetabolicdisorder.
(b)Ahealthinsuranceplanshallprovidecoverageformedicalfoods
prescribedformedicallynecessarytreatmentforaninheritedmetabolic
disorder.
(c)Coverageforlowproteinmodifiedfoodproductsprescribedfor
medicallynecessarytreatmentofaninheritedmetabolicdisordershallbeat
least$2,500.00duringanycontinuousperiodof12monthsforanycovered
individual.
§ 4075.CRANIOFACIALDISORDERS
(a)(1)Ahealthinsuranceplanshallprovidecoveragefordiagnosisand
medicallynecessarytreatment,includingsurgicalandnonsurgicalprocedures,
foramusculoskeletaldisorderthataffectsanyboneorjointintheface,neck,
orheadandistheresultofaccident,trauma,congenitaldefect,developmental
defect,orpathology.Subjecttosubsection(b)ofthissection,thiscoverage
shallbethesameasthatprovidedunderthehealthinsuranceplanforanyother
musculoskeletaldisorderinthebodyandshallbecoveredwhenthediagnosis
ortreatment,orboth,isprescribedoradministeredbyaphysicianoradentist.
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(2)Thissectionshallnotbeconstruedtorequirecoveragefordental
servicesforthediagnosisortreatmentofdentaldisordersordentalpathology
primarilyaffectingthegums,teeth,oralveolarridge.
(b)Ahealthinsuranceplanmayrequireareferralfromahealthcare
providerundercontractwiththeplan.
§ 4076.HOMEHEALTHSERVICES
(a)Asusedinthissection:
(1)“Homehealthagency”meansanonprofithomehealthagencythat
hasbeencertifiedunderTitleXVIIIoftheSocialSecurityAct(42U.S.C.
§ 1395etseq.).
(2)“Homehealthcare”meanscareandtreatmentprovidedbyahome
healthagencyanddesignedandsupervisedbyahealthcareprofessional,
withoutwhichcareandtreatmentapersonwouldrequireadmissiontoa
hospitalorskillednursingfacility,asthosetermsaredefinedbyMedicare
regulations.Thecareandtreatmentshallconsistofoneormoreofthe
following:
(A)Part-timeorintermittentskillednursingcare.
(B)Physicaltherapy.
(C)Part-timeorintermittenthomehealthaideservicesthatconsist
primarilyofcaringforthepatient.
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(D)Medicalsupplies,drugsandequipment,andlaboratoryservices
totheextentthatlaboratoryserviceswouldhavebeencoveredifthepatient
hadbeenadmittedtoahospitalorskillednursingfacility.Themedical
necessityofequipmentmaybereviewedbyreferencetotheMedicare
guidelinesfordurablemedicalequipment.
(b)(1)Amajormedicalinsuranceplanshallprovidecoverageforhome
healthcare.
(2)Ahealthinsurermayrequireevidenceofinsurabilityasa
prerequisitetocoverage.
(3)Thecoverageshallconsistofatleast40visitsbyahomehealth
agencyinanycalendaryear,orinanycontinuousperiodof12months,for
eachpersoncoveredunderthehealthinsuranceplan.
(4)Eachvisitbyamemberofahomehealthcareagency,otherthana
homehealthaide,shallbeconsideredonehomehealthcarevisit,andfour
hoursofhomehealthaideserviceshallbeconsideredonehomehealthcare
visit.Coverageshallbeprovidedformaternityandchildbirth.
(c)Nothinginthissectionshallbedeemedtorequirethathomehealthcare
coveragebeprovidedtoindividualseligibleforMedicare.
(d)Ahealthinsuranceplanshallnotimposegreatercoinsurance,co-
payment,deductible,orothercost-sharingrequirementsforcoverageofhome
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healthcarethanapplytothediagnosisandtreatmentofanyotherphysicalor
mentalconditionundertheplan.
§ 4077.REPRODUCTIVEHEALTHCARESERVICES
(a)(1)Ahealthinsuranceplanshallprovidecoverageforoutpatient
contraceptiveservicesincludingsterilizations,andshallprovidecoveragefor
thepurchaseofallprescriptioncontraceptivesandprescriptioncontraceptive
devicesapprovedbytheU.S.FoodandDrugAdministration(FDA),except
thatahealthinsuranceplanthatdoesnotprovidecoverageofprescription
drugsisnotrequiredtoprovidecoverageofprescriptioncontraceptivesand
prescriptioncontraceptivedevices.
(2)Ahealthinsuranceplanprovidingcoveragerequiredunderthis
sectionshallnotestablishanyrate,term,orconditionthatplacesagreater
financialburdenonacoveredindividualforaccesstocontraceptiveservices,
prescriptioncontraceptives,andprescriptioncontraceptivedevicesthanfor
accesstotreatment,prescriptions,ordevicesforanyotherhealthcondition.
(b)Ahealthinsuranceplanshallprovidecoveragewithoutanydeductible,
coinsurance,co-payment,orothercost-sharingrequirementforatleastone
drug,device,orotherproductwithineachmethodofcontraceptionforwomen
identifiedbytheFDAandprescribedbyacoveredindividual’shealthcare
professional.
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(1)Thecoverageprovidedpursuanttothissubsectionshallinclude
patienteducationandcounselingbythecoveredindividual’shealthcare
providerregardingtheappropriateuseofthecontraceptivemethodprescribed.
(2)(A)Ifthereisatherapeuticequivalentofadrug,device,orother
productforanFDA-approvedcontraceptivemethod,ahealthinsuranceplan
mayprovidecoverageformorethanonedrug,device,orotherproductand
mayimposecost-sharingrequirementsaslongasatleastonedrug,device,or
otherproductforthatmethodisavailablewithoutcostsharing.
(B)Ifacoveredindividual’shealthcareprofessionalrecommendsa
particularserviceorFDA-approveddrug,device,orotherproductforthe
coveredindividualbasedonadeterminationofmedicalnecessity,thehealth
insuranceplanshalldefertothehealthcareprofessional’sdeterminationand
judgmentandshallprovidecoveragewithoutcostsharingforthedrug,device,
orproductprescribedbythehealthcareprofessionalforthecovered
individual.
(c)Ahealthinsuranceplanshallprovidecoverageforvoluntary
sterilizationproceduresformenandwomenwithoutanydeductible,
coinsurance,co-payment,orothercost-sharingrequirement,excepttothe
extentthatsuchcoveragewoulddisqualifyahigh-deductiblehealthplanfrom
eligibilityforahealthsavingsaccountpursuantto26U.S.C.§223.
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(d)Ahealthinsuranceplanshallprovidecoveragewithoutanydeductible,
coinsurance,co-payment,orothercost-sharingrequirementforclinical
servicesassociatedwithprovidingthedrugs,devices,products,andprocedures
coveredunderthissectionandrelatedfollow-upservices,including
managementofsideeffects,counselingforcontinuedadherence,anddevice
insertionandremoval.
(e)(1)Ahealthinsuranceplanshallprovidecoverageforasupplyof
prescribedcontraceptivesintendedtolastovera12-monthduration,which
maybefurnishedordispensedallatonceoroverthecourseofthe12months
atthediscretionofthehealthcareprovider.Thehealthinsuranceplanshall
reimburseahealthcareproviderordispensingentityperunitforfurnishingor
dispensingasupplyofcontraceptivesintendedtolastfor12months.
(2)ThissubsectionshallapplytoMedicaidandanyotherpublichealth
careassistanceprogramofferedoradministeredbytheStateorbyany
subdivisionorinstrumentalityoftheState.
(f)Benefitsprovidedunderthissectionshallbethesameforindividuals
coveredunderthehealthinsuranceplan.
(g)Thecoveragerequirementsofthissectionshallapplytoself-
administeredhormonalcontraceptivesprescribedforacoveredindividualbya
pharmacistinaccordancewith26V.S.A.§2023.
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§ 4078.MIDWIFERYCOVERAGE;HOMEBIRTHS
(a)Ahealthinsuranceplanprovidingmaternitybenefitsshallalsoprovide
coverageforservicesrenderedbyamidwifelicensedpursuantto26V.S.A.
chapter85oranadvancedpracticeregisterednurselicensedpursuantto
26 V.S.A.chapter28whoiscertifiedasanursemidwifeforserviceswithin
thelicensedmidwife’sorcertifiednursemidwife’sscopeofpracticeand
providedinahospitalorotherhealthcarefacilityorathome.
(b)Coverageforservicesprovidedbyalicensedmidwifeorcertifiednurse
midwifeshallnotbesubjecttoanygreaterco-payment,deductible,or
coinsurancethanisapplicabletoanyothersimilarbenefitsprovidedbythe
healthinsuranceplan.
(c)ThissectionshallapplytoMedicaidandanyotherpublichealthcare
assistanceprogramofferedoradministeredbytheStateorbyanysubdivision
orinstrumentalityoftheState.
§ 4079.ABORTIONANDABORTION-RELATEDSERVICES
(a)Asusedinthissection,“abortion”meansanymedicaltreatment
intendedtoinducetheterminationof,ortoterminate,aclinicallydiagnosable
pregnancyexceptforthepurposeofproducingalivebirth.
(b)(1)Ahealthinsuranceplanshallprovidecoverageforabortionand
abortion-relatedcare.
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(2)ThissectionshallapplytoMedicaidandanyotherpublichealthcare
assistanceprogramofferedoradministeredbytheStateorbyanysubdivision
orinstrumentalityoftheState.
(c)Thecoveragerequiredbythissectionshallnotbesubjecttoanyco-
payment,deductible,coinsurance,orothercost-sharingrequirementor
additionalcharge,except:
(1)totheextentsuchcoveragewoulddisqualifyahigh-deductible
healthplanfromeligibilityforahealthsavingsaccountpursuantto26U.S.C.
§223;and
(2)forcoverageprovidedbyMedicaid.
§ 4080.ANESTHESIAFORCERTAINDENTALPROCEDURES
(a)Asusedinthissection:
(1)“Ambulatorysurgicalcenter”hasthesamemeaningasin
18V.S.A.§ 2141.
(2)“Anesthesiologist”meansaphysicianwhoislicensedunder
26 V.S.A.chapter23or33andwhoeither:
(A)hascompletedaresidencyinanesthesiologyapprovedbythe
AmericanBoardofAnesthesiologyortheAmericanOsteopathicBoardof
Anesthesiologyortheirpredecessorsorsuccessors;or
(B)iscredentialedbyahospitaltopracticeanesthesiologyand
engagesinthepracticeofanesthesiologyatthathospitalfull-time.
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(3)“Certifiedregisterednurseanesthetist”meansanadvancedpractice
registerednurselicensedbytheVermontBoardofNursingtopracticeasa
certifiedregisterednurseanesthetist.
(4)“Licensedmentalhealthprofessional”meansalicensedphysician,
psychologist,psychoanalyst,socialworker,marriageandfamilytherapist,
clinicalmentalhealthcounselor,ornursewithprofessionaltraining,
experience,anddemonstratedcompetenceinthetreatmentofamental
conditionorpsychiatricdisability.
(b)Ahealthinsuranceplanshallprovidecoverageforthehospitalor
ambulatorysurgicalcenterchargesandadministrationofgeneralanesthesia
administeredbyalicensedanesthesiologistorcertifiedregisterednurse
anesthetistfordentalproceduresperformedonacoveredindividualwhois:
(1)achildsevenyearsofageoryoungerwhoisdeterminedbyadentist
licensedpursuantto26V.S.A.chapter13tobeunabletoreceiveneededdental
treatmentinanoutpatientsetting,wheretheprovidertreatingthecovered
individualcertifiesthatduetothecoveredindividual’sageandthecovered
individual’sconditionorproblem,hospitalizationorgeneralanesthesiaina
hospitalorambulatorysurgicalcenterisrequiredinordertoperform
significantlycomplexdentalproceduressafelyandeffectively;
(2)achild12yearsofageoryoungerwithdocumentedphobiasora
documentedmentalconditionorpsychiatricdisability,asdeterminedbya
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physicianlicensedpursuantto26V.S.A.chapter23or33orbyalicensed
mentalhealthprofessional,whosedentalneedsaresufficientlycomplexand
urgentthatdelayingordeferringtreatmentcanbeexpectedtoresultin
infection,lossofteeth,orotherincreasedoralordentalmorbidity;forwhoma
successfulresultcannotbeexpectedfromdentalcareprovidedunderlocal
anesthesia;andforwhomasuperiorresultcanbeexpectedfromdentalcare
providedundergeneralanesthesia;or
(3)apersonwhohasexceptionalmedicalcircumstancesora
developmentaldisability,asdeterminedbyaphysicianlicensedpursuantto
26 V.S.A.chapter23or33,thatplacethepersonatseriousrisk.
(c)Ahealthinsuranceplanmayrequirepriorauthorizationforgeneral
anesthesiaandassociatedhospitalorambulatorysurgicalcenterchargesfor
dentalcareinthesamemannerthatpriorauthorizationisrequiredforthese
benefitsinconnectionwithothercoveredmedicalcare.
(d)Ahealthinsuranceplanmayrestrictcoverageforgeneralanesthesia
andassociatedhospitalorambulatorysurgicalcenterchargestodentalcare
thatisprovidedby:
(1)afullyaccreditedspecialistinpediatricdentistry;
(2)afullyaccreditedspecialistinoralandmaxillofacialsurgery;and
(3)adentisttowhomhospitalprivilegeshavebeengranted.
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(e)Theprovisionsofthissectionshallnotbeconstruedtorequireahealth
insuranceplantoprovidecoverageforthedentalprocedureorotherdental
careforwhichgeneralanesthesiaisprovided.
(f)Theprovisionsofthissectionshallnotbeconstruedtopreventor
requirereimbursementbyahealthinsuranceplanfortheprovisionofgeneral
anesthesiaandassociatedfacilitychargestoadentistholdingageneral
anesthesiaendorsementissuedbytheVermontBoardofDentalExaminersif
thedentisthasprovidedservicespursuanttothissectiononanoutpatientbasis
inthedentist’sownofficeandthedentistisincompliancewiththe
endorsement’stermsandconditions.
§ 4081.TOBACCOCESSATION
(a)Asusedinthissection,“tobaccocessationmedication”meansall
therapiesapprovedbytheU.S.FoodandDrugAdministrationforusein
tobaccocessation.
(b)Ahealthinsuranceplanshallprovidecoverageofatleastonethree-
monthsupplyperyearoftobaccocessationmedication,includingover-the-
countermedication,ifprescribedbyalicensedhealthcareprofessionalforan
individualcoveredundertheplan.Ahealthinsuranceplanmayrequirethe
individualtopaytheplan’sapplicableprescriptiondrugco-paymentforthe
tobaccocessationmedication.
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(c)ThissectionshallapplytoMedicaidandanyotherpublichealthcare
assistanceprogramofferedoradministeredbytheStateorbyanysubdivision
orinstrumentalityoftheState.
§ 4082.EARLYCHILDHOODDEVELOPMENT DISORDERS
(a)Asusedinthissection:
(1)“Appliedbehavioranalysis”meansthedesign,implementation,and
evaluationofenvironmentalmodificationsusingbehavioralstimuliand
consequencestoproducesociallysignificantimprovementinhumanbehavior.
Thetermincludestheuseofdirectobservation,measurement,andfunctional
analysisoftherelationshipbetweenenvironmentandbehavior.
(2)“Autismspectrumdisorders”meansoneormorepervasive
developmentaldisordersasdefinedinthemostrecenteditionoftheDiagnostic
andStatisticalManualofMentalDisorders(DSM),includingautisticdisorder,
pervasivedevelopmentaldisordernototherwisespecified,andAsperger’s
disorder.
(3)“Behavioralhealthtreatment”meansevidence-basedcounselingand
treatmentprograms,includingappliedbehavioranalysis,thatare:
(A)necessarytodevelopskillsandabilitiesforthemaximum
reductionofphysicalormentaldisabilityandforrestorationofanindividual
totheindividual’sbestfunctionallevel,ortoensurethatanindividual21
yearsofageachievespropergrowthanddevelopment;and
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(B)providedorsupervisedbyanationallyboard-certifiedbehavior
analystorbyalicensedhealthcareprofessional,providedtheservices
performedarewithinthehealthcareprofessional’sscopeofpracticeand
certifications.
(4)“Diagnosisofearlychildhooddevelopmentaldisorders”means
medicallynecessaryassessments,evaluations,orteststodeterminewhetheran
individualhasanearlychildhooddevelopmentaldelay,includinganautism
spectrumdisorder.
(5)“Earlychildhooddevelopmentaldisorder”meansachildhood
mentalorphysicalimpairmentorcombinationofmentalandphysical
impairmentsthatresultsinfunctionallimitationsinmajorlifeactivities,
accompaniedbyadiagnosisdefinedbytheDSMortheInternational
ClassificationofDiseases(ICD),asperiodicallyrevised.Thetermincludes
autismspectrumdisordersbutdoesnotincludealearningdisability.
(6)“Evidence-based”hasthesamemeaningasin18V.S.A.§4621.
(7)“Medicallynecessary”describeshealthcareservicesthatare
appropriateintermsoftype,amount,frequency,level,setting,anddurationto
theindividual’sdiagnosisorcondition;areinformedbygenerallyaccepted
medicalorscientificevidence;andareconsistentwithgenerallyaccepted
practiceparameters.Suchservicesshallbeinformedbytheuniqueneedsof
eachindividualandeachpresentingsituationandshallincludeadetermination
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thataserviceisneededtoachievepropergrowthanddevelopmentorto
preventtheonsetorworseningofahealthcondition.
(8)“Naturalenvironment”meansahomeorchildcaresetting.
(9)“Pharmacycare”meansmedicationsprescribedbyalicensedhealth
careprofessionalandanyhealth-relatedservicesdeemedmedicallynecessary
todeterminetheneedfororeffectivenessofamedication.
(10)“Psychiatriccare”meansdirectorconsultativeservicesprovided
byalicensedphysiciancertifiedinpsychiatrybytheAmericanBoardof
MedicalSpecialties.
(11)“Psychologicalcare”meansdirectorconsultativeservicesprovided
byapsychologistlicensedpursuantto26V.S.A.chapter55.
(12)“Therapeuticcare”meansservicesprovidedbylicensedorcertified
speechlanguagepathologists,occupationaltherapists,orphysicaltherapists.
(13)“Treatmentforearlydevelopmentaldisorders”meansevidence-
basedcareandrelatedequipmentprescribedororderedforanindividualbya
licensedhealthcareprofessionaloralicensedpsychologistwhodeterminesthe
caretobemedicallynecessary,including:
(A)behavioralhealthtreatment;
(B)pharmacycare;
(C)psychiatriccare;
(D)psychologicalcare;and
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(E)therapeuticcare.
(b)(1)Ahealthinsuranceplanshallprovidecoveragefortheevidence-
baseddiagnosisandtreatmentofearlychildhooddevelopmentaldisorders,
includingappliedbehavioranalysissupervisedbyanationallyboard-certified
behavioranalyst,forchildren,beginningatbirthandcontinuinguntilthechild
reaches21yearsofage.
(2)ThissectionshallapplytoMedicaidandanyotherpublichealthcare
assistanceprogramofferedoradministeredbytheStateorbyanysubdivision
orinstrumentalityoftheState.Coverageprovidedpursuanttothissectionby
Medicaidoranyotherpublichealthcareassistanceprogramshallcomplywith
allfederalrequirementsimposedbytheCentersforMedicareandMedicaid
Services.
(3)Amajormedicalinsuranceplanisnotrequiredtoprovideany
benefitsrequiredbythissectionthatexceedtheessentialhealthbenefits
specifiedunderSection1302(b)ofthePatientProtectionandAffordableCare
Act,PublicLaw111-148,asamended.
(c)Theamount,frequency,anddurationoftreatmentdescribedinthis
sectionshallbebasedonmedicalnecessityandmaybesubjecttoaprior
authorizationrequirementunderthehealthinsuranceplan.
(d)Ahealthinsuranceplanshallnotimposegreatercoinsurance,co-
payment,deductible,orothercost-sharingrequirementsforcoverageofthe
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diagnosisortreatmentofearlychildhooddevelopmentaldisordersthanapply
tothediagnosisandtreatmentofanyotherphysicalormentalconditionunder
theplan.
(e)(1)Ahealthinsuranceplanshallprovidecoverageforappliedbehavior
analysiswhentheservicesareprovidedorsupervisedbyalicensedhealthcare
professionalwhoisworkingwithinthescopeofthehealthcareprofessional’s
licenseorwhoisanationallyboard-certifiedbehavioranalyst.
(2)Ahealthinsuranceplanshallprovidecoverageforservicesunder
thissectiondeliveredinthenaturalenvironmentwhentheservicesare
furnishedbyahealthcareprofessionalworkingwithinthescopeofthehealth
careprofessional’slicenseorunderthedirectsupervisionofalicensedhealth
careprofessionalor,forappliedbehavioranalysis,byorunderthesupervision
ofanationallyboard-certifiedbehavioranalyst.
(f)Exceptforinpatientservices,ifanindividualisreceivingtreatmentfor
anearlydevelopmentaldelay,thehealthinsuranceplanmayrequiretreatment
planreviewsbasedontheneedsofthecoveredindividual,consistentwith
reviewsforotherdiagnosticareasandwithrulesestablishedbythe
DepartmentofFinancialRegulation.Ahealthinsuranceplanmayreviewthe
treatmentplanforchildrenundereightyearsofagenotmorefrequentlythan
onceeverysixmonths.
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(g)Nothinginthissectionshallbeconstruedtoaffectanyobligationto
provideservicestoanindividualunderanindividualizedfamilyserviceplan,
individualizededucationprogram,orindividualizedserviceplan.Ahealth
insuranceplanshallnotreimburseservicesprovidedunder16V.S.A.§2959a.
(h)ItistheintentoftheGeneralAssemblythattheDepartmentof
FinancialRegulationfacilitateandencouragehealthinsuranceplanstobundle
co-paymentsaccruedbybeneficiariesreceivingservicesunderthissectionto
theextentpossible.
§ 4083.SERVICESFORVICTIMSOFSEXUALASSAULT
(a)Asusedinthissection,“sexualassaultexamination”meanseitheror
bothofthefollowing:
(1)aphysicalexaminationofthepatient,documentationofbiological
andphysicalfindings,andcollectionofevidence;and
(2)treatmentofthepatient’sinjuries;providingcareforsexually
transmittedinfections;assessingpregnancyrisk;discussingtreatmentoptions,
includingreproductivehealthservices,screeningforthehuman
immunodeficiencyvirus,andprophylactictreatmentwhenappropriate;and
providinginstructionsandreferralsforfollow-upcare.
(b)Ahealthinsuranceplanshallnotimposeanyco-paymentor
coinsuranceor,totheextentpermittedunderfederallaw,deductibleorother
cost-sharingrequirementforthesexualassaultexaminationofavictimof
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allegedsexualassaultforhealthcareservicesassociatedwithspecific
procedurecodesidentifiedinamemorandumofunderstandingbetweenthe
healthinsurerandtheVermontCenterforCrimeVictimServices.
§ 4084.PHYSICALTHERAPYCO-PAYMENTSFORCERTAINPLANS
Forsilver-andbronze-levelqualifiedhealthbenefitplansandanyreflective
healthbenefitplansofferedatthesilverorbronzelevelpursuantto33V.S.A.
chapter18,subchapter1,healthcareservicesprovidedbyalicensedphysical
therapistmaybesubjecttoaco-paymentrequirement,providedthatany
requiredco-paymentamountshallbebetween125and150percentofthe
amountoftheco-paymentapplicabletocareandservicesprovidedbya
primarycareproviderundertheplan.
Subchapter10.PrescriptionDrugCoverage
§ 4091.DEFINITIONS
Asusedinthissubchapter:
(1)“Directsolicitation”meansdirectcontact,includingtelephone,
computer,email,instantmessaging,orin-personcontact,byapharmacy
provideroritsagenttoanindividualcoveredunderahealthinsuranceplan
withoutthecoveredindividual’sconsentforthepurposeofmarketingthe
pharmacyprovider’sservices.
(2)“Healthcareprofessional”meansanindividuallicensedtopractice
medicineunder26V.S.A.chapter23or33,anindividuallicensedasa
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physicianassistantunder26V.S.A.chapter31,oranindividuallicensedasan
advancedpracticeregisterednurseunder26V.S.A.chapter28.
(3)“Healthinsuranceplan”hasthesamemeaningasinsection4011of
thischapterandincludesprescriptiondrugbenefitsmanagedbyahealth
insurerorbyapharmacybenefitmanageronbehalfofahealthinsurer.
(4)“Interchangeablebiologicalproducts”hasthesamemeaningasin
18 V.S.A.§4601.
(5)“Out-of-pocketexpenditure”meansaco-payment,coinsurance,
deductible,orothercost-sharingmechanism.
(6)“Pharmacybenefitmanager”meansanentitythatperforms
pharmacybenefitmanagement.“Pharmacybenefitmanagement”meansan
arrangementfortheprocurementofprescriptiondrugsatnegotiateddispensing
rates,theadministrationormanagementofprescriptiondrugbenefitsprovided
byahealthinsuranceplanforthebenefitofbeneficiaries,oranyofthe
followingservicesprovidedwithregardtotheadministrationofpharmacy
benefits:
(A)mailservicepharmacy;
(B)claimsprocessing,retailnetworkmanagement,andpaymentof
claimstopharmaciesforprescriptiondrugsdispensedtobeneficiaries;
(C)clinicalformularydevelopmentandmanagementservices;
(D)rebatecontractingandadministration;
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(E)certainpatientcompliance,therapeuticintervention,andgeneric
substitutionprograms;and
(F)diseasemanagementprograms.
(7)“Pharmacybenefitmanageraffiliate”meansapharmacyor
pharmacistthat,directlyorindirectly,throughoneormoreintermediaries,is
ownedorcontrolledby,orisundercommonownershiporcontrolwith,a
pharmacybenefitmanager.
(8)“Prescriptiondrug”or“drug”hasthesamemeaningas“prescription
drug”in26V.S.A.§2022andincludes:
(A)biologicalproducts,asdefinedin18V.S.A.§4601;
(B)medicationsusedtotreatcomplex,chronicconditions,including
medicationsthatrequireadministration,infusion,orinjectionbyahealthcare
professional;
(C)medicationsforwhichthemanufacturerortheU.S.Foodand
DrugAdministrationrequiresexclusive,restricted,orlimiteddistribution;and
(D)medicationswithspecializedhandling,storage,orinventory
reportingrequirements.
(9)“Prescriptioninsulinmedication”meansaprescriptiondrugthat
containsinsulinandisusedtotreatdiabetes.
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(10)“Steptherapy”meansprotocolsthatestablishthespecificsequence
inwhichprescriptiondrugsforaspecificmedicalconditionaretobe
prescribed.
§ 4092.PRESCRIPTIONDRUGCOVERAGE
(a)Ahealthinsuranceplanshallnotincludeanannualdollarlimiton
prescriptiondrugbenefits.
(b)Ahealthinsuranceplanshalllimitacoveredindividual’sout-of-pocket
expendituresforallprescriptiondrugstonotmoreforself-onlyandfamily
coverageperyearthantheminimumdollaramountsineffectunderSection
223(c)(2)(A)(i)oftheInternalRevenueCodeof1986forself-onlyandfamily
coverage,respectively.
(c)(1)Forprescriptiondrugbenefitsofferedinconjunctionwithahigh-
deductiblehealthplan(HDHP),theplanshallnotprovideprescriptiondrug
benefitsuntiltheexpendituresapplicabletothedeductibleundertheHDHP
havemettheamountoftheminimumannualdeductiblesineffectforself-only
andfamilycoverageunderSection223(c)(2)(A)(i)oftheInternalRevenue
Codeof1986forself-onlyandfamilycoverage,respectively,exceptthata
planmayofferfirst-dollarprescriptiondrugbenefitstotheextentpermitted
underfederallaw.
(2)Oncetheapplicableexpenditureamountsetforthinsubdivision(1)
ofthissubsectionhasbeenmetundertheHDHP,coverageforprescription
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drugbenefitsshallbegin,andthelimitonout-of-pocketexpendituresfor
prescriptiondrugbenefitsshallbeasspecifiedinsubsection(b)ofthissection.
(d)(1)Ahealthinsuranceplanthatusesstep-therapyprotocolsshall:
(A)notrequirefailure,includingdiscontinuationduetolackof
efficacyoreffectiveness,diminishedeffect,oranadverseevent,onthesame
drugonmorethanoneoccasionforcoveredindividualswhoarecontinuously
enrolledinaplanofferedbythehealthinsureroritspharmacybenefit
manager;and
(B)grantanexceptiontoitsstep-therapyprotocolsuponrequestofa
coveredindividualorthecoveredindividual’streatinghealthcareprofessional
underthesametimeparametersassetforthforpriorauthorizationrequestsin
18V.S.A.§ 9418b(g)(4)ifanyoneormoreofthefollowingconditionsapply:
(i)theprescriptiondrugrequiredunderthestep-therapyprotocol
iscontraindicatedorwilllikelycauseanadversereactionorphysicalormental
harmtothecoveredindividual;
(ii)theprescriptiondrugrequiredunderthestep-therapyprotocol
isexpectedtobeineffectivebasedonthecoveredindividual’sknownclinical
history,condition,andprescriptiondrugregimen;
(iii)thecoveredindividualhasalreadytriedtheprescriptiondrugs
ontheprotocol,orotherprescriptiondrugsinthesamepharmacologicclassor
withthesamemechanismofaction,whichhavebeendiscontinuedduetolack
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ofefficacyoreffectiveness,diminishedeffect,oranadverseevent,regardless
ofwhetherthecoveredindividualwascoveredatthetimeonaplanofferedby
thecurrentinsureroritspharmacybenefitmanager;
(iv)thecoveredindividualisstableonaprescriptiondrugselected
bythecoveredindividual’streatinghealthcareprofessionalforthemedical
conditionunderconsideration;or
(v)thestep-therapyprotocoloraprescriptiondrugrequiredunder
theprotocolisnotinthecoveredindividual’sbestinterestsbecauseitwill:
(I)poseabarriertoadherence;
(II)likelyworsenacomorbidcondition;or
(III)likelydecreasethecoveredindividual’sabilitytoachieve
ormaintainreasonablefunctionalability.
(2)Nothinginthissubsectionshallbeconstruedtoprohibittheuseof
tieredco-paymentsforcoveredindividualsnotsubjecttoastep-therapy
protocol.
(3)Notwithstandinganyprovisionofsubdivision(1)ofthissubsection
tothecontrary,ahealthinsuranceshallnotutilizeastep-therapy,“failfirst,”or
otherprotocolthatrequiresdocumentedtrialsofaprescriptiondrug,including
atrialdocumentedthrougha“MedWatch”(FDAForm3500),before
approvingaprescriptionforthetreatmentofsubstanceusedisorder.
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(e)(1)Ahealthinsuranceplanshallnotrequire,asaconditionofcoverage,
useofdrugsnotindicatedbytheU.S.FoodandDrugAdministrationforthe
conditiondiagnosedandbeingtreatedunderthesupervisionofahealthcare
professional.
(2)Nothinginthissubsectionshallbeconstruedtopreventahealthcare
professionalfromprescribingaprescriptiondrugforoff-labeluse.
(f)Ahealthinsuranceplanshallapplythesamecost-sharingrequirements
tointerchangeablebiologicalproductsasapplytogenericdrugsunderthe
plan.
(g)(1)Ahealthinsuranceplanshalllimitacoveredindividual’stotalout-
of-pocketresponsibilityforprescriptioninsulindrugstonotmorethan
$100.00per30-daysupply,regardlessoftheamount,type,ornumberof
insulindrugsprescribedforthecoveredindividual.
(2)The$100.00monthlylimitonout-of-pocketspendingfor
prescriptioninsulindrugssetforthinsubdivision(1)ofthissubsectionshall
applyregardlessofwhetherthecoveredindividualhassatisfiedanyapplicable
deductiblerequirementunderthehealthinsuranceplan.
(h)Ahealthinsuranceplanshallcover,withoutrequiringprior
authorization,atleastonereadilyavailableasthmacontrollerdrugfromeach
classofdrugandmodeofadministration.Asusedinthissubsection,“readily
available”meansthatthemedicationisnotlistedonanationaldrugshortage
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list,includinglistsmaintainedbytheU.S.FoodandDrugAdministrationand
bytheAmericanSocietyofHealth-SystemPharmacists.
(i)Onaperiodicbasisbutnotlessthanoncepercalendaryear,eachhealth
insurershallnotifyallindividualscoveredunderitshealthinsuranceplansof
anychangesinpharmaceuticalcoverageandprovideaccesstothepreferred
druglistmaintainedbythehealthinsureroritspharmacybenefitmanager.
(j)TheDepartmentofFinancialRegulationshallenforcethissectionand
mayadoptrulesasnecessarytocarryoutthepurposesofthissection.
(k)Ahealthinsuranceplanshallprovidecoverageforprescriptiondrugs
purchasedinCanadaandusedinCanadaorreimportedlegallyonthesame
benefittermsandconditionsasprescriptiondrugspurchasedinthiscountry.
Fordrugspurchasedbymailorthroughtheinternet,theplanmayrequire
accreditationbytheInternetandMailorderPharmacyAccreditation
Commission(IMPAC/tm)orsimilarorganization.
§ 4093.RETAILPHARMACIES;FILLINGOFPRESCRIPTIONS
(a)Ahealthinsurerorpharmacybenefitmanagerdoingbusinessin
Vermontshallpermitaretailpharmacistlicensedunder26V.S.A.chapter36
tofillprescriptionsforallprescriptiondrugsinthesamemannerandatthe
samelevelofreimbursementastheyarefilledbyanyotherpharmacistor
pharmacy,includingamail-orderpharmacyorapharmacybenefitmanager
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affiliate,withrespecttothequantityofdrugsordays’supplyofdrugs
dispensedundereachprescription.
(b)Notwithstandinganyprovisionofahealthinsuranceplantothe
contrary,ifahealthinsuranceplanprovidesforpaymentorreimbursement
thatiswithinthelawfulscopeofpracticeofapharmacist,thehealthinsurer
mayprovidepaymentorreimbursementfortheservicewhentheserviceis
providedbyapharmacist.
(c)(1)Ahealthinsurerorpharmacybenefitmanagershallpermita
participatingnetworkpharmacytoperformallpharmacyserviceswithinthe
lawfulscopeoftheprofessionofpharmacyassetforthin26V.S.A.chapter
36.
(2)Ahealthinsurerorpharmacybenefitmanagershallnotdoanyof
thefollowing:
(A)Requireacoveredindividual,asaconditionofpaymentor
reimbursement,topurchasepharmacistservices,includingprescriptiondrugs,
exclusivelythroughamail-orderpharmacyorapharmacybenefitmanager
affiliate.
(B)Offerorimplementplandesignsthatrequireacoveredindividual
touseamail-orderpharmacyorapharmacybenefitmanageraffiliate.
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(C)Orderacoveredindividual,orallyorinwriting,including
throughonlinemessaging,touseamail-orderpharmacyorapharmacybenefit
manageraffiliate.
(D)Establishnetworkrequirementsthataremorerestrictivethanor
inconsistentwithStateorfederallaw,rulesadoptedbytheBoardofPharmacy,
orguidanceprovidedbytheBoardofPharmacyorbydrugmanufacturersthat
operatetolimitorprohibitapharmacyorpharmacistfromdispensingor
prescribingdrugs.
(E)Offerorimplementplandesignsthatincreaseplanorpatient
costsifthecoveredindividualchoosesnottouseamail-orderpharmacyora
pharmacybenefitmanageraffiliate.Theprohibitioninthissubdivision(E)
includesrequiringacoveredindividualtopaythefullcostforaprescription
drugwhenthecoveredindividualchoosesnottouseamail-orderpharmacyor
apharmacybenefitmanageraffiliate.
(F)(i)Excludeanyamountpaidbyoronbehalfofacovered
individual,includinganythird-partypayment,financialassistance,discount,
coupon,orotherreduction,whencalculatingacoveredindividual’s
contributiontoward:
(I)theout-of-pocketlimitsforprescriptiondrugcostsunder
section4092ofthistitle;
(II)thecoveredindividual’sdeductible,ifany;or
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(III)totheextentnotinconsistentwithSec.2707ofthePublic
HealthServiceAct,42U.S.C.§ 300gg-6,theannualout-of-pocketmaximums
applicabletothecoveredindividual’shealthbenefitplan.
(ii)Theprovisionsofsubdivision(i)ofthissubdivision(F)
relatingtoathird-partypayment,financialassistance,discount,coupon,or
otherreductioninout-of-pocketexpensesmadeonbehalfofacovered
individualshallonlyapplytoaprescriptiondrug:
(I)forwhichthereisnogenericdrugorinterchangeable
biologicalproduct,asthosetermsaredefinedin18V.S.A.§4601;or
(II)forwhichthereisagenericdrugorinterchangeable
biologicalproduct,asthosetermsaredefinedin18V.S.A.§4601,butfor
whichthecoveredindividualhasobtainedaccessthroughpriorauthorization,
asteptherapyprotocol,orthepharmacybenefitmanager’sorhealthinsurer’s
exceptionsandappealsprocess.
(iii)Theprovisionsofsubdivision(i)ofthissubdivision(F)shall
applytoahigh-deductiblehealthplanonlytotheextentthatitwouldnot
disqualifytheplanfromeligibilityforahealthsavingsaccountpursuantto
26 U.S.C.§ 223.
(3)Ahealthinsurerorpharmacybenefitmanagershallnot,bycontract,
writtenpolicy,orwrittenprocedure,requirethatapharmacydesignatedbythe
healthinsurerorpharmacybenefitmanagerdispenseamedicationdirectlytoa
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coveredindividualwiththeexpectationorintentionthatthecoveredindividual
willtransportthemedicationtoahealthcaresettingforadministrationbya
healthcareprofessional.
(4)Ahealthinsurerorpharmacybenefitmanagershallnot,bycontract,
writtenpolicy,orwrittenprocedure,requirethatapharmacydesignatedbythe
healthinsurerorpharmacybenefitmanagerdispenseamedicationdirectlytoa
healthcaresettingforahealthcareprofessionaltoadministertoacovered
individual.
(5)Ahealthinsurerorpharmacybenefitmanagershalladheretothe
definitionsofprescriptiondrugsandtherequirementsandguidanceregarding
thepharmacyprofessionestablishedbyStateandfederallawandtheVermont
BoardofPharmacyandshallnotestablishclassificationsofordistinctions
betweenprescriptiondrugs,imposepenaltiesonprescriptiondrugclaims,
attempttodictatethebehaviorofpharmaciesorpharmacists,orplace
restrictionsonpharmaciesorpharmaciststhataremorerestrictivethanor
inconsistentwithStateorfederallaworwithrulesadoptedorguidance
providedbytheBoardofPharmacy.
(6)Apharmacybenefitmanagerorlicensedpharmacyshallnotmakea
directsolicitationtoanindividualcoveredbyahealthinsuranceplanunless
oneormoreofthefollowingapplies:
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(A)thecoveredindividualhasgivenwrittenpermissiontothe
supplierortheorderinghealthcareprofessionaltocontactthecovered
individualregardingthefurnishingofaprescriptionitemthatistoberentedor
purchased;
(B)thesupplierhasfurnishedaprescriptionitemtothecovered
individualandiscontactingthecoveredindividualtocoordinatedeliveryof
theitem;or
(C)ifthecontactrelatestothefurnishingofaprescriptionitemother
thanaprescriptionitemalreadyfurnishedtothecoveredindividual,the
supplierhasfurnishedatleastoneprescriptionitemtothecoveredindividual
withinthe15-monthperiodprecedingthedateonwhichthesupplierattempts
tomakethecontact.
(d)Ahealthinsurerorpharmacybenefitmanagershallnotalteracovered
individual’sprescriptiondrugorderorthepharmacychosenbythecovered
individualwithoutthecoveredindividual’sconsent;provided,however,that
nothinginthissubsectionshallbeconstruedtoaffectthedutyofapharmacist
tosubstitutealower-costdrugorbiologicalproductinaccordancewiththe
provisionsof18V.S.A.§ 4605.
(e)Alloftheprovisionsofthissectionexceptsubsection(c)shallapplyto
Medicaidandanyotherpublichealthcareassistanceprogramofferedor
administeredbytheStateorbyanysubdivisionorinstrumentalityoftheState.
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Subchapter11.PreventionandTreatmentofCancer
§ 4095a.COLORECTALCANCERSCREENING
(a)Asusedinthissection,“colonoscopy”meansaprocedurethatenables
ahealthcareprofessionaltoexaminevisuallytheinsideofapatient’sentire
colonandincludestheconcurrentremovalofpolypsorbiopsy,orboth.
(b)Ahealthinsuranceplanshallprovidecoverageforcolorectalcancer
screening,including:
(1)foracoveredindividualwhoisnotathighriskforcolorectalcancer,
colorectalcancerscreeningexaminationsandlaboratorytestsinaccordance
withthemostrecentlypublishedrecommendationsestablishedbytheU.S.
PreventiveServicesTaskForceforaverage-riskindividuals;and
(2)foracoveredindividualwhoisathighriskforcolorectalcancer,
colorectalcancerscreeningexaminationsandlaboratorytestsasrecommended
bythetreatinghealthcareprofessional.
(c)Forthepurposesofsubdivision(b)(2)ofthissection,anindividualisat
highriskforcolorectalcanceriftheindividualhas:
(1)afamilymedicalhistoryofcolorectalcancerorageneticsyndrome
predisposingtheindividualtocolorectalcancer;
(2)aprioroccurrenceofcolorectalcancerorprecursorpolyps;
(3)aprioroccurrenceofachronicdigestivediseaseconditionsuchas
inflammatoryboweldisease,Crohn’sdisease,orulcerativecolitis;or
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(4)otherpredisposingfactorsasdeterminedbytheindividual’streating
healthcareprofessional.
(d)Colorectalcancerscreeningservicesperformedundercontractwiththe
insurershallnotbesubjecttoanyco-payment,deductible,coinsurance,or
othercost-sharingrequirement.Inaddition,acoveredindividualshallnotbe
subjecttoanyadditionalchargeforanyserviceassociatedwithaprocedureor
testforcolorectalcancerscreening,whichmayincludeoneormoreofthe
following:
(1)removaloftissueorothermatter;
(2)laboratoryservices;
(3)healthcareprofessionalservices;
(4)facilityuse;and
(5)anesthesia.
§ 4095b.MAMMOGRAPHY ANDOTHERBREASTIMAGING
SERVICES
(a)(1)Ahealthinsuranceplanshallprovidecoverageforscreening
mammographyandforothermedicallynecessarybreastimagingservicesupon
recommendationofahealthcareprofessionalasneededtodetectthepresence
ofbreastcancerandotherabnormalitiesofthebreastorbreasttissue.In
addition,ahealthinsuranceplanshallprovidecoverageforscreeningby
ultrasoundoranotherappropriateimagingserviceforacoveredindividualfor
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whomtheresultsofascreeningmammogramwereinconclusiveorwhohas
densebreasttissue,orboth.
(2)Benefitsprovidedshallcoverthefullcostofthemammography,
ultrasound,andotherbreastimagingservicesandshallnotbesubjecttoany
co-payment,deductible,coinsurance,orothercost-sharingrequirementor
additionalcharge,excepttotheextentthatsuchcoveragewoulddisqualifya
high-deductiblehealthplanfromeligibilityforahealthsavingsaccount
pursuantto26U.S.C.§ 223.
(b)Thissectionshallapplyonlytoproceduresconductedbytestfacilities
accreditedbytheAmericanCollegeofRadiologists.
(c)Asusedinthissection:
(1)“Mammography”meansthex-rayexaminationofthebreastusing
equipmentdedicatedspecificallyformammography,includingthex-raytube,
filter,compressiondevice,anddigitaldetector.Thetermincludesbreast
tomosynthesis.
(2)“Otherbreastimagingservices”meansdiagnosticmammography,
ultrasound,andmagneticresonanceimagingservicesthatenablehealthcare
professionalstodetectthepresenceorabsenceofbreastcancerandother
abnormalitiesaffectingthebreastorbreasttissue.
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(3)“Screening”includesthemammographyorultrasoundtest
procedureandaqualifiedhealthcareprofessional’sinterpretationoftheresults
oftheprocedure,includingadditionalviewsandinterpretationasneeded.
§ 4095c.PROSTATECANCERSCREENINGS
Ahealthinsuranceplanshallprovidecoverageforprostatecancer
screeningsconsistentwiththerecommendationsoftheCentersforDisease
ControlandPreventionoruponrecommendationofthecoveredindividual’s
healthcareprofessional.Benefitsprovidedshallbeatleastasfavorableas
coverageforothercancerscreeningproceduresandsubjecttothesamedollar
limits,deductibles,andcoinsurancefactorswithintheprovisionsofthepolicy.
§ 4095d.CHEMOTHERAPY TREATMENTANDORALANTICANCER
MEDICATIONS
(a)Ahealthinsuranceplanshallprovidecoverageformedicallynecessary
growthcellstimulatingfactorinjectionstakenaspartofaprescribed
chemotherapyregimen.
(b)Ahealthinsuranceplanshallprovidecoverageforprescribed,orally
administeredanticancermedicationsusedtokillorslowthegrowthof
cancerouscellsthatisnotlessfavorableonafinancialbasisthanintravenously
administeredorinjectedanticancermedicationscoveredunderthecovered
individual’splan.
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§ 4095e.CLINICALTRIALSFORCANCERPATIENTS
(a)TheCommissionershall,afternoticeandhearing,adoptrulesrequiring
thatallhealthinsuranceplansissuedinthisStateprovidecoverageforroutine
costsforcoveredindividualswhoparticipateincancerclinicaltrials.
(1)Anyrulesadoptedunderthissectionshallbelimitedtothecoverage
ofroutinecostsforcoveredindividualswhoparticipateinacancerclinical
trial.
(2)Anyrulesadoptedunderthissectionshallberestrictedtoapproved
cancerclinicaltrialsconductedundertheauspicesofthefollowingcancercare
providers(cancercareproviders):TheUniversityofVermontMedicalCenter,
theNorrisCottonCancerCenteratDartmouth-HitchcockMedicalCenter,and
approvedclinicaltrialsadministeredbyahospitalanditsaffiliated,qualified
cancercareproviders.
(3)ForparticipationinclinicaltrialslocatedoutsideVermont,coverage
underthissectionshallberequiredonlyifthecoveredindividualprovides
noticetothehealthinsuranceplanpriortoparticipationintheclinicaltrial,
andoneormoreofthefollowingcircumstancesapplies:
(A)noclinicaltrialisavailableattheVermontorNewHampshire
cancercareprovidersdescribedinsubdivision(2)ofthissubsection(a);
(B)thecoveredindividualalreadyhascompletedaclinicaltrialat
oneoftheVermontorNewHampshirecancercareprovidersdescribedin
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subdivision(2)ofthissubsection(a)andthecoveredindividual’scancercare
providerdeterminesthatasubsequentclinicaltrialrelatedtotheoriginal
diagnosisisavailableoutsidethehealthbenefitplan’snetworkandthat
participationinthatclinicaltrialwouldbeinthebestinterestsofthecovered
individual,evenifacomparableclinicaltrialisavailableatthattimeatoneor
bothoftheVermontorNewHampshirecancercareprovidersdescribedin
subdivision(2)ofthissubsection(a);or
(C)thehealthinsuranceplanhasalreadyapprovedareferralofthe
coveredindividualtoanout-of-networkcancercareproviderandanout-of-
networkclinicaltrialbecomesavailableandthecoveredindividual’scancer
careproviderdeterminesparticipationinthatclinicaltrialwouldbeinthebest
interestsofthecoveredindividual,evenifacomparableclinicaltrialis
availableatoneorbothoftheVermontorNewHampshirecancercare
providersdescribedinsubdivision(2)ofthissubsection(a).
(4)Ifacoveredindividualparticipatesinaclinicaltrialadministeredby
acancercareproviderthatisnotinthehealthinsuranceplan’sprovider
network,thehealthinsuranceplanmayrequirethatroutinefollow-upcarebe
providedwithinthehealthinsuranceplan’snetwork,unlessthecancercare
providerdeterminesthiswouldnotbeinthebestinterestofthecovered
individual.
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(b)ThissectionshallapplytoMedicaidandanyotherpublichealthcare
assistanceprogramofferedoradministeredbytheStateorbyanysubdivision
orinstrumentalityoftheState.
§ 4095f.OFF-LABELUSEOFPRESCRIPTIONDRUGSFORCANCER
(a)Asusedinthissection:
(1)“Medicalorscientificevidence”meansoneormoreofthefollowing
sources:
(A)peer-reviewedscientificstudiespublishedinoracceptedfor
publicationbymedicaljournalsthatmeetnationallyrecognizedrequirements
forscientificmanuscriptsandthatsubmitmostoftheirpublishedarticlesfor
reviewbyexpertswhoarenotpartoftheeditorialstaff;
(B)peer-reviewedliterature,biomedicalcompendia,andother
medicalliteraturethatmeetthecriteriaoftheNationalInstitutesofHealth’s
NationalLibraryofMedicineforindexinginIndexMedicus,Excerpta
Medicus(EMBASE),Medline,andMEDLARSdatabaseHealthServices
TechnologyAssessmentResearch(HSTAR);
(C)medicaljournalsrecognizedbytheSecretaryoftheU.S.
DepartmentofHealthandHumanServicesunderSection1861(t)(2)ofthe
SocialSecurityAct;
(D)thefollowingstandardreferencecompendia:theAmerican
HospitalFormularyService-DrugInformation,theAmericanMedical
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AssociationDrugEvaluation,andtheUnitedStatesPharmacopoeia-Drug
Information;
(E)findings,studies,orresearchconductedbyorundertheauspices
offederalgovernmentagenciesandnationallyrecognizedfederalresearch
institutes,includingtheAgencyforHealthCarePolicyandResearch,National
InstitutesofHealth,NationalCancerInstitute,NationalAcademyofSciences,
CentersforMedicareandMedicaidServices,andanynationalboard
recognizedbytheNationalInstitutesofHealthforthepurposeofevaluating
themedicalvalueofhealthservices;and
(F)peer-reviewedabstractsacceptedforpresentationatmajor
medicalassociationmeetings.
(2)“Medicallyacceptedindication”includesanyuseofadrugthathas
beenapprovedbytheU.S.FoodandDrugAdministrationandincludes
anotheruseofthedrugifthatuseisprescribedbythecoveredindividual’s
healthcareprofessionalandsupportedbymedicalorscientificevidence.
(3)“Off-labeluse”meanstheprescriptionanduseofdrugsfor
medicallyacceptedindicationsotherthanthosestatedinthelabelingapproved
bytheU.S.FoodandDrugAdministration.
(b)Ahealthinsuranceplanshallprovidecoverageforoff-labelusein
cancertreatmentinaccordancewiththefollowing:
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(1)Ahealthinsuranceplancontractshallnotexcludecoverageforany
drugusedforthetreatmentofcancerongroundsthatthedrughasnotbeen
approvedbytheU.S.FoodandDrugAdministration,providedtheuseofthe
drugisamedicallyacceptedindicationforthetreatmentofcancer.
(2)Coverageofadrugrequiredbythissectionalsoincludesmedically
necessaryservicesassociatedwiththeadministrationofthedrug.
(3)Thissectionshallnotbeconstruedtorequirecoverageforadrug
whentheU.S.FoodandDrugAdministrationhasdetermineditsusetobe
contraindicatedfortreatmentofthecurrentindication.
(4)Adrugusethatiscoveredundersubdivision(1)ofthissubsection
shallnotbedeniedcoveragebasedona“medicalnecessity”requirement
exceptforareasonunrelatedtothelegalstatusofthedruguse.
(5)Ahealthinsuranceplanthatprovidescoverageofadrugasrequired
bythissectionmaycontainprovisionsformaximumbenefitsandcoinsurance
andreasonablelimitations,deductibles,andexclusionstothesameextentthese
provisionsareapplicabletocoverageofallprescriptiondrugsandarenot
inconsistentwiththerequirementsofthissection.
(c)Adeterminationbyahealthinsurerthatanoff-labeluseofa
prescriptiondrugunderthissectionisnotamedicallyacceptedindication
supportedbymedicalorscientificevidenceiseligibleforreviewundersection
4063ofthistitle.
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(d)ThissectionshallapplytoMedicaidandanyotherpublichealthcare
assistanceprogramofferedoradministeredbytheStateorbyanysubdivision
orinstrumentalityoftheState.
Subchapter12.ServiceDeliveryandTreatmentModalities
§ 4098a.COVERAGEOFHEALTHCARESERVICESDELIVERED
THROUGHTELEMEDICINEANDBYSTORE-AND-FORWARD
MEANS
(a)Asusedinthissection:
(1)“Distantsite”meansthelocationofthehealthcareprovider
deliveringservicesthroughtelemedicineatthetimetheservicesareprovided.
(2)“Healthinsuranceplan”hasthesamemeaningasinsection4011of
thistitleandalsoincludesastand-alonedentalplanorpolicyorotherdental
insuranceplanofferedbyadentalinsurer.
(3)“Healthcarefacility”hasthesamemeaningasin18V.S.A.§9402.
(4)“Healthcareprovider”meansaperson,partnership,orcorporation,
otherthanafacilityorinstitution,thatislicensed,certified,orotherwise
authorizedbylawtoprovideprofessionalhealthcareservices,includingdental
services,inthisStatetoanindividualduringthatindividual’smedicalcare,
treatment,orconfinement.
(5)“Originatingsite”meansthelocationofthepatient,whetherornot
accompaniedbyahealthcareprovider,atthetimeservicesareprovidedbya
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healthcareproviderthroughtelemedicine,includingahealthcareprovider’s
office,ahospital,orahealthcarefacility,orthepatient’shomeoranother
nonmedicalenvironmentsuchasaschool-basedhealthcenter,auniversity-
basedhealthcenter,orthepatient’sworkplace.
(6)“Store-and-forward”meansanasynchronoustransmissionof
medicalinformation,suchasoneormorevideoclips,audioclips,stillimages,
x-rays,magneticresonanceimagingscans,electrocardiograms,
electroencephalograms,orlaboratoryresults,sentoverasecureconnection
thatcomplieswiththerequirementsoftheHealthInsurancePortabilityand
AccountabilityActof1996,Pub.L.No.104-191tobereviewedatalaterdate
byahealthcareprovideratadistantsitewhoistrainedintherelevant
specialty.Instore-and-forward,thehealthcareprovideratthedistantsite
reviewsthemedicalinformationwithoutthepatientpresentinrealtimeand
communicatesacareplanortreatmentrecommendationbacktothepatientor
referringprovider,orboth.
(7)“Telemedicine”meansthedeliveryofhealthcareservices,including
dentalservices,suchasdiagnosis,consultation,ortreatment,throughtheuse
ofliveinteractiveaudioandvideooverasecureconnectionthatcomplieswith
therequirementsoftheHealthInsurancePortabilityandAccountabilityActof
1996,Pub.L.No.104-191.
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(b)(1)Ahealthinsuranceplanshallprovidecoverageforhealthcare
servicesanddentalservicesdeliveredthroughtelemedicinebyahealthcare
provideratadistantsitetoacoveredindividualatanoriginatingsitetothe
sameextentthattheplanwouldcovertheservicesiftheywereprovided
throughin-personconsultation.
(2)(A)Ahealthinsuranceplanshallprovidethesamereimbursement
rateforservicesbilledusingequivalentprocedurecodesandmodifiers,subject
tothetermsofthehealthinsuranceplanandprovidercontract,regardlessof
whethertheservicewasprovidedthroughanin-personvisitwiththehealth
careproviderorthroughtelemedicine.
(B)Theprovisionsofsubdivision(A)ofthissubdivision(2)shall
notapply:
(i)toservicesprovidedpursuanttothehealthinsuranceplan’s
contractwithathird-partytelemedicinevendortoprovidehealthcareordental
services;or
(ii)intheeventthatahealthinsurerandhealthcareproviderenter
intoavalue-basedcontractforhealthcareservicesthatincludecaredelivered
throughtelemedicineorbystore-and-forwardmeans.
(c)Ahealthinsuranceplanmaychargeadeductible,co-payment,or
coinsuranceforahealthcareserviceordentalserviceprovidedthrough
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telemedicineaslongasitdoesnotexceedthedeductible,co-payment,or
coinsuranceapplicabletoanin-personconsultation.
(d)Ahealthinsuranceplanmaylimitcoveragetohealthcareprovidersin
theplan’snetwork.Ahealthinsuranceplanshallnotimposelimitationson
thenumberoftelemedicineconsultationsacoveredindividualmayreceive
thatexceedlimitationsotherwiseplacedonin-personcoveredservices.
(e)Nothinginthissectionshallbeconstruedtoprohibitahealthinsurance
planfromprovidingcoverageforonlythoseservicesthataremedically
necessaryandareclinicallyappropriatefordeliverythroughtelemedicine,
subjecttothetermsandconditionsofthecoveredindividual’spolicy.
(f)(1)Ahealthinsuranceplanshallreimburseforhealthcareservicesand
dentalservicesdeliveredbystore-and-forwardmeans.
(2)Ahealthinsuranceplanshallnotimposemorethanonecost-sharing
requirementonacoveredindividualforreceiptofhealthcareservicesor
dentalservicesdeliveredbystore-and-forwardmeans.Iftheserviceswould
requirecostsharingunderthetermsofthecoveredindividual’shealth
insuranceplan,theplanmayimposethecostsharingrequirementonthe
servicesoftheoriginatingsitehealthcareproviderorofthedistantsitehealth
careprovider,butnotboth.
(g)Ahealthinsuranceplanshallnotconstrueacoveredindividual’s
receiptofservicesdeliveredthroughtelemedicineorbystore-and-forward
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meansaslimitinginanywaythecoveredindividual’sabilitytoreceive
additionalcoveredin-personservicesfromthesameoradifferenthealthcare
providerfordiagnosisortreatmentofthesamecondition.
(h)Nothinginthissectionshallbeconstruedtorequireahealthinsurance
plantoreimbursethedistantsitehealthcareproviderifthedistantsitehealth
careproviderhasinsufficientinformationtorenderanopinion.
(i)Inordertofacilitatetheuseoftelemedicineintreatingsubstanceuse
disorder,whentheoriginatingsiteisahealthcarefacility,healthinsurersand
theDepartmentofVermontHealthAccessshallensurethatthehealthcare
provideratthedistantsiteandthehealthcarefacilityattheoriginatingsiteare
bothreimbursedfortheservicesrendered,unlessthehealthcareprovidersat
boththedistantandoriginatingsitesareemployedbythesameentity.
(j)ThissectionshallapplytoMedicaidandanyotherpublichealthcare
assistanceprogramofferedoradministeredbytheStateorbyanysubdivision
orinstrumentalityoftheState.
§4098b.COVERAGEOFHEALTHCARESERVICESDELIVEREDBY
AUDIO-ONLYTELEPHONE
(a)Asusedinthissection,“healthcareprovider”meansaperson,
partnership,orcorporation,otherthanafacilityorinstitution,thatislicensed,
certified,orotherwiseauthorizedbylawtoprovideprofessionalhealthcare
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servicesinthisStatetoanindividualduringthatindividual’smedicalcare,
treatment,orconfinement.
(b)(1)Ahealthinsuranceplanshallprovidecoverageforallmedically
necessary,clinicallyappropriatehealthcareservicesdeliveredremotelyby
audio-onlytelephonetothesameextentthattheplanwouldcovertheservices
iftheywereprovidedthroughin-personconsultation.Servicescoveredunder
thissubdivisionshallincludeservicesthatarecoveredwhenprovidedinthe
homebyhomehealthagencies.
(2)(A)Ahealthinsuranceplanshallprovidethesamereimbursement
rateforservicesbilledusingequivalentprocedurecodesandmodifiers,subject
tothetermsofthehealthinsuranceplanandprovidercontract,regardlessof
whethertheservicewasprovidedthroughanin-personvisitwiththehealth
careproviderorbyaudio-onlytelephone.
(B)Theprovisionsofsubdivision(A)ofthissubdivision(2)shall
notapplyintheeventthatahealthinsurerandhealthcareproviderenterintoa
value-basedcontractforhealthcareservicesthatincludecaredeliveredby
audio-onlytelephone.
(c)Ahealthinsuranceplanmaychargeanotherwisepermissible
deductible,co-payment,orcoinsuranceforahealthcareservicedeliveredby
audio-onlytelephone,providedthatitdoesnotexceedthedeductible,co-
payment,orcoinsuranceapplicabletoanin-personconsultation.
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(d)Ahealthinsuranceplanshallnotrequireahealthcareprovidertohave
anexistingrelationshipwithacoveredindividualinordertobereimbursedfor
healthcareservicesdeliveredbyaudio-onlytelephone.
(e)ThissectionshallapplytoMedicaid,totheextentpermittedbythe
CentersforMedicareandMedicaidServices,andanyotherpublichealthcare
assistanceprogramofferedoradministeredbytheStateorbyanysubdivision
orinstrumentalityoftheState.
§ 4098c.COVEREDSERVICESPROVIDEDBYNATUROPATHIC
PHYSICIANS
(a)Ahealthinsuranceplanshallprovidecoverageformedicallynecessary
healthcareservicescoveredbytheplanwhenprovidedbyanaturopathic
physicianlicensedinthisStatefortreatmentwithinthescopeofpractice
describedin26V.S.A.chapter81andshallrecognizenaturopathicphysicians
whopracticeprimarycaretobeprimarycarephysicians.
(b)Healthcareservicesprovidedbynaturopathicphysiciansmaybe
subjecttoreasonabledeductibles,co-paymentandcoinsuranceamounts,and
feeorbenefitlimitsconsistentwiththoseapplicabletootherprimarycare
physiciansundertheplan,aswellaspracticeparameters,cost-effectiveness
andclinicalefficacystandards,andutilizationreviewconsistentwithany
applicablerulespublishedbytheDepartmentofFinancialRegulation.Any
amounts,limits,standards,andreviewshallnotfunctiontodirecttreatmentin
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amannerunfairlydiscriminativeagainstnaturopathiccare,andcollectively
shallbenotmorerestrictivethanthoseapplicableunderthesameplantocare
orservicesprovidedbyotherprimarycarephysicians,butmayallowforthe
managementofthebenefitconsistentwithvariationsinpracticepatternsand
treatmentmodalitiesamongdifferenttypesofhealthcareprofessionals.
(c)Ahealthinsuranceplanmayrequirethatthenaturopathicphysician’s
servicesbeprovidedbyalicensednaturopathicphysicianundercontractwith
theinsurerorshallbecoveredinamannerconsistentwithout-of-network
providerreimbursementpracticesforprimarycarephysicians;however,this
shallnotrelieveahealthinsuranceplanfromcompliancewiththeapplicable
networkadequacyrequirementsadoptedbytheCommissionerbyrule.
(d)Nothingcontainedinthissectionshallbeconstruedasimpedingor
preventingeithertheprovisionorthecoverageofhealthcareservicesby
licensednaturopathicphysicians,withinthelawfulscopeofnaturopathic
practice,inhospitalfacilitiesonastafforemployeebasis.
(e)ThissectionshallapplytoMedicaidandanyotherpublichealthcare
assistanceprogramofferedoradministeredbytheStateorbyanysubdivision
orinstrumentalityoftheState.
§ 4098d.COVEREDSERVICESPROVIDEDBYATHLETICTRAINERS
(a)Totheextentahealthinsuranceplanprovidescoverageforaparticular
typeofhealthcareserviceorforanyparticularmedicalconditionthatis
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withinthescopeofpracticeofathletictrainers,alicensedathletictrainerwho
actswithinthescopeofpracticeauthorizedby26V.S.A.chapter83shallnot
bedeniedreimbursementbythehealthinsuranceplanforthosecovered
servicesifthehealthinsuranceplanwouldreimburseanotherhealthcare
professionalforthoseservices.
(b)Healthcareservicesprovidedbyathletictrainersmaybesubjectto
reasonabledeductibles,co-paymentandco-insuranceamounts,feeorbenefit
limits,practiceparameters,andutilizationreviewconsistentwithapplicable
rulesadoptedbytheDepartmentofFinancialRegulation,providedthatthe
amounts,limits,andreviewshallnotfunctiontodirecttreatmentinamanner
unfairlydiscriminativeagainstathletictrainercare,andcollectivelyshallbe
notmorerestrictivethanthoseapplicableunderthesamepolicyforcareor
servicesprovidedbyotherhealthcareprofessionalsbutallowingforthe
managementofthebenefitconsistentwithvariationsinpracticepatternsand
treatmentmodalitiesamongdifferenttypesofhealthcareprofessionals.
(c)Ahealthinsurermayrequirethattheathletictrainerservicesbe
providedbyalicensedathletictrainerundercontractwiththeinsurer.
(d)Nothinginthissectionshallbeconstruedasimpedingorpreventing
eithertheprovisionorcoverageofhealthcareservicesbylicensedathletic
trainerswithinthelawfulscopeofathletictrainerpractice.
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§ 4098e.CHOICEOFPROVIDERSFORVISIONCAREANDMEDICAL
EYECARESERVICES
(a)Asusedinthissection:
(1)“Coveredservices”meansservicesandmaterialsforwhich
reimbursementfromavisioncareplanorotherhealthinsuranceplanis
providedbyamember’sorsubscriber’splancontract,orforwhicha
reimbursementwouldbeavailablebutforapplicationofthedeductible,co-
payment,orcoinsurancerequirementsunderthemember’sorsubscriber’s
healthinsuranceplan.
(2)“Healthinsuranceplan”hasthesamemeaningasinsection4011of
thischapterandalsoincludesvisioncareplans.
(3)“Materials”includeslenses,devicescontaininglenses,prisms,lens
treatmentsandcoatings,contactlenses,andprostheticdevicestocorrect,
relieve,ortreatdefectsorabnormalconditionsofthehumaneyeoritsadnexa.
(4)“Ophthalmologist”meansaphysicianlicensedpursuantto26V.S.A.
chapter23oranosteopathicphysicianlicensedpursuantto26V.S.A.chapter
33whohashadspecialtraininginthefieldofophthalmology.
(5)“Optician”meansapersonlicensedpursuantto26V.S.A.chapter
47.
(6)“Optometrist”meansapersonlicensedpursuantto26V.S.A.
chapter30.
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(7)“Visioncareplan”meansanintegratedorstand-aloneplan,policy,
orcontractprovidingvisionbenefitstoenrolleeswithrespecttocovered
servicesorcoveredmaterials,orboth.
(b)Totheextentahealthinsuranceplanprovidescoverageforvisioncare
ormedicaleyecareservices,itshallcoverthoseserviceswhetherprovidedby
alicensedoptometristorbyalicensedophthalmologist,providedthehealth
careprofessionalisactingwithinthehealthcareprofessional’sauthorized
scopeofpracticeandparticipatesintheplan’snetwork.
(c)Ahealthinsuranceplanshallimposenogreaterco-payment,
coinsurance,orothercost-sharingamountforserviceswhenprovidedbyan
optometristthanforthesameservicewhenprovidedbyanophthalmologist.
(d)Ahealthinsuranceplanshallprovidetoalicensedhealthcare
professionalactingwithinthehealthcareprofessional’sscopeofpracticethe
samelevelofreimbursementorothercompensationforprovidingvisioncare
andmedicaleyecareservicesthatarewithinthelawfulscopeofpracticeof
theprofessionsofmedicine,optometry,andosteopathy,regardlessofwhether
thehealthcareprofessionalisanoptometristoranophthalmologist.
(e)(1)Ahealthinsurershallpermitalicensedoptometristtoparticipatein
plansorcontractsprovidingforvisioncareormedicaleyecaretothesame
extentasitdoesanophthalmologist.
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(2)Ahealthinsurershallnotrequirealicensedoptometristor
ophthalmologisttoprovidediscountedmaterialsbenefitsortoparticipateasa
providerinanotherhealthinsuranceorvisioncareplanorcontractasa
conditionorrequirementfortheoptometrist’sorophthalmologist’s
participationasaproviderinanyhealthinsuranceorvisioncareplanor
contract.
(f)(1)Anagreementbetweenahealthinsurerandanoptometristor
ophthalmologistfortheprovisionofvisionservicestoplanmembersor
subscribersinconnectionwithcoverageunderastand-alonevisioncareplan
orotherhealthinsuranceplanshallnotrequirethatanoptometristor
ophthalmologistprovideservicesormaterialsatafeelimitedorsetbytheplan
orinsurerunlesstheservicesormaterialsarereimbursedascoveredservices
underthecontract.
(2)Anoptometristorophthalmologistshallnotchargemoreforservices
andmaterialsthatarenoncoveredservicesunderavisioncareplanorother
healthinsuranceplanthantheoptometrist’sorophthalmologist’susualand
customaryrateforthoseservicesandmaterials.
(3)Reimbursementpaidbyavisioncareplanorotherhealthinsurance
planforcoveredservicesandmaterialsshallbereasonableandshallnot
providenominalreimbursementinordertoclaimthatservicesandmaterials
arecoveredservices.
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(4)(A)Avisioncareplanorotherhealthinsuranceplanshallnotrestrict
orotherwiselimit,directlyorindirectly,anoptometrist’s,ophthalmologist’s,
orindependentoptician’schoiceoforrelationshipwithsourcesandsuppliers
ofproducts,services,ormaterialsoruseofopticallaboratoriesifthe
optometrist,ophthalmologist,oropticiandeterminesthatthesource,supplier,
orlaboratorythattheoptometrist,ophthalmologist,oropticianhasselected
offerstheproducts,services,ormaterialsinamannerthatismorebeneficialto
theconsumer,includingwithrespecttocost,quality,timing,orselection,than
thesource,supplier,orlaboratoryselectedbythevisioncareplanorother
healthinsuranceplan.Theplanshallnotimposeanypenaltyorfeeonan
optometrist,ophthalmologist,orindependentopticianforusinganysupplier,
opticallaboratory,product,service,ormaterial.
(B)Theoptometrist,ophthalmologist,oropticianshallnotifythe
consumerofanyadditionalcoststheconsumermayincurastheresultof
procuringtheproducts,services,ormaterialsfromthesource,supplier,or
laboratoryselectedbytheoptometrist,ophthalmologist,oropticianinsteadof
fromthesource,supplier,orlaboratoryselectedbythevisioncareplanor
otherhealthinsuranceplan.
(C)Nothinginthissubdivision(4)shallbeconstruedtopreventa
visioncareplanorotherhealthinsuranceplanfrominformingits
policyholdersofthebenefitsavailableundertheplanorfromconductingan
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auditofanoptometrist’s,ophthalmologist’s,oroptician’suseofalternative
sources,suppliers,orlaboratories.
(D)Theprovisionsofthissubdivision(4)shallnotapplyto
Medicaid.
(g)(1)Exceptasotherwisespecifiedinsubdivision(f)(4),thissectionshall
applytoMedicaidandanyotherpublichealthcareassistanceprogramoffered
oradministeredbytheStateorbyanysubdivisionorinstrumentalityofthe
State.
(2)TheDepartmentofFinancialRegulationshallenforcetheprovisions
ofthissectionastheyrelatetohealthinsuranceplansandvisioncareplans
otherthanMedicaid.
***ConformingRevisions***
Sec.3.1V.S.A.§ 317(c)isamendedtoread:
(c)Thefollowingpublicrecordsareexemptfrompublicinspectionand
copying:
***
(28)Recordsof,andinternalmaterialspreparedfor,independent
externalreviewsofhealthcareservicedecisionspursuantto8V.S.A.§4089f
8V.S.A.§ 4063andofmentalhealthcareservicedecisionspursuantto
8V.S.A.§4089a8V.S.A.§ 4064.
***
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Sec.4.8V.S.A.§ 4512(b)isamendedtoread:
(b)SubjecttotheapprovaloftheCommissionerortheGreenMountain
CareBoardestablishedin18V.S.A.chapter220,asappropriate,ahospital
servicecorporationmayestablish,maintain,andoperateamedicalserviceplan
asdefinedinsection4583ofthistitle.TheCommissionerortheBoardmay
refuseapprovaliftheCommissionerortheBoardfindsthattheratessubmitted
areexcessive,inadequate,orunfairlydiscriminatory,failtoprotectthehospital
servicecorporation’ssolvency,orfailtomeetthestandardsofaffordability,
promotionofqualitycare,andpromotionofaccesspursuanttosection4062
4026ofthistitle.Thecontractsofahospitalservicecorporationthatoperates
amedicalserviceplanunderthissubsectionshallbegovernedbychapter125
ofthistitletotheextentthattheyprovideformedicalservicebenefits,andby
thischaptertotheextentthatthecontractsprovideforhospitalservice
benefits.
Sec.5.8V.S.A.§ 4515aisamendedtoread:
§4515a.FORMANDRATEFILING;FILINGFEES
Everycontractorcertificateform,oramendmentthereof,includingthe
ratesproposedtobechargedbythecorporation,shallbefiledwiththe
CommissionerortheGreenMountainCareBoardestablishedin18V.S.A.
chapter220,asappropriate,fortheCommissioner’sortheBoard’sapproval
priortoissuanceoruse.Priortoapproval,thereshallbeapubliccomment
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periodpursuanttosection40624026ofthistitle.Inaddition,eachsuchfiling
shallbeaccompaniedbypaymenttotheCommissionerortheBoard,as
appropriate,ofanonrefundablefeeof$150.00andtheplainlanguage
summaryofrateincreasespursuanttosection40624026ofthistitle.
Sec.6.8V.S.A.§ 4516isamendedtoread:
§4516.ANNUALREPORTTOCOMMISSIONER
Annually,onorbeforeMarch1,ahospitalservicecorporationshallfile
withtheCommissionerofFinancialRegulationastatementsworntobythe
presidentandtreasurerofthecorporationshowingitsconditiononDecember
31.Thestatementshallbeinsuchformandcontainsuchmattersasthe
Commissionershallprescribe.Toqualifyforthetaxexemptionsetforthin
section4518ofthistitle,thestatementshallincludeacertificationthatthe
hospitalservicecorporationoperatesonanonprofitbasisforthepurposeof
providinganadequatehospitalserviceplantoindividualsoftheState,both
groupsandnongroups,withoutdiscriminationbasedonage,gender,
geographicarea,industry,andmedicalhistory,exceptasallowedby
subdivisions4080g(b)(7)(B)(ii)and4080g(c)(8)(B)(ii)ofthistitleandby33
V.S.A.§1811(f)(2)(B).
Sec.7.8V.S.A.§ 4587isamendedtoread:
§4587.FILINGANDAPPROVALOFCONTRACTS
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Amedicalservicecorporationthathasreceivedapermitfromthe
CommissionerofFinancialRegulationundersection4584ofthistitleshallnot
thereafterissueacontracttoasubscriberorchargearatethatisdifferentfrom
copiesofthecontractsandratesoriginallyfiledwithandapprovedbythe
Commissioneratthetimethepermitwasissuedtothemedicalservice
corporation,untilthemedicalservicecorporationhasfiledcopiesofits
proposedcontractsandratesandtheyhavebeenapprovedbythe
CommissionerortheGreenMountainCareBoardestablishedin18V.S.A.
chapter220,asappropriate.Priortoapproval,thereshallbeapubliccomment
periodpursuanttosection40624026ofthistitle.Eachsuchfilingofa
contractortheratethereforshallbeaccompaniedbypaymenttothe
CommissionerortheBoard,asappropriate,ofanonrefundablefeeof$150.00.
Amedicalservicecorporationshallfileaplainlanguagesummaryofrate
increasespursuanttosection40624026ofthistitle.
Sec.8.8V.S.A.§ 4588isamendedtoread:
§4588.ANNUALREPORTTOCOMMISSIONER
Annually,onorbeforeMarch1,amedicalservicecorporationshallfile
withtheCommissionerofFinancialRegulationastatementsworntobythe
presidentandtreasurerofthecorporationshowingitsconditiononDecember
31,whichshallbeinsuchformandcontainsuchmattersastheCommissioner
shallprescribe.Toqualifyforthetaxexemptionsetforthinsection4590of
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thistitle,thestatementshallincludeacertificationthatthemedicalservice
corporationoperatesonanonprofitbasisforthepurposeofprovidingan
adequatemedicalserviceplantoindividualsoftheState,bothgroupsand
nongroups,withoutdiscriminationbasedonage,gender,geographicarea,
industry,andmedicalhistory,exceptasallowedbysubdivisions
4080g(b)(7)(B)(ii)and4080g(c)(8)(B)(ii)ofthistitleandby33V.S.A.§
1811(f)(2)(B).
Sec.9.8V.S.A.§ 4724(7)(E)isamendedtoread:
(E)Makingorpermittingunfairdiscriminationbetweenmarried
couplesandpartiestoacivilunionasdefinedunder15V.S.A.§1201,with
regardtotheofferingofinsurancebenefitstoacouple,aspouse,apartytoa
civilunion,ortheirfamily.TheCommissionershalladoptrulesnecessaryto
carryoutthepurposesofthissubdivision.Therulesshallensurethat
insurancecontractsandpoliciesofferedtomarriedcouples,spouses,and
familiesarealsomadeavailabletopartiestoacivilunionandtheirfamilies.
TheCommissionermayadoptbyorderstandardsandaprocesstobringthe
formscurrentlyonfileandapprovedbytheDepartmentintocompliancewith
Vermontlaw.Thestandardsandprocessmaydifferfromtheprovisions
containedinchapter101,subchapter6,andsections40624026,4201,4515a,
4587,4685,4687,4688,4985,5104,and8005ofthistitlewhere,inthe
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Commissioner’sopinion,theprovisionsregardingfilingandapprovalofforms
arenotdesirableornecessarytoeffectuatethepurposesofthissection.
Sec.10.8V.S.A.§ 5104(a)isamendedtoread:
(a)(1)Ahealthmaintenanceorganizationthathasreceivedacertificateof
authorityundersection5102ofthistitleshallfileandobtainapprovalofall
policyformsandratesasprovidedinsections4062and4062a4026and4027
ofthistitle.Thisrequirementshallincludethefilingofadministrative
retentionsforanybusinessinwhichtheorganizationactsasathirdparty
administratororinanyotheradministrativeprocessingcapacity.The
CommissionerortheGreenMountainCareBoard,asappropriate,mayrequest
andshallreceiveanyinformationthattheCommissionerortheBoarddeems
necessarytoevaluatethefiling.Inadditiontoanyotherinformation
requested,theCommissionerortheBoardshallrequirethefilingof
informationoncostsforprovidingservicestotheorganization’sVermont
membersaffectedbythepolicyformorrate,includingVermontclaims
experience,andadministrativeandoverheadcostsallocatedtotheserviceof
Vermontmembers.Priortoapproval,thereshallbeapubliccommentperiod
pursuanttosection40624026ofthistitle.Ahealthmaintenanceorganization
shallfileasummaryofratefilingspursuanttosection40624026ofthistitle.
(2)TheCommissionerortheBoardshallrefusetoapprovetheformof
evidenceofcoverage,filing,orrateifitcontainsanyprovisionthatisunjust,
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unfair,inequitable,misleading,orcontrarytothelawoftheStateorplanof
operation,oriftheratesareexcessive,inadequate,orunfairlydiscriminatory,
failtoprotecttheorganization’ssolvency,orfailtomeetthestandardsof
affordability,promotionofqualitycare,andpromotionofaccesspursuantto
section40624026ofthistitle.Noevidenceofcoverageshallbeofferedto
anypotentialmemberunlessthepersonmakingtheofferhasfirstbeen
licensedasaninsuranceagentinaccordancewithchapter131ofthistitle.
Sec.11.8V.S.A.§ 5115isamendedtoread:
§5115.DUTYOFNONPROFITHEALTHMAINTENANCE
ORGANIZATIONS
Anynonprofithealthmaintenanceorganizationsubjecttothischaptershall
offernongroupplanstoindividualsinaccordancewith33V.S.A.§1811
withoutdiscriminationbasedonage,gender,industry,andmedicalhistory,
exceptasallowedbysubdivisions4080g(b)(7)(B)(ii)and4080g(c)(8)(B)(ii)of
thistitleandby33V.S.A.§1811(f)(2)(B).
Sec.12.8V.S.A.§ 8083isamendedtoread:
§8083.EXTRATERRITORIAL JURISDICTION
Nogrouplong-termcareinsurancecoveragemaybeofferedtoaresidentof
thisStateunderagrouppolicyissuedinanotherstatetoagroupdescribedin
subdivision8082(4)(D)ofthistitle,unlessthisStateoranotherstatehaving
statutoryandregulatorylong-termcareinsurancerequirementssubstantially
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similartothoseadoptedinthisStatehasmadeadeterminationthatsuch
requirementshavebeenmet.Allotherjurisdictionshallbepursuanttosection
40624026ofthistitle.
Sec.13.8V.S.A.§ 8094(e)isamendedtoread:
(e)Intheeventofthedeathoftheinsured,thissectionshallnotapplyto
theremainingdeathbenefitofalifeinsurancepolicythatacceleratesbenefits
forlong-termcare.Inthissituation,theremainingdeathbenefitsunderthese
policiesshallbegovernedbysections3731and40654029ofthistitle.Inall
othersituations,thissectionshallapplytolifeinsurancepoliciesthat
acceleratebenefitsforlong-termcare.
Sec.14.18V.S.A.§ 701isamendedtoread:
§701.DEFINITIONS
Asusedinthischapter:
***
(8)“Healthbenefitinsuranceplan”shallhavehasthesamemeaningas
healthmajormedicalinsuranceplanin8V.S.A.§4088h8V.S.A.§ 4011.
***
Sec.15.18V.S.A.§ 706isamendedtoread:
§706.HEALTHINSURERPARTICIPATION
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(a)Asprovidedforin8V.S.A.§4088hsetforthin8V.S.A.§ 4025,health
insuranceplansshallbeconsistentwiththeBlueprintforHealthasdetermined
bytheCommissionerofFinancialRegulation.
(b)HealthinsurersshallparticipateintheBlueprintforHealthasa
conditionofdoingbusinessinthisStateasprovidedforinthissectionandin
8V.S.A.§4088h8V.S.A.§ 4025.Under8V.S.A.§4088h,the
CommissionerofFinancialRegulationmayexcludeorlimittheparticipation
ofhealthinsurersofferingastand-alonedentalplanorspecificdiseaseorother
limitedbenefitcoverageintheBlueprintforHealth.Healthinsurersshallbe
exemptfromparticipationiftheinsureronlyoffersbenefitplansthatarepaid
directlytotheindividualinsuredortheinsured’sassignedbeneficiariesandfor
whichtheamountofthebenefitisnotbaseduponpotentialmedicalcostsor
actualcostsincurred.
***
Sec.16.18V.S.A.§ 4750isamendedtoread:
§4750.DEFINITIONS
Asusedinthischapter:
(1)“Healthinsuranceplan”hasthesamemeaningasin8V.S.A.§
4089b8V.S.A.§ 4011.
***
Sec.17.18V.S.A.§ 9361(a)isamendedtoread:
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(a)Asusedinthissection,“distantsite,”“healthcareprovider,”
“originatingsite,”“storeandforward,”“store-and-forward,”and
“telemedicine”shallhavethesamemeaningsasin8V.S.A.§4100k8V.S.A.
§ 4089a.
Sec.18.18V.S.A.§ 9362(a)isamendedtoread:
(a)Asusedinthissection,“health:
(1)“Healthinsuranceplan”and“healthhasthesamemeaningasin
8 V.S.A.§ 4011.
(2)“Healthcareprovider”havehasthesamemeaningasin8V.S.A.
§ 4100land“telemedicine”8V.S.A.§ 4098b.
(3)“Telemedicine”hasthesamemeaningasin8V.S.A.§4100k
8 V.S.A.§ 4098a.
Sec.19.18V.S.A.§ 9375(b)isamendedtoread:
(b)TheBoardshallhavethefollowingduties:
***
(6)Approve,modify,ordisapproverequestsforhealthinsurancerates
pursuantto8V.S.A.§40628V.S.A.§ 4026,takingintoconsiderationthe
requirementsintheunderlyingstatutes,changesinhealthcaredelivery,
changesinpaymentmethodsandamounts,protectinginsurersolvency,and
otherissuesatthediscretionoftheBoard.
***
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(12)Reviewdataregardingmentalhealthandsubstanceabusetreatment
reportedtotheDepartmentofFinancialRegulationpursuantto8V.S.A.§
4089b(g)(1)(G)anddiscusssuchinformation,asappropriate,withtheMental
HealthTechnicalAdvisoryGroupestablishedpursuanttosubdivision
9374(e)(2)ofthistitle.[Repealed.]
***
Sec.20.18V.S.A.§ 9377(g)(1)isamendedtoread:
(g)(1)Healthinsurersshallparticipateinthedevelopmentofthepayment
reformstrategicplanforthepilotprojectsandintheimplementationofthe
pilotprojects,includingprovidingincentives,fees,orpaymentmethods,as
requiredinthissection.ThisrequirementmaybeenforcedbytheDepartment
ofFinancialRegulationtothesameextentastherequirementtoparticipatein
theBlueprintforHealthpursuantto8V.S.A.§4088h8V.S.A.§ 4025.
Sec.21.18V.S.A.§ 9381(d)isamendedtoread:
(d)AdecisionoftheBoard’sapproving,modifying,ordisapprovinga
healthinsurer’sproposedratepursuantto8V.S.A.§40628V.S.A.§ 4026
shallbeconsideredafinalactionoftheBoardandmaybeappealedtothe
SupremeCourtpursuanttosubsection(b)ofthissection.
Sec.22.18V.S.A.§ 9404(d)isamendedtoread:
(d)ThereisherebycreatedaspecialfundtobeknownastheGreen
MountainCareBoardRegulatoryandAdministrativeFundpursuantto
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32 V.S.A.chapter7,subchapter5,forthepurposeofprovidingthefinancial
meansfortheGreenMountainCareBoardtoadministeritsobligations,
responsibilities,anddutiesasrequiredbylaw,includingpursuantto8V.S.A.
§ 40628V.S.A.§ 4026,chapters220and221ofthistitle,and33V.S.A.
chapter18.Allfees,fines,penalties,andsimilarassessmentsreceivedbythe
Boardintheadministrationofitsobligations,responsibilities,anddutiesshall
becreditedtotheFund.TheFundmayalsobeusedbytheDepartmentof
Healthtoadministeritsobligations,responsibilities,anddutiesasrequiredby
chapter221ofthistitle.
Sec.23.18V.S.A.§ 9414a(a)isamendedtoread:
(a)Asusedinthissection:
***
(5)“Independentexternalreview”meansareviewofahealthcare
decisionbyanindependentrevieworganizationpursuantto8V.S.A.§4089f8
V.S.A.§ 4063.
***
Sec.24.18V.S.A.§ 9462isamendedtoread:
§9462.QUALITYIMPROVEMENT PROJECTS
Inadditiontoreviewingmentalhealthandsubstanceabusetreatmentdata
pursuanttosubdivision9375(b)(12)ofthistitle,theTheGreenMountainCare
Boardshallconsidertheresultsofanyqualityimprovementprojectsnot
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otherwiseconfidentialorprivilegedundertakenbymanagedcareorganizations
formentalhealthandsubstanceabusecareandtreatmentpursuantto8V.S.A.
§4089b(d)(1)(B)(vii)andsubsection9414(i)ofthistitle.
Sec.25.18V.S.A.§ 9573(a)isamendedtoread:
(a)OnorbeforeDecember31ofeachyear,theGreenMountainCare
Boardshallreviewanyall-inclusivepopulation-basedpaymentarrangement
betweentheDepartmentofVermontHealthAccessandanaccountablecare
organizationforthefollowingcalendaryear.TheBoard’sreviewshallinclude
thenumberofattributedlives,eligibilitygroups,coveredservices,elementsof
thepermember,permonthpayment,andanyothernonclaimspayments.The
Board’sreviewmayincludedeliberativesessionstothesameextentpermitted
forinsuranceratereviewunder8V.S.A.§40628V.S.A.§ 4026.
Sec.26.32V.S.A.§ 1407(b)isamendedtoread:
(b)TheStateshallbearthecostsofforensicmedicalandpsychological
examinationsadministeredtovictimsofcrimecommittedinthisState,in
instanceswherethatexaminationisrequestedbyalawenforcementofficeror
aprosecutingauthorityoftheStateoranyofitssubdivisionsandthevictim
doesnothavehealthcoverageorthevictim’shealthcoveragedoesnotcover
theentirecostoftheexamination.TheStateshallalsobearthecostsofsexual
assaultexaminations,asdefinedin8V.S.A.§40898V.S.A.§ 4083,
administeredtovictimsincasesofallegedsexualassaultwherethevictim
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obtainssuchanexaminationpriortoreceivingsucharequestifthevictimdoes
nothavehealthcoverageorthevictim’shealthcoveragedoesnotcoverthe
entirecostoftheexamination.If,asaresultofasexualassaultexamination,
theallegedvictimhasbeenreferredformentalhealthcounseling,theState
shallbearanycostsofsuchexaminationnotcoveredbythevictim’shealth
coverage.ThesecostsmaybepaidfromtheVictims’CompensationFund
fromfundsappropriatedforthatpurpose.
Sec.27.32V.S.A.§ 10401isamendedtoread:
§ 10401.DEFINITIONS
Asusedinthischapter:
(1)“Healthinsurance”meansanygrouporindividualhealthcare
benefitpolicy,contract,orotherhealthbenefitplanoffered,issued,renewed,
oradministeredbyanyhealthinsurer,includinganyhealthcarebenefitplan
offered,issued,renewed,oradministeredbyanyhealthinsurancecompany,
anynonprofithospitalandmedicalservicecorporation,anydentalservice
corporation,oranymanagedcareorganizationasdefinedin18V.S.A.§9402.
Thetermincludescomprehensivemajormedicalpolicies,contracts,orplans;
short-term,limited-durationhealthinsurancepoliciesandcontractsasdefined
in8V.S.A.§4084a8V.S.A.§ 4053;studenthealthinsurancepolicies;and
Medicaresupplementalsupplementinsurancepolicies,contracts,orplans,but
doesnotincludeMedicaidoranyotherStatehealthcareassistanceprogramin
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whichclaimsarefinancedinwholeorinpartthroughafederalprogramunless
authorizedbyfederallawandapprovedbytheGeneralAssembly.Theterm
doesnotincludepoliciesissuedforspecifieddisease,accident,injury,hospital
indemnity,long-termcare,disabilityincome,orotherlimitedbenefithealth
insurancepolicies,exceptthatanypolicyprovidingcoveragefordental
servicesshallbeincluded.
***
Sec.28.33V.S.A.§ 1813(a)(2)isamendedtoread:
(2)Initsreviewandapprovalofpremiumratespursuantto8V.S.A.
§ 40628V.S.A.§ 4026,theGreenMountainCareBoardshallensurethat:
***
Sec.29.33V.S.A.§ 1814isamendedtoread:
§1814.MAXIMUMOUT-OF-POCKETLIMITFORPRESCRIPTION
DRUGSINBRONZEPLANS
(a)(1)Notwithstandinganyprovisionof8V.S.A.§4089i8V.S.A.§ 4092
tothecontrary,theGreenMountainCareBoardmayapprovemodificationsto
theout-of-pocketprescriptiondruglimitestablishedin8V.S.A.§4089i
8 V.S.A.§ 4092foroneormorebronze-levelplans,aslongastheBoardfinds
thattheofferingofsuchplanswillnotadverselyimpacttheplanoptions
availabletoconsumerswithhighprescriptiondrugneedswhobenefitfromthe
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out-of-pocketprescriptiondruglimitestablishedin8V.S.A.§4089i8V.S.A.
§ 4092.
(2)TheDepartmentofVermontHealthAccessshallcertifyatleasttwo
standardbronze-levelplansthatincludetheout-of-pocketprescriptiondrug
limitestablishedin8V.S.A.§4089i8V.S.A.§ 4092,aslongastheplans
complywithfederalrequirements.Notwithstandinganyprovisionof8V.S.A.
§4089i8V.S.A.§ 4092tothecontrary,theDepartmentmaycertifyoneor
morebronze-levelqualifiedhealthbenefitplanswithmodificationstotheout-
of-pocketprescriptiondruglimitestablishedin8V.S.A.§4089i8V.S.A.
§ 4092.
(b)(1)Foreachindividualenrolledinabronze-levelqualifiedhealth
benefitplanfortheprevioustwoplanyearswhohadout-of-pocket
prescriptiondrugexpendituresthatmettheout-of-pocketprescriptiondrug
limitestablishedin8V.S.A.§4089i8V.S.A.§ 4092forthemostrecentplan
yearforwhichinformationisavailable,thehealthinsurershall,absentan
alternativeplanselectionorplancancellationbytheindividual,automatically
reenrolltheindividualinabronze-levelqualifiedhealthplanforthe
forthcomingplanyearwithanout-of-pocketprescriptiondruglimitator
belowthelimitestablishedin8V.S.A.§4089i8V.S.A.§ 4092.
(2)Priortoreenrollinganindividualinaplanpursuanttosubdivision
(1)ofthissubsection,thehealthinsurershallnotifytheindividualofthe
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insurer’sintenttoreenrolltheindividualautomaticallyinabronze-level
qualifiedhealthplanfortheforthcomingplanyearwithanout-of-pocket
prescriptiondruglimitatorbelowthelimitestablishedin8V.S.A.§4089i
8 V.S.A.§ 4092unlesstheindividualcontactstheinsurertoselectadifferent
planandoftheavailabilityofbronze-levelplanswithhigherout-of-pocket
prescriptiondruglimits.Thehealthinsurershallcollaboratewiththe
DepartmentofVermontHealthAccessandtheOfficeoftheHealthCare
Advocateastothenotification’sformandcontent.
Sec.30.33V.S.A.§ 4110(a)(6)isamendedtoread:
(6)ForpurposesofAsusedinthissection,“dependentcoverage”shall
havehasthesamemeaningasin8V.S.A.§4100b(a)(3)8V.S.A.§ 4058.
Sec.31.ADDITIONALCONFORMINGREVISIONS
WhenpreparingtheVermontStatutesAnnotatedforpublication,theOffice
ofLegislativeCounselshallupdateanyadditionalcross-referencestostatutes
in8V.S.A.chapter107thatusethenumberingschemeineffectpriortothe
effectivedateofthisacttoconformtothenewnumberingschemeenactedby
thisact.
***InterpretationandRuleAlignment***
Sec.32.INTERPRETATION;RULEALIGNMENT
(a)Thepurposeofthisbillistoupdateandreorganizethehealthinsurance
statutes.ItistheintentoftheGeneralAssemblythatthetechnical
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amendmentsinthisactshallnotsupersedesubstantivechangescontainedin
otherbillsenactedbytheGeneralAssemblyduringthecurrentbiennium.
Wherepossible,theamendmentsinthisactshallbeinterpretedtobe
supplementaltootheramendmentsmadetothesectionsof8V.S.A.chapter
107usingthenumberingschemeineffectpriortotheeffectivedateofthisact;
totheextenttheprovisionsconflict,thesubstantivechangesinotheractsshall
takeprecedenceoverthetechnicalchangesinthisact.Statutesaddedtoor
amendedin8V.S.A.chapter107thatareenactedduringthe2025–2026
bienniumusingthenumberingschemethatexistedpriortotheeffectivedate
ofthisactshallbecodifiedinthecorrespondingstatutesasrenumberedbythis
act.
(b)Rulesadoptedandorders,bulletins,forms,andguidancedocuments
issuedbytheDepartmentofFinancialRegulation,theGreenMountainCare
Board,andotherStateagenciesthatrefertostatutesin8V.S.A.chapter107
usingthenumberingthatexistedpriortotheeffectivedateofthisactshall
continuetobevalidfollowingtheeffectivedateofthisactuntilsuchtimeas
therelevantdocumentscanbeamendedorupdatedtoalignwiththe
renumberingofthatchapterbythisact.
***EffectiveDate***
Sec.33.EFFECTIVEDATE
ThisactshalltakeeffectonJanuary1,2026.
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