S 30 — An act relating to updating and reorganizing the health insurance statutes in 8 V.S.A. chapter 107

VT LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 12 of 180 § 4022a.

or BILL AS INTRODUCED AND PASSED BY SENATE S.30 Page 13 of 181 (D) any other valuable consideration or inducement to or for insurance on any risk in this State, or for or upon any renewal of any such insurance, that is not specified in the health insurance plan;

VT LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 13 of 180 (c) No person insured under a group insurance policy or party or applicant for group insurance shall directly or indirectly receive or accept or agree to receive or accept any rebate of premium or of any part of the premium, or all or any part of any agent’s or broker’s commission on the premium, or any favor or advantage, or share in any benefit to accrue under any health insurance plan, or any valuable consideration or inducement, that is not specified in the health insurance plan.

BILL AS INTRODUCED AND PASSED BY SENATE S.30 Page 14 of 181 (3) any health insurer from returning or otherwise abating, in full or in part, the premiums of its policyholders out of surplus accumulated from nonparticipating insurance;

(e) A health insurer that pays a commission, fee, or other compensation, directly or indirectly, to a licensed or unlicensed agent, broker, or other individual other than a bona fide employee of the health insurer in connection with the sale of a group insurance policy shall clearly disclose to the purchaser VT LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 14 of 180 of the policy the amount of any such commission, fee, or compensation paid or to be paid.

§§ 4023. 4023.

§BILL 4024.AS INTRODUCED AND PASSED BY SENATE S.30 Page 15 of 181 § 4024.

(b) A health insurer that issues, sells, renews, or offers health insurance coverage in Vermont or who is required to be licensed or registered with the VT LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 15 of 180 Department shall comply with the requirements of 33 V.S.A.

§§ 4025. 4025.

BILL AS INTRODUCED AND PASSED BY SENATE S.30 Page 16 of 181 Subchapter 2.

Policy Forms and Filing Requirements §§ 4026. 4026.

VT LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 16 of 180 (2)(A) The Green Mountain Care Board shall review rate requests and shall approve, modify, or disapprove a rate request within 90 calendar days after receipt of an initial rate filing from a health insurer.

BILL AS INTRODUCED AND PASSED BY SENATE S.30 Page 17 of 181 (3) The Board shall determine whether a rate is affordable;

The plain language summary VT LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 17 of 180 shall be in the format required by the Secretary of HHS pursuant to the Patient Protection and Affordable Care Act of 2010, Pub.

BILL AS INTRODUCED AND PASSED BY SENATE S.30 Page 18 of 181 (i) for all covered prescription drugs, including generic drugs, brand-name drugs excluding specialty drugs, and specialty drugs dispensed at a pharmacy, network pharmacy, or mail-order pharmacy for outpatient use:

VT LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 18 of 180 (B) The insurer shall provide, if available, the percentage of the premium rate attributable to prescription drugs administered by a health care provider in an outpatient setting that are part of the medical benefit as separate from the pharmacy benefit.

(C) The insurer shall include information on its use of a pharmacy benefit manager, if any, including which components of the prescription drug coverage described in subdivisions (A) and (B) of this subdivision (2) are BILL AS INTRODUCED AND PASSED BY SENATE S.30 Page 19 of 181 managed by the pharmacy benefit manager, as well as the name of the pharmacy benefit manager or managers used.

VT LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 19 of 180 (C) Notwithstanding 1 V.S.A.

(2)(A) The Board shall post the rate filings pursuant to subsection (a) of this section and summaries pursuant to subsection (b) of this section on the BILL AS INTRODUCED AND PASSED BY SENATE S.30 Page 20 of 181 Board’s website within five calendar days following filing.

VT LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 20 of 180 chapter 229, acting on behalf of health insurance consumers in this State, may, within 30 calendar days after the Board receives a health insurer’s rate request pursuant to this section, submit to the Board, in writing, suggested questions regarding the filing for the Board to provide to its contracting actuary, if any.

BILL AS INTRODUCED AND PASSED BY SENATE S.30 Page 21 of 181 (d)(1) Not later than 60 calendar days after receiving a health insurer’s rate request pursuant to this section, the Green Mountain Care Board shall make available to the public the insurer’s rate filing, the Department’s analysis and opinion of the effect of the proposed rate on the insurer’s solvency, and the analysis and opinion of the rate filing by the Board’s contracting actuary, if any.

VT LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 21 of 180 (e) Within the time period set forth in subdivision (a)(2)(A) of this section, the Board shall:

BILL AS INTRODUCED AND PASSED BY SENATE S.30 Page 22 of 181 (2) at a public hearing, announce the Board’s decision of whether to approve, modify, or disapprove the proposed rate;

(g) A health insurer, the Office of the Health Care Advocate, and any member of the public with party status, as defined by the Board by rule, may VT LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 22 of 180 appeal a decision of the Board approving, modifying, or disapproving the insurer’s proposed rate to the Vermont Supreme Court.

(h)(1) The authority of the Board under this section shall apply only to the rate review process for policies for major medical insurance coverage and shall not apply to the policy forms for major medical insurance coverage or to the rate and policy form review process for policies for specific disease, accident, injury, hospital indemnity, dental care, vision care, disability income, long- term care, student health insurance coverage, Medicare supplement insurance BILL AS INTRODUCED AND PASSED BY SENATE S.30 Page 23 of 181 coverage, or other limited benefit coverage;

and, for a policy form for VT LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 23 of 180 major medical insurance coverage, whether it ensures equal access to appropriate mental health care in a manner equivalent to other aspects of health care as part of an integrated, holistic system of care.

At the expiration of the 30-30-day day period, the form, premium rate, or rule shall be deemed approved unless prior to then it has been affirmatively approved or disapproved by the Commissioner or found to be incomplete.

The Commissioner shall notify a BILL AS INTRODUCED AND PASSED BY SENATE S.30 Page 24 of 181 health insurer in writing if the insurer files any form, premium rate, or rule containing a provision that does not meet the standards expressed in this subsection.

§§ 4027. 4027.

FILING FEES Each filing of a policy, contract, or document form or premium rates or rules, submitted pursuant to section 4026 of this title, shall be accompanied by VT LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 24 of 180 payment to the Commissioner or the Green Mountain Care Board, as appropriate, of a nonrefundable fee of $150.00.

§§ 4028. 4028.

BILL AS INTRODUCED AND PASSED BY SENATE S.30 Page 25 of 181 (2) The policy sets forth the time at which the insurance takes effect and terminates.

(4) The style, arrangement, and overall appearance of the policy give no undue prominence to any portion of the text, and every printed portion of the text of the policy and of any endorsements or attached papers is plainly printed in light-faced type of a style in general use, the size of which shall be uniform and not less than 10-point with a lowercase unspaced alphabet length not less VT LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 25 of 180 than 120-point.

provided, however, that if an BILL AS INTRODUCED AND PASSED BY SENATE S.30 Page 26 of 181 exception or reduction specifically applies only to a particular benefit of the policy, the statement of the exception or reduction shall be included with the benefit provision to which it applies.

(8) Either prominently printed on or attached to the first page of the policy is a notice to the effect that during a period of 30 days following the date the policy is delivered to persons eligible for Medicare by reason of age, VT LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 26 of 180 and 10 days following the date of delivery to all other persons, the policy may be surrendered to the insurer together with a written request for cancellation of the policy, and that in such event, the insurer will refund any premium paid, including any policy fees or other charges;

§BILL 4029.AS INTRODUCED AND PASSED BY SENATE S.30 Page 27 of 181 § 4029.

No change in this policy shall be valid until approved by an executive officer of the insurer and unless such approval be endorsed hereon or VT LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 27 of 180 attached hereto.

(a) After three years from the date of issue of this policy no misstatements, except fraudulent misstatements, made by the applicant in the application for such policy, shall be used to void the policy or to deny a claim for loss incurred or disability (as BILL AS INTRODUCED AND PASSED BY SENATE S.30 Page 28 of 181 defined in the policy) commencing after the expiration of such three year period.

(insert a number not less than “7” for weekly premium policies, “10” for monthly premium policies and “31” for all other policies) days will be granted for the payment of each VT LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 28 of 180 premium falling due after the first premium, during which grace period the policy shall continue in force.

(A policy which contains a cancellation provision may add, at the end of the above provision, subject to the right of the insurer to cancel in accordance with the cancellation provision hereof, BILL AS INTRODUCED AND PASSED BY SENATE S.30 Page 29 of 181 A policy in which the insurer reserves the right to refuse any renewal shall have, at the beginning of the above provision, Unless not less than five days prior to the premium due date the insurer has delivered to the insured or has mailed to his or her last address as shown by the records of the insurer written notice of its intention not to renew this policy beyond the period for which the premium has been accepted.) (4) REINSTATEMENT:

provided, however, that if the insurer or such agent requires an application for reinstatement and issues a conditional receipt for the premium tendered, the policy will be reinstated upon approval of such application by the insurer or, lacking such approval, upon the 45th day following the date of such conditional receipt unless the insurer has previously VT LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 29 of 180 notified the insured in writing of its disapproval of such application.

In all other respects the insured and insurer shall have the same rights thereunder as they had under the policy immediately before the due date of the defaulted premium, subject to BILL AS INTRODUCED AND PASSED BY SENATE S.30 Page 30 of 181 any provisions endorsed hereon or attached hereto in connection with the reinstatement.

VT LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 30 of 180 (In a policy providing a loss-of-time benefit which may be payable for at least two years, an insurer may at its option insert the following between the first and second sentences of the above provision:

Subject to the qualifications set forth below, if the insured suffers loss of time on account of disability for which indemnity may be payable for at least two years, he or she shall, at least once in every six months after having given BILL AS INTRODUCED AND PASSED BY SENATE S.30 Page 31 of 181 notice of claim, give to the insurer notice of continuance of said disability, except in the event of legal incapacity.

VT LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 31 of 180 (7) PROOFS OF LOSS:

Failure to furnish such proof within the time required shall not invalidate nor reduce any claim if BILL AS INTRODUCED AND PASSED BY SENATE S.30 Page 32 of 181 it was not reasonably possible to give proof within such time, provided such proof is furnished as soon as reasonably possible and in no event, except in the absence of legal capacity, later than one year from the time proof is otherwise required.

VT LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 32 of 180 If no such designation or provision is then effective, such indemnity shall be payable to the estate of the insured.

BILL AS INTRODUCED AND PASSED BY SENATE S.30 Page 33 of 181 (The following provisions, or either of them, may be included with the foregoing provision at the option of the insurer:

Subject to any written direction of the insured in the application or otherwise all or a portion of any indemnities provided by this policy on account of hospital, nursing, medical, or surgical services may, at the insurer’s option and unless the insured requests otherwise in writing not later than the time of filing proofs of such loss, be paid directly to the hospital or person VT LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 33 of 180 rendering such services;

The insurer at its own expense shall have the right and the opportunity to examine the person of the insured when and as often as it may reasonably require during the BILL AS INTRODUCED AND PASSED BY SENATE S.30 Page 34 of 181 pendency of a claim hereunder and to make an autopsy in case of death where it is not forbidden by law.

(The first clause of this provision, relative to the irrevocable designation of beneficiary, may be omitted at the insurer’s option.) VT§ 4030. LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 34 of 180 § 4030.

provided, however, that a health insurer may, at its option, substitute different language approved by the Commissioner for one or more provisions, provided the substituted language is BILL AS INTRODUCED AND PASSED BY SENATE S.30 Page 35 of 181 not less favorable in any respect to the insured or covered individual than the language used in this section.

If the insured changes his or her occupation to one classified by the insurer as less hazardous than that stated in this policy, the insurer, upon receipt of proof of such change of VT LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 35 of 180 occupation, will reduce the premium rate accordingly, and will return the excess pro rata unearned premium from the date of change of occupation or from the policy anniversary date immediately preceding receipt of such proof, whichever is the more recent.

In applying this provision, the classification of occupational risk and the premium rates shall be such as have been last filed by the insurer prior to the occurrence of the loss for which the insurer is liable or prior to date of proof of change in occupation with the state official having BILL AS INTRODUCED AND PASSED BY SENATE S.30 Page 36 of 181 supervision of insurance in the state where the insured resided at the time this policy was issued;

(insert maximum limit of indemnity or indemnities) the excess VT LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 36 of 180 insurance shall be void and all premiums paid for such excess shall be returned to the insured or to his or her estate.

If there be other valid coverage, not with this insurer, providing benefits for the same loss on a BILL AS INTRODUCED AND PASSED BY SENATE S.30 Page 37 of 181 provision of service basis or on an expense incurred basis and of which this insurer has not been given written notice prior to the occurrence or commencement of loss, the only liability under any expense incurred coverage of this policy shall be for such proportion of the loss as the amount which would otherwise have been payable hereunder plus the total of the like amounts under all such other valid coverages for the same loss of which this insurer had notice bears to the total like amounts under all valid coverages for such loss, and for the return of such portion of the premiums paid as shall exceed the pro rata portion for the amount so determined.

VT LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 37 of 180 (If the foregoing policy provision is included in a policy which also contains the next following policy provision there shall be added to the caption of the foregoing provision the phrase “—EXPENSE INCURRED BENEFITS.” The insurer may, at its option, include in this provision a definition of “other valid coverage,” approved as to form by the Commissioner, which definition shall be limited in subject matter to coverage provided by organizations subject to regulation by insurance law or by insurance authorities of this or any other state of the United States or any province of Canada, and by hospital or medical service organizations, and to BILL AS INTRODUCED AND PASSED BY SENATE S.30 Page 38 of 181 any other coverage the inclusion of which may be approved by the Commissioner.

In applying the foregoing policy provision no third party liability coverage shall be included as “other valid coverage.”) VT LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 38 of 180 (5) INSURANCE WITH OTHER INSURERS:

If there be other valid coverage, not with this insurer, providing benefits for the same loss on other than an expense incurred basis and of which this insurer has not been given written notice prior to the occurrence or commencement of loss, the only liability for such benefits under this policy shall be for such proportion of the indemnities otherwise provided hereunder for such loss as the like indemnities of which the insurer had notice (including the indemnities under this policy) bear to the total amount of all like indemnities for such loss, and for the return BILL AS INTRODUCED AND PASSED BY SENATE S.30 Page 39 of 181 of such portion of the premium paid as shall exceed the pro rata portion for the indemnities thus determined.

In the absence of such definition such term shall not include group insurance, or benefits provided by union welfare plans or by employer or employee benefit VT LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 39 of 180 organizations.

In applying the foregoing policy provision no third party liability coverage shall be included as “other valid coverage.”) BILL AS INTRODUCED AND PASSED BY SENATE S.30 Page 40 of 181 (6) RELATION OF EARNINGS TO INSURANCE:

but this shall not operate to reduce the VT LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 40 of 180 total monthly amount of benefits payable under all such coverage upon the insured below the sum of $200.00 or the sum of the monthly benefits specified in such coverages, whichever is the lesser, nor shall it operate to reduce benefits other than those payable for loss of time.

The insurer BILL AS INTRODUCED AND PASSED BY SENATE S.30 Page 41 of 181 may, at its option, include in this provision a definition of “valid loss of time coverage,” approved as to form by the Commissioner, which definition shall be limited in subject matter to coverage provided by governmental agencies or by organizations subject to regulation by insurance law or by insurance authorities of this or any other state of the United States or any province of Canada, or to any other coverage the inclusion of which may be approved by the Commissioner or any combination of such coverages.

In the absence of such definition such term shall not include any coverage provided for such insured pursuant to any compulsory benefit statute (including any workers’ compensation or employer’s liability statute), or benefits provided by union welfare plans or by employer or employee benefit organizations.) VT LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 41 of 180 (7) UNPAID PREMIUM:

In the event of BILL AS INTRODUCED AND PASSED BY SENATE S.30 Page 42 of 181 cancellation, the insurer will return promptly the unearned portion of any premium paid.

VT LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 42 of 180 (10) ILLEGAL OCCUPATION:

§§ 4031. 4031.

OMISSION OF INAPPLICABLE OR INCONSISTENT STANDARD PROVISIONS If any provision of sections 4029 and 4030 of this title is in whole or in part inapplicable to or inconsistent with the coverage provided by a particular form of policy, the health insurer, with the approval of the Commissioner, shall omit from such policy any inapplicable provision or part of a provision, and shall BILL AS INTRODUCED AND PASSED BY SENATE S.30 Page 43 of 181 modify any inconsistent provision or part of the provision in such manner as to make the provision as contained in the policy consistent with the coverage provided by the policy.

§§ 4032. 4032.

ORDER OF STANDARD POLICY PROVISIONS The provisions specified in sections 4029 and 4030 of this title, or any corresponding provisions used in lieu of those provisions as permitted by those sections, shall either be printed in the same order as the provisions are set forth in those sections or, at the option of the health insurer, any such provision may appear as a unit in any part of the policy, with other provisions to which it may be logically related, provided the resulting policy shall not be in whole or in VT LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 43 of 180 part unintelligible, uncertain, ambiguous, abstruse, or likely to mislead a person to whom the policy is offered, delivered, or issued.

§§ 4033. 4033.

BILL AS INTRODUCED AND PASSED BY SENATE S.30 Page 44 of 181 (1) “Disability income protection coverage” means a policy, contract, certificate, or agreement that provides for weekly, monthly, or other periodic payments for a specified period during the continuance of disability resulting from illness, injury, or a combination of illness and injury.

VT LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 44 of 180 (c) No policy, contract, certificate, or agreement offered or issued in this State by a health insurer to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services may contain a provision purporting to reserve discretion to the health insurer to interpret the terms of the contract or to provide standards of interpretation or review that are inconsistent with the laws of this State, and any such provision in a policy, contract, certificate, or agreement shall be null and void.

(d) No policy, contract, certificate, or agreement offered or issued in this State providing for disability income protection coverage may contain a provision purporting to reserve discretion to the insurer to interpret the terms of the contract or to provide standards of interpretation or review that are BILL AS INTRODUCED AND PASSED BY SENATE S.30 Page 45 of 181 inconsistent with the laws of this State, and any such provision in a policy, contract, certificate, or agreement shall be null and void.

VT§ 4034. LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 45 of 180 § 4034.

§§ 4035. 4035.

BILL AS INTRODUCED AND PASSED BY SENATE S.30 Page 46 of 181 (1) any policy of workers’ compensation insurance or any policy of liability insurance, with or without supplementary coverage;

VT LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 46 of 180 (A) provide additional benefits in case of death or dismemberment or loss of sight by accident;

§§ 4036. 4036.

BILL AS INTRODUCED AND PASSED BY SENATE S.30 Page 47 of 181 (b) A policy delivered or issued for delivery to any person in this State in violation of sections 4029 and 4030 of this title shall be held valid but shall be construed as provided in this chapter.

§§ 4037. 4037.

VT LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 47 of 180 (2) If a policy delivered or issued for delivery to any person in this State is reinstated or renewed and the covered individual or assignee of the policy makes a written request to the health insurer for a copy of the application, if any, for such reinstatement or renewal, the health insurer shall deliver or mail a copy of the application to the individual making the request within 15 days after the receipt of the request.

(b) No alteration of a written application for a policy shall be made by any person other than the applicant without the applicant’s written consent, except BILL AS INTRODUCED AND PASSED BY SENATE S.30 Page 48 of 181 that insertions may be made by the health insurer, for administrative purposes only, in a manner that indicates clearly that the insertions are not to be ascribed to the applicant.

§§ 4038. 4038.

RULEMAKING ON POLICY FILINGS The Commissioner may adopt such reasonable rules concerning the procedure for the filing or submission of policies subject to sections 4023 and VT LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 48 of 180 4028–4030 of this title as are necessary, proper, or advisable for the administration of these sections.

Group Coverage §§ 4041. 4041.

and the individual proprietors, partners, and employees of BILL AS INTRODUCED AND PASSED BY SENATE S.30 Page 49 of 181 individuals and firms, the business of which is controlled by the insured employer through stock ownership, contract, or otherwise.

VT LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 49 of 180 (1)(A) Under a policy issued to an employer, who is deemed the policyholder, insuring at least one employee of the employer, for the benefit of persons other than the employer.

BILL AS INTRODUCED AND PASSED BY SENATE S.30 Page 50 of 181 (i) to an association, a trust, or one or more trustees of a fund established by one or more associations otherwise eligible for the issuance of a policy under this subdivision (2) and maintained, directly or indirectly, by one or more associations for the benefit of its members or a contract or plan issued by such an association or trust;

VT LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 50 of 180 (I) a minimum of 100 persons at the time of incorporation or formation;

BILL AS INTRODUCED AND PASSED BY SENATE S.30 Page 51 of 181 (ii)(I) The association or associations shall not be controlled by a health insurer, as evidenced by the operation of the association or associations.

VT LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 51 of 180 (bb) common ownership of the health insurer and the association, or of the association and another eligible group;

BILL AS INTRODUCED AND PASSED BY SENATE S.30 Page 52 of 181 (ii) A policy issued by an association shall insure all eligible persons, except those who reject coverage in writing.

VT LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 52 of 180 (3)(A) Under a policy issued to a trust, or to one or more trustees of a fund established and maintained, directly or indirectly, by:

BILL AS INTRODUCED AND PASSED BY SENATE S.30 Page 53 of 181 (ii) A policy issued to a trust shall insure all eligible persons, except those who reject coverage in writing.

§§ 4042. 4042.

REQUIRED POLICY PROVISIONS VT LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 53 of 180 (a) Terms and conditions.

and the individual applications, if any, submitted by the employees or members in connection with the policy shall constitute the entire contract between the parties, and that all statements, in the absence of fraud, made by any applicant or applicants shall be deemed representations and not warranties, and that no such statement shall avoid the BILL AS INTRODUCED AND PASSED BY SENATE S.30 Page 54 of 181 insurance or reduce benefits under the policy unless contained in a written application, of which a copy is attached to the policy.

VT LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 54 of 180 (3) A provision that to the group originally insured may be added from time to time eligible new employees or members or dependents, as the case may be, in accordance with the terms of the policy.

BILL AS INTRODUCED AND PASSED BY SENATE S.30 Page 55 of 181 (b) Protections for covered individuals.

§§ 156.130. 156.130.

VT LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 55 of 180 (ii) The annual limitation on cost sharing for other than self-only coverage for any year shall be twice the dollar limit for self-only coverage described in subdivision (i) of this subdivision (A).

(ii) The annual limitation on cost sharing for other than self-only coverage for any year in which the federal government does not establish an BILL AS INTRODUCED AND PASSED BY SENATE S.30 Page 56 of 181 annual limitation on cost sharing shall be twice the dollar limit for self-only coverage described in subdivision (i) of this subdivision (B).

111-152, and applicable regulations and federal guidance, for any individual insured under VT LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 56 of 180 the policy, regardless of whether the services are provided in-network or out- of-network.

(iii) with respect to infants, children, and adolescents, evidence- informed preventive care and screenings as set forth in comprehensive BILL AS INTRODUCED AND PASSED BY SENATE S.30 Page 57 of 181 guidelines supported by the federal Health Resources and Services Administration;

VT LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 57 of 180 (B) Subdivision (A) of this subdivision (4) shall apply to a high- deductible health plan only to the extent that it would not disqualify the plan from eligibility for a health savings account pursuant to 26 U.S.C.

(5) Definition of “group insurance policy.” As used in this subsection, “group insurance policy” has the same meaning as “group health plan” and shall be subject to the same excepted benefits, in each case, as set forth in 4545 C.F.R. C.F.R.

§§ 4043. 4043.

BILL AS INTRODUCED AND PASSED BY SENATE S.30 Page 58 of 181 (2) No association health plan shall be issued, offered, or renewed in this State to any person other than an association that was formed or could have been formed under the Employee Retirement Income Security Act of 1974, 29 U.S.C.

chapter 25 regulating association health plans in order to protect Vermont consumers and VT LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 58 of 180 promote the stability of Vermont’s health insurance markets, to the extent permitted under federal law, including rules regarding licensure, solvency and reserve requirements, and rating requirements.

Continuation and Conversion of Group Health Insurance Policies §§ 4047a. 4047a.

BILL AS INTRODUCED AND PASSED BY SENATE S.30 Page 59 of 181 (1) loss of employment, including a reduction in hours that results in ineligibility for employer-sponsored coverage;

VT LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 59 of 180 (c) The provisions of this section shall not apply if one or more of the following conditions applies:

BILL AS INTRODUCED AND PASSED BY SENATE S.30 Page 60 of 181 (d) The continuation required by this section only applies to major medical insurance and dental insurance benefits.

VT§ 4047b. LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 60 of 180 § 4047b.

§BILL 4047c.AS INTRODUCED AND PASSED BY SENATE S.30 Page 61 of 181 § 4047c.

VT LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 61 of 180 (3) The person is covered by Medicare.

BILL AS INTRODUCED AND PASSED BY SENATE S.30 Page 62 of 181 (A) the person shall have the right to become covered under that replacement policy for the balance of the period that the person would have remained covered under the prior group policy;

and VT LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 62 of 180 (C) the prior group policy shall continue to provide benefits to the extent of its accrued liabilities and extensions of benefits as if the replacement has not occurred.

Group Health Insurance Termination and Replacement §§ 4048a. 4048a.

and BILL AS INTRODUCED AND PASSED BY SENATE S.30 Page 63 of 181 (4) there is sponsorship of the plan by the employer, organization, or group.

VT§ 4048b. LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 63 of 180 § 4048b.

BILL AS INTRODUCED AND PASSED BY SENATE S.30 Page 64 of 181 (c) The health insurer shall notify a policyholder or other responsible entity of any premium payment due on a policy at least 21 days before the due date.

VT§ 4048c. LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 64 of 180 § 4048c.

The BILL AS INTRODUCED AND PASSED BY SENATE S.30 Page 65 of 181 form shall contain a statement directing employees or members to refer to their certificates or contracts in order to determine their rights.

VT§ 4048d. LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 65 of 180 § 4048d.

BILL AS INTRODUCED AND PASSED BY SENATE S.30 Page 66 of 181 (e) Nothing in this section shall be construed to require an extension of dental benefits.

VT§ 4048e. LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 66 of 180 § 4048e.

or BILL AS INTRODUCED AND PASSED BY SENATE S.30 Page 67 of 181 (B) are a member of a class eligible for coverage under the succeeding health insurer’s policy or contract on the date of termination of the prior health insurer’s policy or contract.

VT LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 67 of 180 (3) The succeeding health insurer is not liable under this subsection for benefits required to be paid by the prior health insurer.

BILL AS INTRODUCED AND PASSED BY SENATE S.30 Page 68 of 181 (6) The succeeding health insurer, in applying a deductible or waiting- period provision in its policy or contract, shall give credit for the satisfaction of the same or similar provisions under the prior health insurer’s policy or contract.

VT LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 68 of 180 (7) At the succeeding health insurer’s request, the prior health insurer shall furnish all information needed to determine the benefits available under the prior health insurer’s policy or contract.

Other Forms of Health Coverage §§ 4051. 4051.

The premium charged shall not deviate from the community rate and the rules shall not permit medical underwriting and screening, except that a health insurer BILL AS INTRODUCED AND PASSED BY SENATE S.30 Page 69 of 181 may set different community rates for persons eligible for Medicare by reason of age and persons eligible for Medicare by reason of disability.

(1) Within five days after receiving a request for approval of any composite average rate increase in excess of three percent, or any other VT LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 69 of 180 coverage changes that the Commissioner determines will have a comparable impact on cost or availability of coverage for a Medicare supplement insurance policy issued by any health insurer with 5,000 or more total lives in the Vermont Medicare supplement insurance market, the Commissioner shall notify the Department of Disabilities, Aging, and Independent Living of the proposed premium increase.

Any approved rate increase shall not be based on an unreasonable change in loss ratio from the previous year, unless BILL AS INTRODUCED AND PASSED BY SENATE S.30 Page 70 of 181 the Commissioner makes written findings that such change is necessary to prevent a substantial adverse impact on the financial condition of the health insurer.

A decision by the VT LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 70 of 180 Commissioner other than an approval of the rate requested may be appealed by the health insurer, provided that the burden of proof shall be on the health insurer to show that the approved rate does not meet the statutory standards established under this subsection.

§§ 6706 6706 and in which the health insurer’s requested composite average increase, the independent expert’s recommended composite average rate increase, or the Department actuary’s recommended composite average rate increase differ by two percentage points or more, the Commissioner shall hold a public hearing at which the health insurer, the Department’s actuary, the independent expert, any intervenor, and the public will have the opportunity to present written and BILL AS INTRODUCED AND PASSED BY SENATE S.30 Page 71 of 181 oral testimony and will be available to answer questions of the Commissioner and those present.

(ii) The hearing shall be noticed and held at a time and place so as to facilitate public participation, and shall be recorded and become part of the VT LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 71 of 180 record before the Commissioner.

The maximum payment shall be $2,500.00 except when BILL AS INTRODUCED AND PASSED BY SENATE S.30 Page 72 of 181 waived by the Commissioner for good cause shown.

VT LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 72 of 180 (E) Nonproprietary, relevant information in any Medicare supplement insurance rate filing, including any analysis by the Department’s actuary and the independent expert, shall be made available to the public upon request.

The Department of Financial Regulation shall collaborate with health insurers, advocates for older Vermonters and for other BILL AS INTRODUCED AND PASSED BY SENATE S.30 Page 73 of 181 Medicare-eligible adults, and the Office of the Health Care Advocate to educate the public about the benefits and limitations of Medicare supplement insurance policies and Medicare Advantage plans, including information to VT LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 73 of 180 help the public understand issues relating to coverage, costs, and provider networks.

§§ 4052. 4052.

(3) under a policy or contract issued to a public school, independent school, or approved education program, as those terms are defined in 1616 V.S.A. V.S.A.

§§ 11; 11;

§§ 176(b)(1); 176(b)(1);

§BILL 829(a)(3),AS INTRODUCED AND PASSED BY SENATE S.30 Page 74 of 181 § 829(a)(3), or to the head or principal of the school, program, or provider, who or which shall be deemed the policyholder, covering students or teachers, or both;

VT LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 74 of 180 (4) under a policy or contract issued in the name of any volunteer fire department, emergency medical services provider, or other such volunteer group, which shall be deemed the policyholder, covering all of the members of the department or group in connection with their department or group activities;

BILL AS INTRODUCED AND PASSED BY SENATE S.30 Page 75 of 181 (3) All benefits under any blanket health policy shall, unless for hospital and physician service or surgical benefits, be payable to the person insured, or to the person’s designated beneficiary or beneficiaries, or to the person’s estate, except that if the person insured is a minor, the benefits may be made VT LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 75 of 180 payable to the minor’s parent, guardian, or other person actually supporting the minor.

§§ 4053. 4053.

SHORT-TERM, LIMITED-DURATION HEALTH INSURANCE (a) As used in this section, “short-term, limited-duration health insurance” means health insurance that provides medical, hospital, or major medical BILL AS INTRODUCED AND PASSED BY SENATE S.30 Page 76 of 181 expense benefits coverage pursuant to a policy or contract with a health insurer and that has an expiration date specified in the policy or contract that is three months or less after the original effective date of the policy or contract.

VT LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 76 of 180 (b) No person shall provide short-term, limited-duration health insurance coverage without a certificate of authority from the Commissioner to offer health insurance in this State unless the person is exempted by subdivision 3368(a)(4) of this title.

BILL AS INTRODUCED AND PASSED BY SENATE S.30 Page 77 of 181 (e) The Commissioner shall adopt rules pursuant to 3 V.S.A.

VT LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 77 of 180 (1) establishing the minimum financial, marketing, service, and other requirements for registration of a health insurer to provide short-term, limited- duration health insurance coverage to individuals in this State;

Child and Dependent Coverage §§ 4057. 4057.

COVERAGE OF CHILDREN BILL AS INTRODUCED AND PASSED BY SENATE S.30 Page 78 of 181 (a) Definition.

VT LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 78 of 180 (b) Newborn coverage.

BILL AS INTRODUCED AND PASSED BY SENATE S.30 Page 79 of 181 (A) “Child” means, in connection with any adoption or placement for adoption of the child, an individual who has not attained 18 years of age as of the date of the adoption or placement for adoption.

(B) “Placement for adoption” means the assumption and retention by a person of a legal obligation for total or partial support of a child in VT LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 79 of 180 anticipation of the adoption of the child.

A health insurance plan that provides dependent coverage of children shall continue to make that coverage available for an adult child until the child attains 26 years of age, provided that BILL AS INTRODUCED AND PASSED BY SENATE S.30 Page 80 of 181 this subsection shall not apply to a plan providing coverage for a specified disease or other limited benefit coverage, and further provided that nothing in this subsection shall require a plan to make coverage available for the child of a child receiving dependent coverage.

VT LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 80 of 180 (1) A health insurance plan that provides for terminating the coverage of a dependent child upon attainment of the limiting age for dependent children specified in the policy shall not limit or restrict coverage with respect to an unmarried child who meets all of the following criteria:

BILL AS INTRODUCED AND PASSED BY SENATE S.30 Page 81 of 181 (f) Coverage of leave of absence from college.

A health insurance plan that covers dependent children who are full-time college students beyond 18 years of age shall include coverage for a dependent’s medically necessary leave of absence from school for a period not to exceed 24 months or the date on which coverage would otherwise end pursuant to the terms and conditions of the policy or coverage, whichever comes first, except that coverage may continue VT LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 81 of 180 under subsection (b) of this section as appropriate.

(2) permit either parent, a provider with parental authorization, the State Medicaid agency as assignee, or any State agency administering health benefits or a health benefit plan for which Medicaid is a source of funding to BILL AS INTRODUCED AND PASSED BY SENATE S.30 Page 82 of 181 submit claims for covered services, and to appeal the denial of any benefit, without the approval of the other parent;

VT LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 82 of 180 (h) Child vaccine coverage.

§§ 4058. 4058.

BILL AS INTRODUCED AND PASSED BY SENATE S.30 Page 83 of 181 (2) the child is not claimed as a dependent on the parent’s federal tax return;

VT LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 83 of 180 (1) To enroll, under the dependent coverage, a child who is otherwise eligible for the coverage without regard to any enrollment season restrictions or any seasonal restrictions on switching from one plan to another, upon application of either parent, the employer, the State agency administering the Medicaid program, any State agency administering health benefits or a health insurance plan for which Medicaid is a source of funding, or the child support enforcement program.

or BILL AS INTRODUCED AND PASSED BY SENATE S.30 Page 84 of 181 (C) the employer has eliminated dependent health coverage for all of its employees if allowed by law.

VT LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 84 of 180 (d) A health insurer shall not impose requirements on a State agency that has been assigned the rights of an individual eligible for medical assistance under Medicaid and covered for health benefits from the health insurer that are different from requirements applicable to an agent or assignee of any other individual so covered.

(e) Any health insurer that fails to enroll a child after notice under 1515 V.S.A. V.S.A.

Any period of time that is determined under this section by the giving of notice shall commence to run from the date BILL AS INTRODUCED AND PASSED BY SENATE S.30 Page 85 of 181 of mailing, if the notice is mailed, or the date of actual receipt if another method of transmitting the notice is used.

Any health insurer cancelling a health insurance plan for nonpayment of premium shall reinstate VT LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 85 of 180 the health insurance plan effective from the date of cancellation if the nonpayment of premium is cured within 45 days of the cancellation.

§§ 4059. 4059.

§§ 1201. 1201.

§BILL 4060.AS INTRODUCED AND PASSED BY SENATE S.30 Page 86 of 181 § 4060.

VT LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 86 of 180 (b) To the extent permitted under federal law, health insurance coverage provided to Vermont residents who work for an employer domiciled outside Vermont shall not distinguish between parties to a civil union, married same- sex couples, and married opposite-sex couples.

Internal and External Reviews §§ 4063. 4063.

(b) A covered individual who has exhausted all applicable internal review procedures provided by the health insurance plan shall have the right to an independent external review of a decision under a health insurance plan to deny, reduce, or terminate health care coverage or to deny payment for a BILL AS INTRODUCED AND PASSED BY SENATE S.30 Page 87 of 181 health care service.

VT LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 87 of 180 (2) A limitation is placed on the selection of a health care provider that is claimed by the covered individual to be inconsistent with limits imposed by the health insurance plan and any applicable laws and rules.

(5) The decision involves an adverse determination related to surprise medical billing, as established under Section 2799A-1 or 2799A-2 of the Public Health Service Act, including with respect to whether an item or service BILL AS INTRODUCED AND PASSED BY SENATE S.30 Page 88 of 181 that is the subject of the adverse determination is an item or service to which Section 2799A-1 or 2799A-2 of the Public Health Service Act, or both, applies.

VT LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 88 of 180 (d) The Department shall adopt rules necessary to carry out the purposes of this section.

BILL AS INTRODUCED AND PASSED BY SENATE S.30 Page 89 of 181 (B) Have the right to use outside assistance during the review process and to submit evidence relating to the health care service.

The application fee may be waived or reduced based on a VT LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 89 of 180 determination by the Commissioner that the financial circumstances of the covered individual warrant a waiver or reduction.

BILL AS INTRODUCED AND PASSED BY SENATE S.30 Page 90 of 181 (6) The records of, and internal materials prepared for, specific reviews by any independent review organization under this section shall be exempt from public inspection and copying under the Public Records Act.

VT LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 90 of 180 (1) health care services provided by the Vermont Medicaid program or Medicaid benefits provided through a contracted health plan;

§§ 4064. 4064.

and BILL AS INTRODUCED AND PASSED BY SENATE S.30 Page 91 of 181 (4) ensure the confidentiality of clients’ and patients’ mental health records in the performance of service review activities in accordance with applicable State and federal laws.

VT LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 91 of 180 (2) “Mental health provider” means any individual, corporation, facility, or institution certified or licensed by this State to provide mental health services, including a physician, nurse with recognized psychiatric specialties, hospital or other health care facility, psychologist, clinical social worker, mental health counselor, alcohol or drug abuse counselor, or an employee or agent of such mental health provider acting in the course and scope of employment or an agency related to mental health services.

(4) “Review agent” means a person or entity performing service review activities within one year following the date of submission of a fully compliant application for licensure who is affiliated with, under contract with, or acting on behalf of a business entity in this State and who provides or administers BILL AS INTRODUCED AND PASSED BY SENATE S.30 Page 92 of 181 mental health benefits to members of health insurance plans subject to the Department’s jurisdiction, including a health insurer.

(5) “Service review” means any system for reviewing the appropriate and efficient allocation of mental health services given or proposed to be given to a client or patient, or to a group of clients or patients, for the purpose of recommending or determining whether the services should be covered and VT LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 92 of 180 includes activities of utilization review and managed care, but does not include professional peer review that does not affect reimbursement for or provision of services.

(1) A requirement that within 10 business days after receiving a request for them, the review agent shall make available at no cost to the clients, BILL AS INTRODUCED AND PASSED BY SENATE S.30 Page 93 of 181 patients, and providers affected by its service review activities the specific review criteria and standards, credentials of the reviewing professionals, and procedures and methods to be used in evaluating proposed or delivered mental health services.

VT LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 93 of 180 (3) A requirement that any determination regarding mental health services rendered or to be rendered to a client or patient that may result in a denial of third-party reimbursement or a denial of precertification for that service shall include the evaluation, findings, and concurrence of a mental health professional whose training and expertise is at least comparable to that of the treating mental health provider.

BILL AS INTRODUCED AND PASSED BY SENATE S.30 Page 94 of 181 (6) A requirement that any determination that care rendered or to be rendered is inappropriate shall include the written evaluation and findings of the review agent.

The external reviewer engaged by the independent review VT LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 94 of 180 organization shall have training and expertise at least comparable to that of the treating health care provider.

BILL AS INTRODUCED AND PASSED BY SENATE S.30 Page 95 of 181 (B) Nothing in this subdivision (10) shall prohibit capitation arrangements for reimbursement for mental health services.

VT LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 95 of 180 (e) The Commissioner shall have the authority to examine, take administrative action against, and penalize review agents as provided in chapters 3, 101, and 129 of this title.

Records of, and internal materials prepared for, specific reviews under BILL AS INTRODUCED AND PASSED BY SENATE S.30 Page 96 of 181 this section shall be exempt from public inspection and copying under the Public Records Act.

Required Covered Benefits §§ 4067. 4067.

VT LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 96 of 180 (2) may be subject to deductibles, co-payment and coinsurance amounts, fee or benefit limits, practice parameters, and utilization review consistent with any applicable rules and guidance adopted by the Department of Financial Regulation;

§§ 4068. 4068.

chapter 10, BILL AS INTRODUCED AND PASSED BY SENATE S.30 Page 97 of 181 but limiting adjunctive therapies to physiotherapy modalities and rehabilitative exercises.

VT LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 97 of 180 (c) For silver- and bronze-level qualified health benefit plans and any reflective health benefit plans offered at the silver or bronze level pursuant to 33 V.S.A.

§§ 4069. 4069.

BILL AS INTRODUCED AND PASSED BY SENATE S.30 Page 98 of 181 (b) A health insurance plan shall provide coverage for prosthetic devices that is at least equivalent to the coverage provided by the federal Medicare program.

VT LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 98 of 180 (c) A health insurance plan may require prior authorization for prosthetic devices in the same manner and to the same extent as prior authorization is required for any other covered benefit.

§§ 4070. 4070.

BILL AS INTRODUCED AND PASSED BY SENATE S.30 Page 99 of 181 (1) “Hearing aid” means any small, wearable electronic instrument or device designed and intended for the ear for the purpose of aiding or compensating for impaired human hearing and any related parts, attachments, or accessories, including earmolds and associated remote microphones that pair with hearing aids to improve word comprehension in difficult listening situations in live or telecommunication settings.

The term does not include large-audience assisted listening devices, such as those designed for VT LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 99 of 180 auditoriums, or stand-alone assisted listening devices that can function without a hearing aid.

BILL AS INTRODUCED AND PASSED BY SENATE S.30 Page 100 of 181 (3) “Hearing care professional” means an audiologist or hearing aid dispenser licensed under 26 V.S.A.

chapter 67, a physician licensed under 2626 V.S.A. V.S.A.

VT LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 100 of 180 (A) a qualified health benefit plan or reflective health benefit plan offered in accordance with 33 V.S.A.

(2) A large group health insurance plan may limit coverage to not more than one hearing aid per ear every three years, except that a plan shall cover the cost of one or more new hearing aids for a covered individual prior to the BILL AS INTRODUCED AND PASSED BY SENATE S.30 Page 101 of 181 expiration of the three-year period based on a hearing care professional’s determination that a new hearing aid for one or both ears is medically necessary.

VT LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 101 of 180 (d) The coverage required by this section shall not be subject to a deductible, co-payment, or coinsurance provision that is less favorable to a covered individual than the deductible, co-payment, or coinsurance provisions that apply generally to other nonprimary care items and services under the large group health insurance plan.

§§ 4071. 4071.

and BILL AS INTRODUCED AND PASSED BY SENATE S.30 Page 102 of 181 (B) are included in the State’s essential health benefits benchmark plan.

VT LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 102 of 180 (d) This section shall apply to Medicaid and any other public health care assistance program offered or administered by the State or by any subdivision or instrumentality of the State.

§§ 4072. 4072.

MENTAL HEALTH AND SUBSTANCE USE DISORDER SERVICES (a) It is the goal of the General Assembly that treatment for mental conditions be recognized as an integral component of health care, that health insurance plans cover all necessary and appropriate medical services without BILL AS INTRODUCED AND PASSED BY SENATE S.30 Page 103 of 181 imposing practices that create barriers to receiving appropriate care, and that integration of health care be recognized as the standard for care in this State.

(2) “Mental health provider” means any individual, corporation, facility, or institution certified or licensed by this State to provide mental health services, including a physician, nurse with recognized psychiatric specialties, VT LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 103 of 180 hospital or other health care facility, psychologist, clinical social worker, mental health counselor, alcohol or drug abuse counselor, or an employee or agent of such provider acting in the course and scope of employment or an agency related to mental health services.

BILL AS INTRODUCED AND PASSED BY SENATE S.30 Page 104 of 181 (1) not establish any rate, term, or condition that places a greater burden on a covered individual for access to treatment for a mental condition than for access to treatment for other health conditions, including no greater co- payment for primary mental health care or services than the co-payment applicable to care or services provided by a primary care provider under a covered individual’s health insurance plan and no greater co-payment for specialty mental health care or services than the co-payment applicable to care or services provided by a specialist provider under a covered individual’s health insurance plan;

(2) not exclude from its network or list of authorized providers any licensed mental health or substance use disorder treatment provider located VT LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 104 of 180 within the geographic coverage area of the health insurance plan if the provider is willing to meet the terms and conditions for participation established by the health insurer;

Food and Drug Administration for the treatment of substance use disorder, including for opioid use disorder, methadone, buprenorphine, and BILL AS INTRODUCED AND PASSED BY SENATE S.30 Page 105 of 181 naltrexone, is available on the lowest cost-sharing tier of the plan’s prescription drug formulary.

In reviewing policy rates and forms pursuant to section 4026 of this title, the Commissioner or the Green Mountain Care Board established in VT18 V.S.A. LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 105 of 180 18 V.S.A.

BILL AS INTRODUCED AND PASSED BY SENATE S.30 Page 106 of 181 (iv) utilization review and other administrative and clinical protocols do not deter timely and appropriate care, including emergency hospital admissions;

VT LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 106 of 180 (vii) a quality improvement project is completed annually as a joint project between the health insurance plan and its mental health managed care organization to implement policies and incentives to increase collaboration among providers that will facilitate clinical integration of services for medical and mental conditions, including:

and BILL AS INTRODUCED AND PASSED BY SENATE S.30 Page 107 of 181 (II) demonstration of how the quality improvement project is supporting the incorporation of best practices and evidence-based guidelines into the utilization review of mental conditions;

VT LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 107 of 180 (i) developing incentives and other measures addressing the availability of providers of care and treatment for mental conditions, especially in medically underserved areas;

BILL AS INTRODUCED AND PASSED BY SENATE S.30 Page 108 of 181 (2) A managed care organization providing or administering coverage for treatment of mental conditions on behalf of a health insurance plan shall comply with this section, sections 4064 and 4724 of this title, and 18 V.S.A.

§§ 9414; 9414;

(3) A health insurer that contracts with a managed care organization to provide or administer coverage for treatment of mental conditions is fully responsible for the acts and omissions of the managed care organization, VT LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 108 of 180 including any violations of this section or a rule adopted pursuant to this section.

BILL AS INTRODUCED AND PASSED BY SENATE S.30 Page 109 of 181 (B) order the health insurer or managed care organization to cease and desist in further violations;

VT LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 109 of 180 (B) a health insurer or its delegate;

§§ 9402 9402 or under rules adopted by the Commissioner.

BILL AS INTRODUCED AND PASSED BY SENATE S.30 Page 110 of 181 (1) For treatment of a mental condition, either:

or VT LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 110 of 180 (B) in an institution, approved by the Secretary of Human Services, that provides a program for the treatment of substance use disorder pursuant to a written plan.

§BILL 4073.AS INTRODUCED AND PASSED BY SENATE S.30 Page 111 of 181 § 4073.

§§ 4074. 4074.

(2) “Low protein modified food product” means a food product that is specifically formulated to have less than one gram of protein per serving and is VT LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 111 of 180 intended to be used under the direction of a health care professional for the dietary treatment of a metabolic disorder.

BILL AS INTRODUCED AND PASSED BY SENATE S.30 Page 112 of 181 (3) “Medical food” means an amino acid modified preparation that is intended to be used under the direction of a health care professional for the dietary treatment of an inherited metabolic disorder.

§§ 4075. 4075.

VTBILL LEGAS #380954INTRODUCED v.1AND AS PASSED BY SENATE S.30 Page 112113 of 180181 (2) This section shall not be construed to require coverage for dental services for the diagnosis or treatment of dental disorders or dental pathology primarily affecting the gums, teeth, or alveolar ridge.

§§ 4076. 4076.

§§ 1395 1395 et seq.).

VTBILL LEGAS #380954INTRODUCED v.1AND AS PASSED BY SENATE S.30 Page 113114 of 180181 (D) Medical supplies, drugs and equipment, and laboratory services to the extent that laboratory services would have been covered if the patient had been admitted to a hospital or skilled nursing facility.

(d) A health insurance plan shall not impose greater coinsurance, co- payment, deductible, or other cost-sharing requirements for coverage of home VTBILL LEGAS #380954INTRODUCED v.1AND AS PASSED BY SENATE S.30 Page 114115 of 180181 health care than apply to the diagnosis and treatment of any other physical or mental condition under the plan.

§§ 4077. 4077.

VTBILL LEGAS #380954INTRODUCED v.1AND AS PASSED BY SENATE S.30 Page 115116 of 180181 (1) The coverage provided pursuant to this subsection shall include patient education and counseling by the covered individual’s health care provider regarding the appropriate use of the contraceptive method prescribed.

VTBILL LEGAS #380954INTRODUCED v.1AND AS PASSED BY SENATE S.30 Page 116117 of 180181 (d) A health insurance plan shall provide coverage without any deductible, coinsurance, co-payment, or other cost-sharing requirement for clinical services associated with providing the drugs, devices, products, and procedures covered under this section and related follow-up services, including management of side effects, counseling for continued adherence, and device insertion and removal.

VTBILL LEGAS #380954INTRODUCED v.1AND AS PASSED BY SENATE S.30 Page 117118 of 180181 §§ 4078. 4078.

chapter 85 or an advanced practice registered nurse licensed pursuant to 2626 V.S.A. V.S.A.

§§ 4079. 4079.

VTBILL LEGAS #380954INTRODUCED v.1AND AS PASSED BY SENATE S.30 Page 118119 of 180181 (2) This section shall apply to Medicaid and any other public health care assistance program offered or administered by the State or by any subdivision or instrumentality of the State.

§§ 4080. 4080.

§§ 2141. 2141.

(2) “Anesthesiologist” means a physician who is licensed under 2626 V.S.A. V.S.A.

VTBILL LEGAS #380954INTRODUCED v.1AND AS PASSED BY SENATE S.30 Page 119120 of 180181 (3) “Certified registered nurse anesthetist” means an advanced practice registered nurse licensed by the Vermont Board of Nursing to practice as a certified registered nurse anesthetist.

(2) a child 12 years of age or younger with documented phobias or a documented mental condition or psychiatric disability, as determined by a VTBILL LEGAS #380954INTRODUCED v.1AND AS PASSED BY SENATE S.30 Page 120121 of 180181 physician licensed pursuant to 26 V.S.A.

or (3) a person who has exceptional medical circumstances or a developmental disability, as determined by a physician licensed pursuant to 2626 V.S.A. V.S.A.

VTBILL LEGAS #380954INTRODUCED v.1AND AS PASSED BY SENATE S.30 Page 121122 of 180181 (e) The provisions of this section shall not be construed to require a health insurance plan to provide coverage for the dental procedure or other dental care for which general anesthesia is provided.

§§ 4081. 4081.

VTBILL LEGAS #380954INTRODUCED v.1AND AS PASSED BY SENATE S.30 Page 122123 of 180181 (c) This section shall apply to Medicaid and any other public health care assistance program offered or administered by the State or by any subdivision or instrumentality of the State.

§§ 4082. 4082.

and VTBILL LEGAS #380954INTRODUCED v.1AND AS PASSED BY SENATE S.30 Page 123124 of 180181 (B) provided or supervised by a nationally board-certified behavior analyst or by a licensed health care professional, provided the services performed are within the health care professional’s scope of practice and certifications.

Such services shall be informed by the unique needs of each individual and each presenting situation and shall include a determination VTBILL LEGAS #380954INTRODUCED v.1AND AS PASSED BY SENATE S.30 Page 124125 of 180181 that a service is needed to achieve proper growth and development or to prevent the onset or worsening of a health condition.

and VTBILL LEGAS #380954INTRODUCED v.1AND AS PASSED BY SENATE S.30 Page 125126 of 180181 (E) therapeutic care.

(d) A health insurance plan shall not impose greater coinsurance, co- payment, deductible, or other cost-sharing requirements for coverage of the VTBILL LEGAS #380954INTRODUCED v.1AND AS PASSED BY SENATE S.30 Page 126127 of 180181 diagnosis or treatment of early childhood developmental disorders than apply to the diagnosis and treatment of any other physical or mental condition under the plan.

VTBILL LEGAS #380954INTRODUCED v.1AND AS PASSED BY SENATE S.30 Page 127128 of 180181 (g) Nothing in this section shall be construed to affect any obligation to provide services to an individual under an individualized family service plan, individualized education program, or individualized service plan.

§§ 4083. 4083.

(b) A health insurance plan shall not impose any co-payment or coinsurance or, to the extent permitted under federal law, deductible or other cost-sharing requirement for the sexual assault examination of a victim of VTBILL LEGAS #380954INTRODUCED v.1AND AS PASSED BY SENATE S.30 Page 128129 of 180181 alleged sexual assault for health care services associated with specific procedure codes identified in a memorandum of understanding between the health insurer and the Vermont Center for Crime Victim Services.

§§ 4084. 4084.

Prescription Drug Coverage §§ 4091. 4091.

chapter 23 or 33, an individual licensed as a VTBILL LEGAS #380954INTRODUCED v.1AND AS PASSED BY SENATE S.30 Page 129130 of 180181 physician assistant under 26 V.S.A.

(4) “Interchangeable biological products” has the same meaning as in 1818 V.S.A. V.S.A.

VTBILL LEGAS #380954INTRODUCED v.1AND AS PASSED BY SENATE S.30 Page 130131 of 180181 (E) certain patient compliance, therapeutic intervention, and generic substitution programs;

VTBILL LEGAS #380954INTRODUCED v.1AND AS PASSED BY SENATE S.30 Page 131132 of 180181 (10) “Step therapy” means protocols that establish the specific sequence in which prescription drugs for a specific medical condition are to be prescribed.

§§ 4092. 4092.

(2) Once the applicable expenditure amount set forth in subdivision (1) of this subsection has been met under the HDHP, coverage for prescription VTBILL LEGAS #380954INTRODUCED v.1AND AS PASSED BY SENATE S.30 Page 132133 of 180181 drug benefits shall begin, and the limit on out-of-pocket expenditures for prescription drug benefits shall be as specified in subsection (b) of this section.

§§ 9418b(g)(4) 9418b(g)(4) if any one or more of the following conditions apply:

(iii) the covered individual has already tried the prescription drugs on the protocol, or other prescription drugs in the same pharmacologic class or with the same mechanism of action, which have been discontinued due to lack VTBILL LEGAS #380954INTRODUCED v.1AND AS PASSED BY SENATE S.30 Page 133134 of 180181 of efficacy or effectiveness, diminished effect, or an adverse event, regardless of whether the covered individual was covered at the time on a plan offered by the current insurer or its pharmacy benefit manager;

VTBILL LEGAS #380954INTRODUCED v.1AND AS PASSED BY SENATE S.30 Page 134135 of 180181 (e)(1) A health insurance plan shall not require, as a condition of coverage, use of drugs not indicated by the U.S.

As used in this subsection, “readily available” means that the medication is not listed on a national drug shortage VTBILL LEGAS #380954INTRODUCED v.1AND AS PASSED BY SENATE S.30 Page 135136 of 180181 list, including lists maintained by the U.S.

§§ 4093. 4093.

chapter 36 to fill prescriptions for all prescription drugs in the same manner and at the same level of reimbursement as they are filled by any other pharmacist or pharmacy, including a mail-order pharmacy or a pharmacy benefit manager VTBILL LEGAS #380954INTRODUCED v.1AND AS PASSED BY SENATE S.30 Page 136137 of 180181 affiliate, with respect to the quantity of drugs or days’ supply of drugs dispensed under each prescription.

VTBILL LEGAS #380954INTRODUCED v.1AND AS PASSED BY SENATE S.30 Page 137138 of 180181 (C) Order a covered individual, orally or in writing, including through online messaging, to use a mail-order pharmacy or a pharmacy benefit manager affiliate.

or VTBILL LEGAS #380954INTRODUCED v.1AND AS PASSED BY SENATE S.30 Page 138139 of 180181 (III) to the extent not inconsistent with Sec.

§§ 300gg-6, 300gg-6, the annual out-of-pocket maximums applicable to the covered individual’s health benefit plan.

(iii) The provisions of subdivision (i) of this subdivision (F) shall apply to a high-deductible health plan only to the extent that it would not disqualify the plan from eligibility for a health savings account pursuant to 2626 U.S.C. U.S.C.

§§ 223. 223.

(3) A health insurer or pharmacy benefit manager shall not, by contract, written policy, or written procedure, require that a pharmacy designated by the health insurer or pharmacy benefit manager dispense a medication directly to a VTBILL LEGAS #380954INTRODUCED v.1AND AS PASSED BY SENATE S.30 Page 139140 of 180181 covered individual with the expectation or intention that the covered individual will transport the medication to a health care setting for administration by a health care professional.

VTBILL LEGAS #380954INTRODUCED v.1AND AS PASSED BY SENATE S.30 Page 140141 of 180181 (A) the covered individual has given written permission to the supplier or the ordering health care professional to contact the covered individual regarding the furnishing of a prescription item that is to be rented or purchased;

§§ 4605. 4605.

VTBILL LEGAS #380954INTRODUCED v.1AND AS PASSED BY SENATE S.30 Page 141142 of 180181 Subchapter 11.

Prevention and Treatment of Cancer §§ 4095a. 4095a.

or VTBILL LEGAS #380954INTRODUCED v.1AND AS PASSED BY SENATE S.30 Page 142143 of 180181 (4) other predisposing factors as determined by the individual’s treating health care professional.

§§ 4095b. 4095b.

In addition, a health insurance plan shall provide coverage for screening by ultrasound or another appropriate imaging service for a covered individual for VTBILL LEGAS #380954INTRODUCED v.1AND AS PASSED BY SENATE S.30 Page 143144 of 180181 whom the results of a screening mammogram were inconclusive or who has dense breast tissue, or both.

§§ 223. 223.

VTBILL LEGAS #380954INTRODUCED v.1AND AS PASSED BY SENATE S.30 Page 144145 of 180181 (3) “Screening” includes the mammography or ultrasound test procedure and a qualified health care professional’s interpretation of the results of the procedure, including additional views and interpretation as needed.

§§ 4095c. 4095c.

§§ 4095d. 4095d.

VTBILL LEGAS #380954INTRODUCED v.1AND AS PASSED BY SENATE S.30 Page 145146 of 180181 §§ 4095e. 4095e.

(B) the covered individual already has completed a clinical trial at one of the Vermont or New Hampshire cancer care providers described in VTBILL LEGAS #380954INTRODUCED v.1AND AS PASSED BY SENATE S.30 Page 146147 of 180181 subdivision (2) of this subsection (a) and the covered individual’s cancer care provider determines that a subsequent clinical trial related to the original diagnosis is available outside the health benefit plan’s network and that participation in that clinical trial would be in the best interests of the covered individual, even if a comparable clinical trial is available at that time at one or both of the Vermont or New Hampshire cancer care providers described in subdivision (2) of this subsection (a);

VTBILL LEGAS #380954INTRODUCED v.1AND AS PASSED BY SENATE S.30 Page 147148 of 180181 (b) This section shall apply to Medicaid and any other public health care assistance program offered or administered by the State or by any subdivision or instrumentality of the State.

§§ 4095f. 4095f.

the American Hospital Formulary Service-Drug Information, the American Medical VTBILL LEGAS #380954INTRODUCED v.1AND AS PASSED BY SENATE S.30 Page 148149 of 180181 Association Drug Evaluation, and the United States Pharmacopoeia-Drug Information;

VTBILL LEGAS #380954INTRODUCED v.1AND AS PASSED BY SENATE S.30 Page 149150 of 180181 (1) A health insurance plan contract shall not exclude coverage for any drug used for the treatment of cancer on grounds that the drug has not been approved by the U.S.

VTBILL LEGAS #380954INTRODUCED v.1AND AS PASSED BY SENATE S.30 Page 150151 of 180181 (d) This section shall apply to Medicaid and any other public health care assistance program offered or administered by the State or by any subdivision or instrumentality of the State.

Service Delivery and Treatment Modalities §§ 4098a. 4098a.

(5) “Originating site” means the location of the patient, whether or not accompanied by a health care provider, at the time services are provided by a VTBILL LEGAS #380954INTRODUCED v.1AND AS PASSED BY SENATE S.30 Page 151152 of 180181 health care provider through telemedicine, including a health care provider’s office, a hospital, or a health care facility, or the patient’s home or another nonmedical environment such as a school-based health center, a university- based health center, or the patient’s workplace.

VTBILL LEGAS #380954INTRODUCED v.1AND AS PASSED BY SENATE S.30 Page 152153 of 180181 (b)(1) A health insurance plan shall provide coverage for health care services and dental services delivered through telemedicine by a health care provider at a distant site to a covered individual at an originating site to the same extent that the plan would cover the services if they were provided through in-person consultation.

(c) A health insurance plan may charge a deductible, co-payment, or coinsurance for a health care service or dental service provided through VTBILL LEGAS #380954INTRODUCED v.1AND AS PASSED BY SENATE S.30 Page 153154 of 180181 telemedicine as long as it does not exceed the deductible, co-payment, or coinsurance applicable to an in-person consultation.

(g) A health insurance plan shall not construe a covered individual’s receipt of services delivered through telemedicine or by store-and-forward meansBILL asAS VTINTRODUCED LEGAND #380954 v.1 AS PASSED BY SENATE S.30 Page 154155 of 180181 means as limiting in any way the covered individual’s ability to receive additional covered in-person services from the same or a different health care provider for diagnosis or treatment of the same condition.

COVERAGE OF HEALTH CARE SERVICES DELIVERED BY AUDIO-ONLY TELEPHONE (a) As used in this section, “health care provider” means a person, partnership, or corporation, other than a facility or institution, that is licensed, certified, or otherwise authorized by law to provide professional health care VTBILL LEGAS #380954INTRODUCED v.1AND AS PASSED BY SENATE S.30 Page 155156 of 180181 services in this State to an individual during that individual’s medical care, treatment, or confinement.

VTBILL LEGAS #380954INTRODUCED v.1AND AS PASSED BY SENATE S.30 Page 156157 of 180181 (d) A health insurance plan shall not require a health care provider to have an existing relationship with a covered individual in order to be reimbursed for health care services delivered by audio-only telephone.

§§ 4098c. 4098c.

Any amounts, limits, standards, and review shall not function to direct treatment in VTBILL LEGAS #380954INTRODUCED v.1AND AS PASSED BY SENATE S.30 Page 157158 of 180181 a manner unfairly discriminative against naturopathic care, and collectively shall be not more restrictive than those applicable under the same plan to care or services provided by other primary care physicians, but may allow for the management of the benefit consistent with variations in practice patterns and treatment modalities among different types of health care professionals.

§§ 4098d. 4098d.

COVERED SERVICES PROVIDED BY ATHLETIC TRAINERS (a) To the extent a health insurance plan provides coverage for a particular type of health care service or for any particular medical condition that is withinBILL VTAS LEGINTRODUCED #380954AND v.1 AS PASSED BY SENATE S.30 Page 158159 of 180181 within the scope of practice of athletic trainers, a licensed athletic trainer who acts within the scope of practice authorized by 26 V.S.A.

VTBILL LEGAS #380954INTRODUCED v.1AND AS PASSED BY SENATE S.30 Page 159160 of 180181 §§ 4098e. 4098e.

VTBILL LEGAS #380954INTRODUCED v.1AND AS PASSED BY SENATE S.30 Page 160161 of 180181 (7) “Vision care plan” means an integrated or stand-alone plan, policy, or contract providing vision benefits to enrollees with respect to covered services or covered materials, or both.

VTBILL LEGAS #380954INTRODUCED v.1AND AS PASSED BY SENATE S.30 Page 161162 of 180181 (2) A health insurer shall not require a licensed optometrist or ophthalmologist to provide discounted materials benefits or to participate as a provider in another health insurance or vision care plan or contract as a condition or requirement for the optometrist’s or ophthalmologist’s participation as a provider in any health insurance or vision care plan or contract.

VTBILL LEGAS #380954INTRODUCED v.1AND AS PASSED BY SENATE S.30 Page 162163 of 180181 (4)(A) A vision care plan or other health insurance plan shall not restrict or otherwise limit, directly or indirectly, an optometrist’s, ophthalmologist’s, or independent optician’s choice of or relationship with sources and suppliers of products, services, or materials or use of optical laboratories if the optometrist, ophthalmologist, or optician determines that the source, supplier, or laboratory that the optometrist, ophthalmologist, or optician has selected offers the products, services, or materials in a manner that is more beneficial to the consumer, including with respect to cost, quality, timing, or selection, than the source, supplier, or laboratory selected by the vision care plan or other health insurance plan.

(C) Nothing in this subdivision (4) shall be construed to prevent a vision care plan or other health insurance plan from informing its policyholders of the benefits available under the plan or from conducting an auditBILL ofAS anINTRODUCED VTAND LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 163164 of 180181 audit of an optometrist’s, ophthalmologist’s, or optician’s use of alternative sources, suppliers, or laboratories.

§§ 317(c) 317(c) is amended to read:

§§ 4063 4063 and of mental health care service decisions pursuant to 8 V.S.A.

§§ 4064. 4064.

* * * VTBILL LEGAS #380954INTRODUCED v.1AND AS PASSED BY SENATE S.30 Page 164165 of 180181 Sec.

§§ 4512(b) 4512(b) is amended to read:

§§ 4515a 4515a is amended to read:

Prior to approval, there shall be a public comment BILL AS INTRODUCED AND PASSED BY SENATE S.30 Page 166 of 181 period pursuant to section 4062 4026 of this title.

In addition, each such filing VT LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 165 of 180 shall be accompanied by payment to the Commissioner or the Board, as appropriate, of a nonrefundable fee of $150.00 and the plain language summary of rate increases pursuant to section 4062 4026 of this title.

§§ 4516 4516 is amended to read:

§§ 4587 4587 is amended to read:

FILING AND APPROVAL OF CONTRACTS BILL AS INTRODUCED AND PASSED BY SENATE S.30 Page 167 of 181 A medical service corporation that has received a permit from the Commissioner of Financial Regulation under section 4584 of this title shall not VT LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 166 of 180 thereafter issue a contract to a subscriber or charge a rate that is different from copies of the contracts and rates originally filed with and approved by the Commissioner at the time the permit was issued to the medical service corporation, until the medical service corporation has filed copies of its proposed contracts and rates and they have been approved by the Commissioner or the Green Mountain Care Board established in 18 V.S.A.

§§ 4588 4588 is amended to read:

To qualify for the tax exemption set forth in section 4590 of BILL AS INTRODUCED AND PASSED BY SENATE S.30 Page 168 of 181 this title, the statement shall include a certification that the medical service corporation operates on a nonprofit basis for the purpose of providing an VT LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 167 of 180 adequate medical service plan to individuals of the State, both groups and nongroups, without discrimination based on age, gender, geographic area, industry, and medical history, except as allowed by subdivisions 4080g(b)(7)(B)(ii) and 4080g(c)(8)(B)(ii) of this title and by 33 V.S.A.

§§ 4724(7)(E) 4724(7)(E) is amended to read:

The standards and process may differ from the provisions contained in chapter 101, subchapter 6, and sections 4062 4026, 4201, 4515a, 4587, 4685, 4687, 4688, 4985, 5104, and 8005 of this title where, in the BILL AS INTRODUCED AND PASSED BY SENATE S.30 Page 169 of 181 Commissioner’s opinion, the provisions regarding filing and approval of forms are not desirable or necessary to effectuate the purposes of this section.

VT LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 168 of 180 Sec.

§§ 5104(a) 5104(a) is amended to read:

(2) The Commissioner or the Board shall refuse to approve the form of evidence of coverage, filing, or rate if it contains any provision that is unjust, BILL AS INTRODUCED AND PASSED BY SENATE S.30 Page 170 of 181 unfair, inequitable, misleading, or contrary to the law of the State or plan of operation, or if the rates are excessive, inadequate, or unfairly discriminatory, VT LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 169 of 180 fail to protect the organization’s solvency, or fail to meet the standards of affordability, promotion of quality care, and promotion of access pursuant to section 4062 4026 of this title.

§§ 5115 5115 is amended to read:

§§ 8083 8083 is amended to read:

EXTRATERRITORIAL JURISDICTION No group long-term care insurance coverage may be offered to a resident of this State under a group policy issued in another state to a group described in subdivision 8082(4)(D) of this title, unless this State or another state having statutory and regulatory long-term care insurance requirements substantially BILL AS INTRODUCED AND PASSED BY SENATE S.30 Page 171 of 181 similar to those adopted in this State has made a determination that such VT LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 170 of 180 requirements have been met.

§§ 8094(e) 8094(e) is amended to read:

§§ 701 701 is amended to read:

§§ 4011. 4011.

§§ 706 706 is amended to read:

HEALTH INSURER PARTICIPATION BILL AS INTRODUCED AND PASSED BY SENATE S.30 Page 172 of 181 (a) As provided for in 8 V.S.A.

§§ 4025, 4025, health insurance plans shall be consistent with the Blueprint for Health as determined by the Commissioner of Financial Regulation.

VT LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 171 of 180 (b) Health insurers shall participate in the Blueprint for Health as a condition of doing business in this State as provided for in this section and in 8 V.S.A.

§§ 4025. 4025.

§§ 4750 4750 is amended to read:

§§ 4011. 4011.

§§ 9361(a) 9361(a) is amended to read:

BILL AS INTRODUCED AND PASSED BY SENATE S.30 Page 173 of 181 (a) As used in this section, “distant site,” “health care provider,” “originating site,” “store and forward,” “store-and-forward,” and VT LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 172 of 180 “telemedicine” shall have the same meanings as in 8 V.S.A.

§§ 4089a. 4089a.

§§ 9362(a) 9362(a) is amended to read:

(1) “Health insurance plan” and “health has the same meaning as in 88 V.S.A. V.S.A.

§§ 4011. 4011.

§§ 4100l 4100l and “telemedicine” 8 V.S.A.

§§ 4098b. 4098b.

§ 4100k 88 V.S.A. V.S.A.

§§ 4098a. 4098a.

§§ 9375(b) 9375(b) is amended to read:

§§ 4026, 4026, taking into consideration the requirements in the underlying statutes, changes in health care delivery, changes in payment methods and amounts, protecting insurer solvency, and other issues at the discretion of the Board.

* * * BILL AS INTRODUCED AND PASSED BY SENATE S.30 Page 174 of 181 (12) Review data regarding mental health and substance abuse treatment reported to the Department of Financial Regulation pursuant to 8 V.S.A.

§ VT LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 173 of 180 4089b(g)(1)(G) and discuss such information, as appropriate, with the Mental Health Technical Advisory Group established pursuant to subdivision 9374(e)(2) of this title.

§§ 9377(g)(1) 9377(g)(1) is amended to read:

§§ 4025. 4025.

§§ 9381(d) 9381(d) is amended to read:

§§ 4026 4026 shall be considered a final action of the Board and may be appealed to the Supreme Court pursuant to subsection (b) of this section.

§§ 9404(d) 9404(d) is amended to read:

(d) There is hereby created a special fund to be known as the Green Mountain Care Board Regulatory and Administrative Fund pursuant to 32BILL V.S.A.AS INTRODUCED AND PASSED BY SENATE S.30 Page 175 of 181 32 V.S.A.

chapter 7, subchapter 5, for the purpose of providing the financial means for the Green Mountain Care Board to administer its obligations, VT LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 174 of 180 responsibilities, and duties as required by law, including pursuant to 8 V.S.A.

§§ 4062 4062 8 V.S.A.

§§ 4026, 4026, chapters 220 and 221 of this title, and 33 V.S.A.

§§ 9414a(a) 9414a(a) is amended to read:

§§ 4063. 4063.

§§ 9462 9462 is amended to read:

QUALITY IMPROVEMENT PROJECTS In addition to reviewing mental health and substance abuse treatment data pursuant to subdivision 9375(b)(12) of this title, the The Green Mountain Care Board shall consider the results of any quality improvement projects not otherwiseBILL confidentialAS orINTRODUCED privilegedAND undertakenPASSED byBY managedSENATE careS.30 organizationsPage VT176 LEGof #380954181 v.1otherwise ASconfidential PASSEDor BYprivileged SENATEundertaken S.30by Pagemanaged 175care oforganizations 180 for mental health and substance abuse care and treatment pursuant to 8 V.S.A.

§§ 9573(a) 9573(a) is amended to read:

§§ 4026. 4026.

§§ 1407(b) 1407(b) is amended to read:

§§ 4083, 4083, administered to victims in cases of alleged sexual assault where the victim BILL AS INTRODUCED AND PASSED BY SENATE S.30 Page 177 of 181 obtains such an examination prior to receiving such a request if the victim does VT LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 176 of 180 not have health coverage or the victim’s health coverage does not cover the entire cost of the examination.

§§ 10401 10401 is amended to read:

§§ 10401. 10401.

§§ 4053; 4053;

and Medicare supplemental supplement insurance policies, contracts, or plans, but does not include Medicaid or any other State health care assistance program in BILL AS INTRODUCED AND PASSED BY SENATE S.30 Page 178 of 181 which claims are financed in whole or in part through a federal program unless VT LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 177 of 180 authorized by federal law and approved by the General Assembly.

§§ 1813(a)(2) 1813(a)(2) is amended to read:

§§ 4062 4062 8 V.S.A.

§§ 4026, 4026, the Green Mountain Care Board shall ensure that:

§§ 1814 1814 is amended to read:

§§ 4092 4092 to the contrary, the Green Mountain Care Board may approve modifications to the out-of-pocket prescription drug limit established in 8 V.S.A.

§ 4089i 8 V.S.A.

§ 4092 for one or more bronze-level plans, as long as the Board finds that the offering of such plans will not adversely impact the plan options available to consumers with high prescription drug needs who benefit from the BILL AS INTRODUCED AND PASSED BY SENATE S.30 Page 179 of 181 out-of-pocket prescription drug limit established in 8 V.S.A.

§§ 4092. 4092 for one or more bronze-level plans, as long as the Board finds that the offering of such plans will not adversely impact the plan options available to consumers with high prescription drug needs who benefit from the out-of-pocket prescription drug limit established in 8 V.S.A.

(2) The Department of Vermont Health Access shall certify at least two standard bronze-level plans that include the out-of-pocket prescription drug limit established in 8 V.S.A.

§§ 4092, 4092.as long as the plans comply with federal requirements.

VT LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 178 of 180 (2) The Department of Vermont Health Access shall certify at least two standard bronze-level plans that include the out-of-pocket prescription drug limit established in 8 V.S.A.

§ 4089i 8 V.S.A.

§ 4092, as long as the plans comply with federal requirements.

§§ 4092 4092 to the contrary, the Department may certify one or more bronze-level qualified health benefit plans with modifications to the out- of-pocket prescription drug limit established in 8 V.S.A.

§§ 4092. 4092.

§§ 4092 4092 for the most recent plan year for which information is available, the health insurer shall, absent an alternative plan selection or plan cancellation by the individual, automatically reenroll the individual in a bronze-level qualified health plan for the forthcoming plan year with an out-of-pocket prescription drug limit at or below the limit established in 8 V.S.A.

§§ 4092. 4092.

(2) Prior to reenrolling an individual in a plan pursuant to subdivision (1) of this subsection, the health insurer shall notify the individual of the BILL AS INTRODUCED AND PASSED BY SENATE S.30 Page 180 of 181 insurer’s intent to reenroll the individual automatically in a bronze-level qualified health plan for the forthcoming plan year with an out-of-pocket VT LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 179 of 180 prescription drug limit at or below the limit established in 8 V.S.A.

§ 4089i 88 V.S.A. V.S.A.

§§ 4092 4092 unless the individual contacts the insurer to select a different plan and of the availability of bronze-level plans with higher out-of-pocket prescription drug limits.

§§ 4110(a)(6) 4110(a)(6) is amended to read:

§§ 4058. 4058.

It is the intent of the General Assembly that the technical BILL AS INTRODUCED AND PASSED BY SENATE S.30 Page 181 of 181 amendments in this act shall not supersede substantive changes contained in other bills enacted by the General Assembly during the current biennium.

VT LEG #380954 v.1 AS PASSED BY SENATE S.30 Page 180 of 180 Where possible, the amendments in this act shall be interpreted to be supplemental to other amendments made to the sections of 8 V.S.A.

VT LEG #380954 v.1