Vermont § 1806 - Qualified health benefit plans

§ 1806. Qualified health benefit plans

• (a) Prior to contracting with a health insurer to offer a qualified health benefit plan,
  the Commissioner shall determine that making the plan available through the Vermont
  Health Benefit Exchange is in the best interests of individuals and qualified employers
  in this State. In determining the best interests, the Commissioner shall consider
  affordability; promotion of high-quality care, prevention, and wellness; promotion
  of access to health care; participation in the State’s health care reform efforts;
  and such other criteria as the Commissioner, in the Commissioner’s discretion, deems
  appropriate. (b)(1) A qualified health benefit plan shall provide the following benefits: (A) The essential benefits package required by Section 1302(a) of the Affordable Care
  Act and any additional benefits required by the Secretary of Human Services by rule
  after consultation with the Advisory Committee established in section 402 of this title and after approval from the Green Mountain Care Board established in 18 V.S.A. chapter 220. (B) Notwithstanding subdivision (1)(A) of this subsection (b), a health insurer or a stand-alone
  dental insurer, including a nonprofit dental service corporation, may offer a plan
  that provides only limited dental benefits, either separately or in conjunction with
  a qualified health benefit plan, if it meets the requirements of Section 9832(c)(2)(A) of the Internal Revenue Code and provides pediatric dental benefits meeting the requirements of Section 1302(b)(1)(J)
  of the Affordable Care Act. Said plans may include child-only policies or family policies.
  If permitted under federal law, a qualified health benefit plan offered in conjunction
  with a stand-alone dental plan providing pediatric dental benefits meeting the requirements
  of Section 1302(b)(1)(J) of the Affordable Care Act shall be deemed to meet the requirements
  of this subsection. (2) At least the bronze level of coverage as defined by Section 1302 of the Affordable
  Care Act and the cost-sharing limitations for individuals provided in Section 1302
  of the Affordable Care Act, as well as any more restrictive cost-sharing requirements
  specified by the Secretary of Human Services by rule after consultation with the Advisory
  Committee established in section 402 of this title and after approval from the Green Mountain Care Board established in 18 V.S.A. chapter 220. (3) For qualified health benefit plans offered to employers, a deductible that meets the
  limitations provided in Section 1302 of the Affordable Care Act and any more restrictive
  deductible requirements specified by the Secretary of Human Services by rule after
  consultation with the Advisory Committee established in section 402 of this title and after approval from the Green Mountain Care Board established in 18 V.S.A. chapter 220. (c) A qualified health benefit plan shall meet the following minimum prevention, quality,
  and wellness requirements: (1) standards for marketing practices, network adequacy, essential community providers
  in underserved areas, appropriate services to enable access for underserved individuals
  or populations, accreditation, quality improvement, and information on quality measures
  for health benefit plan performance, as provided in Section 1311 of the Affordable
  Care Act and any more restrictive requirements provided by 8 V.S.A. chapter 107; (2) quality and wellness standards, including a requirement for joint quality improvement
  activities with other plans, as specified in rule by the Secretary of Human Services,
  after consultation with the Commissioners of Health and of Financial Regulation and
  with the Advisory Committee established in section 402 of this title; and (3) standards for participation in the Blueprint for Health as provided in 18 V.S.A. chapter 13. (d) A health insurer offering a qualified health benefit plan shall use the uniform enrollment
  forms and descriptions of coverage provided by the Commissioners of Vermont Health
  Access and of Financial Regulation. (e)(1) A health insurer offering a qualified health benefit plan shall comply with the following
  insurance and consumer information requirements: (A)(i) obtain premium approval through the rate review process provided in 8 V.S.A. chapter 107; and (ii) submit to the Commissioner of Financial Regulation a justification for any premium
  increase before implementation of that increase and prominently post this information
  on the health insurer’s website. (B) Offer at least one qualified health benefit plan at the silver level and at least
  one qualified health benefit plan at the gold level that meet the requirements of
  Section 1302 of the Affordable Care Act and any additional requirements specified
  by the Secretary of Human Services by rule. In addition, a health insurer may choose
  to offer one or more qualified health benefit plans at the platinum level that meet
  the requirements of Section 1302 of the Affordable Care Act and any additional requirements
  specified by the Secretary of Human Services by rule. (C) Charge the same premium rate for a health benefit plan without regard to whether the
  plan is offered through the Vermont Health Benefit Exchange and without regard to
  whether the plan is offered directly from the carrier or through an insurance agent. (D) Provide accurate and timely disclosure of information to the public and to the Vermont
  Health Benefit Exchange relating to claims denials, enrollment data, rating practices,
  out-of-network coverage, enrollee and participant rights provided by Title I of the
  Affordable Care Act, and other information as required by the Commissioner of Vermont
  Health Access or by the Commissioner of Financial Regulation. The Commissioner of
  Financial Regulation shall define, by rule, the acceptable time frame for provision
  of information in accordance with this subdivision. (E) Provide information in a timely manner to an individual, upon request, regarding the
  cost-sharing amounts for that individual’s health benefit plan. (2) A health insurer offering a qualified health benefit plan shall comply with all other
  insurance requirements for health insurers as provided in 8 V.S.A. chapter 107 and as specified by rule by the Commissioner of Financial Regulation. (f) Consistent with Section 1311(e)(1)(B) of the Affordable Care Act, the Vermont Health
  Benefit Exchange shall not exclude a health benefit plan: (1) on the basis that the plan is a fee-for-service plan; (2) through the imposition of premium price controls by the Vermont Health Benefit Exchange;
  or (3) on the basis that the health benefit plan provides for treatments necessary to prevent
  patients’ deaths in circumstances the Vermont Health Benefit Exchange determines are
  inappropriate or too costly. (g) The Vermont Health Benefit Exchange shall clearly indicate to any prospective purchaser
  of a bronze-level plan, and of other plans as appropriate, the potential for significant
  out-of-pocket costs, in addition to the premium, associated with the plan. (Added 2011, No. 48, § 4; amended 2011, No. 171 (Adj. Sess.), §§ 2a, 2h; 2021, No. 20, § 297.)