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2023 Vermont Statutes › Title 8 - Banking and Insurance › Chapter 107 - Health Insurance › § 4080d. Coordination of insurance coverage with Medicaid

§ 4080d. Coordination of insurance coverage with Medicaid
Any insurer as defined in section 4100b of this title is prohibited from considering the availability or eligibility for medical assistance in this or any other state under 42 U.S.C. § 1396a (Section 1902 of the Social Security Act), herein referred to as Medicaid, when considering eligibility for coverage or making payments under its plan for eligible enrollees, subscribers, policyholders, or certificate holders. (Added 1993, No. 231 (Adj. Sess.), § 1; amended 2005, No. 191 (Adj. Sess.), § 17; 2013, No. 79, § 6, eff. Jan. 1, 2014.)
2023 Vermont Statutes › Title 8 - Banking and Insurance › Chapter 107 - Health Insurance › § 4080e. Medicare supplemental health insurance policies; community rating; disability

§ 4080e. Medicare supplemental health insurance policies; community rating; disability
(a) A health insurance company, hospital or medical service corporation, or health maintenance organization shall use a community rating method acceptable to the Commissioner for determining premiums for Medicare supplemental insurance policies.
(b) The Commissioner shall adopt rules for standards and procedure for permitting health insurance companies, hospital or medical service organizations, or health maintenance organizations that issue Medicare supplemental insurance policies to use one or more risk classifications in their community rating method. The premium charged shall not deviate from the community rate and the rules shall not permit medical underwriting and screening, except that a health insurance company, hospital or medical service corporation, or health maintenance organization may set different community rates for persons eligible for Medicare by reason of age and persons eligible for Medicare by reason of disability.
(c) A health insurance company, hospital or medical service corporation, or health maintenance organization that issues Medicare supplemental insurance policies or certificates to a person eligible for Medicare by reason of age shall make available, to persons eligible for Medicare by reason of disability, the same policies or certificates that are offered and sold to persons eligible for Medicare by reason of age. This subsection does not apply to persons eligible for Medicare by reason of end stage renal disease. The initial enrollment period for any such policies or certificates shall be at least six months following the date the individual becomes eligible for Medicare by reason of disability. Any additional enrollment periods as required by law and offered to individuals eligible by reason of age shall be offered to individuals eligible by reason of disability.
(d) The Department of Financial Regulation shall collaborate with health insurers, advocates for older Vermonters and for other Medicare-eligible adults, and the Office of the Health Care Advocate to educate the public about the benefits and limitations of Medicare supplemental insurance policies and Medicare Advantage plans, including information to help the public understand issues relating to coverage, costs, and provider networks. (Added 1997, No. 13, § 2; amended 2001, No. 96 (Adj. Sess.), § 1, eff. May 8, 2002; 2021, No. 99 (Adj. Sess.), § 1, eff. April 27, 2022.)
2023 Vermont Statutes › Title 8 - Banking and Insurance › Chapter 107 - Health Insurance › § 4081. Blanket health insurance

§ 4081. Blanket health insurance
Blanket health insurance is hereby declared to be that form of health insurance which is supplemental to comprehensive health insurance, or which provides coverage other than the payment of all or a portion of the cost of health care services or products, and covering special groups of persons set forth as follows:
(1) under a policy or contract issued to any common carrier, which shall be deemed the policyholder, covering a group defined as all persons who may become passengers on such common carrier;
(2) under a policy or contract issued to an employer, who shall be deemed the policyholder, covering any group of employees defined by reference to exceptional hazards incident to such employment;
(3) under a policy or contract issued to a college, school, or other institution of learning or to the head or principal thereof, who or which shall be deemed the policyholder, covering students or teachers;
(4) under a policy or contract issued in the name of any volunteer fire department, first aid, or other such volunteer group, which shall be deemed the policyholder, covering all of the members of such department or group in connection with their department or group activities; or
(5) under a policy or contract issued to any other substantially similar group which, in the discretion of the Commissioner and after the prior approval by the Commissioner of the group, may be subject to the issuance of a blanket health policy or contract. (Amended 2009, No. 137 (Adj. Sess.), § 24.)
2023 Vermont Statutes › Title 8 - Banking and Insurance › Chapter 107 - Health Insurance › § 4082. Blanket insurance; policy contents

§ 4082. Blanket insurance; policy contents
(a) No such blanket health insurance policy shall contain any provision relative to notice of claim, proofs of loss, time of payment of claims, or time within which legal action must be brought upon the policy which, in the opinion of the Commissioner, is less favorable to the persons insured than would be permitted by the provisions set forth in section 4065 of this title. An individual application shall not be required from a person covered under a blanket health policy or contract, nor shall it be necessary for the insurer to furnish each person a certificate. 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 his or her designated beneficiary or beneficiaries, or to his or her estate, except that if the person insured be a minor, such benefits may be made payable to his or her parent, guardian, or other person actually supporting him or her. Nothing contained in this section or section 4081 of this title shall be deemed to affect the legal liability of policyholders for the death of, or injury to, any such members of such group.
(b) No such blanket health insurance policy which provides coverage for the payment of all or a portion of the cost of health care services or products shall contain any provision not in compliance with a requirement of this title, or a rule adopted pursuant to this title applicable to health insurance, other than those requirements applicable to nongroup health insurance or small group health insurance. The Commissioner may waive the application to a blanket insurance policy of one or more of the health insurance requirements of this title, or a rule adopted pursuant to this title, if such requirement is not relevant to the types of risks and duration of risks insured against in such blanket insurance policy. (Amended 2009, No. 137 (Adj. Sess.), § 25.)
2023 Vermont Statutes › Title 8 - Banking and Insurance › Chapter 107 - Health Insurance › § 4083. Discrimination prohibited

§ 4083. Discrimination prohibited
No insurer doing in this State the business specified in subdivision 3301(a)(2) of this title shall make or permit any unfair discrimination between individuals of substantially the same hazard in the amount of premium rates charged for any policy or contract of such insurance or in the benefits payable thereunder. This section shall not prohibit different premium rates, different benefits, or different underwriting procedure for individuals insured under group, family expense, franchise, or blanket plans of insurance.
2023 Vermont Statutes › Title 8 - Banking and Insurance › Chapter 107 - Health Insurance › § 4084. Advertising practices

§ 4084. Advertising practices
No company doing business in this State, and no insurance agent or broker shall use in connection with the solicitation of health insurance any advertising copy or advertising practice or any plan of solicitation which is materially misleading or deceptive. An advertising copy or advertising practice or plan of solicitation shall be considered to be materially misleading or deceptive if by implication or otherwise it transmits information in such manner or of such substance that a prospective applicant for health insurance may be misled thereby to his or her material damage. If the Commissioner finds that any such advertising copy or advertising practice or plan of solicitation is materially misleading or deceptive he or she shall order the company or the agent or broker using such copy or practice or plan to cease and desist from such use. Before making any such finding and order, the Commissioner shall give notice, not less than 10 days in advance, and a hearing to the company, agent, or broker affected. If the Commissioner finds, after due notice and hearing, that any authorized insurer, licensed insurance agent, or licensed insurance broker has wilfully violated any such order to cease and desist he or she may suspend or revoke the license of such insurer, agent, or broker.
2023 Vermont Statutes › Title 8 - Banking and Insurance › Chapter 107 - Health Insurance › § 4085a. Rebates prohibited for group insurance policies

§ 4085a. Rebates prohibited for group insurance policies
(a) As used in this section, “group insurance” means any policy described in section 4079 of this title, except that it shall not include any small group policy issued pursuant to section 4080a or 4080g of this title or to 33 V.S.A. § 1811.
(b) No insurer doing business in this State and no insurance agent or broker shall offer, promise, allow, give, set off, or pay, directly or indirectly, any rebate of or part of the premium payable on a group insurance policy, or on any group insurance policy or agent’s commission thereon or earnings, profits, dividends, or other benefits founded, arising, accruing or to accrue thereon or therefrom, or any special advantage in date of policy or age of issue, or any paid employment or contract for services of any kind or any other valuable consideration or inducement to or for insurance on any risk in this State, now or hereafter to be written, or for or upon any renewal of any such insurance, which is not specified in the policy contract of insurance, or offer, promise, give, option, sell, purchase any stocks, bonds, securities, or property or any dividends or profits accruing or to accrue thereon, or other thing of value whatsoever as inducement to insurance or in connection therewith, or any renewal thereof, which is not specified in the policy.
(c) No insured person 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 thereof or all or any part of any agent’s or broker’s commission thereon, or any favor or advantage, or share in any benefit to accrue under any policy of insurance, or any valuable consideration or inducement, other than such as is specified in the policy.
(d) Nothing in this section shall be construed as prohibiting the payment of commission or other compensation to any duly licensed agent or broker; or as prohibiting any insurer from allowing or returning to its participating policyholders dividends, savings, or unused premium deposits; or as prohibiting any insurer from returning or otherwise abating, in full or in part, the premiums of its policyholders out of surplus accumulated from nonparticipating insurance, or as prohibiting the taking of a bona fide obligation, with interest not exceeding six percent per annum, in payment of any premium.
(e) An 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 insurer in connection with the sale of a group insurance policy shall clearly disclose to the purchaser of such group policy the amount of any such commission, fee, or compensation paid or to be paid. (Added 2011, No. 171 (Adj. Sess.), § 2f.)
2023 Vermont Statutes › Title 8 - Banking and Insurance › Chapter 107 - Health Insurance › § 4086. Exemption from attachment and trustee process

§ 4086. Exemption from attachment and trustee process
So much of any benefits under all policies of health insurance as does not exceed $200.00 for each month during any period of disability covered thereby shall not be liable to attachment, trustee process, or other process, or to be seized, taken, appropriated, or applied by any legal or equitable process or by operation of law, either before or after payment of such benefits, to pay any debt or liabilities of the person insured under such policy. However, this exemption shall not apply where an action is brought to recover for necessaries contracted for during such period and the writ or bill of complaint contains a statement to that effect. When a policy provides for a lump sum payment because of a dismemberment or other loss insured, such payment shall be exempt from execution of the insured’s creditors.
2023 Vermont Statutes › Title 8 - Banking and Insurance › Chapter 107 - Health Insurance › § 4087. Penalties for violations

§ 4087. Penalties for violations
Any person, partnership, or corporation wilfully violating any provision of this chapter or order of the Commissioner made in accordance with this chapter shall pay an administrative penalty to the people of the State a sum not to exceed $750.00 for each such violation. The Commissioner may also suspend or revoke the license of an insurer or agent for any such wilful violation. (Amended 1995, No. 167 (Adj. Sess.), § 9.)
2023 Vermont Statutes › Title 8 - Banking and Insurance › Chapter 107 - Health Insurance › § 4088. Appeal

§ 4088. Appeal
Any person, partnership, or corporation aggrieved by any action of the Commissioner may obtain a review by appeal to the Superior Court within and for the County of Washington. Such appeal shall be on the basis of the record of the proceedings before the Commissioner and shall not be limited to questions of law. If the appeal is from an order of the Commissioner, such order shall not take effect during the pendency of the appeal unless the court shall determine otherwise. The court may review all the facts and in disposing of any issue before it may modify, affirm, or reverse any order of the Commissioner in whole or in part. Either party may appeal from the decision of the Superior Court to the Supreme Court in the manner provided by law.
2023 Vermont Statutes › Title 8 - Banking and Insurance › Chapter 107 - Health Insurance › § 4088a. Chiropractic services

§ 4088a. Chiropractic services
(a)(1) A health insurance plan shall provide coverage for clinically necessary health care services provided by a chiropractic physician licensed in this State for treatment within the scope of practice described in 26 V.S.A. chapter 10, but limiting adjunctive therapies to physiotherapy modalities and rehabilitative exercises. A health insurance plan does not have to provide coverage for the treatment of any visceral condition arising from problems or dysfunctions of the abdominal or thoracic organs.
(2) A health insurer may require that the chiropractic services be provided by a licensed chiropractic physician under contract with the insurer or upon referral from a health care provider under contract with the insurer.
(3) Health care services provided by chiropractic physicians may be subject to reasonable deductibles, co-payment and coinsurance amounts, fee or benefit limits, practice parameters, and utilization review consistent with any applicable regulations published by the Department of Financial Regulation; provided that any such amounts, limits, and review shall not function to direct treatment in a manner unfairly discriminative against chiropractic care and collectively shall be no more restrictive than those applicable under the same policy to care or services provided by other health care providers but allowing for the management of the benefit consistent with variations in practice patterns and treatment modalities among different types of health care providers.
(4) 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. chapter 18, subchapter 1, health care services provided by a chiropractic physician may be subject to a co-payment requirement, provided that any required co-payment amount shall be between 125 and 150 percent of the amount of the co-payment applicable to care and services provided by a primary care provider under the plan.
(5) Nothing contained in this section shall be construed as impeding or preventing either the provision or coverage of health care services by licensed chiropractic physicians, within the lawful scope of chiropractic practice, in hospital facilities on a staff or employee basis.
(b) As used in this section, “health insurance plan ” means any individual or group health insurance policy, any hospital or medical service corporation or health maintenance organization subscriber contract, or any other health benefit plan offered, issued, or renewed for any person in this State by a health insurer, as defined by 18 V.S.A. § 9402. The term shall not include benefit plans providing coverage for specific disease or other limited benefit coverage. (Added 1999, No. 16, § 1; amended 2011, No. 78 (Adj. Sess.), § 2, eff. April 2, 2012; 2018, No. 7 (Sp. Sess.), § 2, eff. Jan. 1, 2020; 2019, No. 19, § 1, eff. Jan. 1, 2020.)
2023 Vermont Statutes › Title 8 - Banking and Insurance › Chapter 107 - Health Insurance › § 4088c. Chemotherapy treatment

§ 4088c. Chemotherapy treatment
(a) A health insurance plan shall provide coverage for medically necessary growth cell stimulating factor injections taken as part of a prescribed chemotherapy regimen.
(b) As used in this section, “health insurance plan” means an individual or group health insurance policy, hospital or medical service corporation service contract, or health maintenance organization health benefit plan offered, issued, or renewed in this State. (Added 2003, No. 124 (Adj. Sess.), § 3.)
2023 Vermont Statutes › Title 8 - Banking and Insurance › Chapter 107 - Health Insurance › § 4088d. Coverage for covered services provided by naturopathic physicians

§ 4088d. Coverage for covered services provided by naturopathic physicians
(a) A health insurance plan shall provide coverage for medically necessary health care services covered by the plan when provided by a naturopathic physician licensed in this State for treatment within the scope of practice described in 26 V.S.A. chapter 81 and shall recognize naturopathic physicians who practice primary care to be primary care physicians. Health care services provided by naturopathic physicians may be subject to reasonable deductibles, co-payment and coinsurance amounts, and fee or benefit limits consistent with those applicable to other primary care physicians under the plan, as well as practice parameters, cost-effectiveness and clinical efficacy standards, and utilization review consistent with any applicable rules published by the Department of Financial Regulation. Any amounts, limits, standards, and review shall not function to direct treatment in a manner unfairly discriminative against naturopathic care, and collectively shall be not more restrictive than those applicable under the same policy 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 providers. A health insurance plan may require that the naturopathic physician’s services be provided by a licensed naturopathic physician under contract with the insurer or shall be covered in a manner consistent with out-of-network provider reimbursement practices for primary care physicians; however, this shall not relieve a health insurance plan from compliance with the applicable network adequacy requirements adopted by the Commissioner by rule. Nothing contained in this section shall be construed as impeding or preventing either the provision or the coverage of health care services by licensed naturopathic physicians, within the lawful scope of naturopathic practice, in hospital facilities on a staff or employee basis.
(b) As used in this section, “health insurance plan” means Medicaid and any other public health care assistance program, any individual or group health insurance policy, any hospital or medical service corporation or health maintenance organization subscriber contract, or any other health benefit plan offered, issued, or renewed for any person in this State by a health insurer, as defined by 18 V.S.A. § 9402. The term shall not include benefit plans providing coverage for a specific disease or other limited benefit coverage. (Added 2007, No. 59, § 1, eff. Oct. 1, 2007; amended 2007, No. 88 (Adj. Sess.), § 1, eff. March 6, 2008; 2011, No. 78 (Adj. Sess.), §§ 2, 30, eff. April 2, 2012; 2011, No. 96 (Adj. Sess.), § 1, eff. Oct. 1, 2012; 2015, No. 97 (Adj. Sess.), § 15; 2017, No. 113 (Adj. Sess.), § 43.)
2023 Vermont Statutes › Title 8 - Banking and Insurance › Chapter 107 - Health Insurance › § 4088e. Notice of preferred drug list changes

§ 4088e. Notice of preferred drug list changes
On a periodic basis, no less than once per calendar year, a health insurer as defined in 18 V.S.A. § 9471(2)(A), (C), and (D) shall notify beneficiaries of changes in pharmaceutical coverage and provide access to the preferred drug list maintained by the insurer. (Added 2007, No. 80, § 11.)
2023 Vermont Statutes › Title 8 - Banking and Insurance › Chapter 107 - Health Insurance › § 4088f. Prosthetic parity

§ 4088f. Prosthetic parity
(a) As used in this section:
(1) “Health insurance plan” means any health insurance policy or health benefit plan offered by a health insurer, as defined in 18 V.S.A. § 9402, as well as Medicaid and any other public health care assistance program offered or administered by the State or by any subdivision or instrumentality of the State. The term shall not include policies or plans providing coverage for a specific disease or other limited benefit coverage.
(2) “Prosthetic device” means an artificial limb device to replace, in whole or in part, an arm or a leg.
(b) A health insurance plan shall provide coverage for prosthetic devices in all health plans at least equivalent to that provided by the federal Medicare program. Coverage may be limited to the prosthetic device that is the most appropriate model that is medically necessary to meet the patient’s medical needs. Any dispute between the insured and the carrier concerning coverage and the application of this section shall be subject to independent external review under section 4089f of this title.
(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.
(d) A health insurance plan shall provide coverage under this section for the medically necessary repair or replacement of a prosthetic device.
(e) A health insurance plan shall not impose any annual or lifetime dollar maximum on coverage for prosthetics that is less than the annual or lifetime dollar maximum that applies generally to all terms and services covered under the plan.
(f) The coverage required may 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 non-primary care items and services under the health plan. (Added 2007, No. 103 (Adj. Sess.), § 1, eff. Oct. 1, 2008; amended 2015, No. 97 (Adj. Sess.), § 16.)
2023 Vermont Statutes › Title 8 - Banking and Insurance › Chapter 107 - Health Insurance › § 4088g. Coverage for covered services provided by athletic trainers

§ 4088g. Coverage for covered services provided by athletic trainers
(a) To the extent a health insurance plan provides coverage for a particular type of health service or for any particular medical condition that is within the scope of practice of athletic trainers, a licensed athletic trainer who acts within the scope of practice authorized by law shall not be denied reimbursement by the health insurer for those covered services if the health insurer would reimburse another health care provider for those services. A health insurer may require that the athletic trainer services be provided by a licensed athletic trainer under contract with the insurer. Services provided by athletic trainers may be subject to reasonable deductibles, co-payment and co-insurance amounts, fee or benefit limits, practice parameters, and utilization review consistent with applicable rules adopted by the Department of Financial Regulation; provided that the amounts, limits, and review shall not function to direct treatment in a manner unfairly discriminative against athletic trainer care, and collectively shall be no more restrictive than those applicable under the same policy for care or services provided by other health care providers but allowing for the management of the benefit consistent with variations in practice patterns and treatment modalities among different types of health care providers. Nothing in this section shall be construed as impeding or preventing either the provision or coverage of health care services by licensed athletic trainers within the lawful scope of athletic trainer practice.
(b) As used in this section, “health insurance plan” means an individual or group health insurance policy, a hospital or medical service corporation or health maintenance organization subscriber contract, or another health benefit plan offered, issued, or renewed for a person in this State by a health insurer, as defined in 18 V.S.A. § 9402(8). The term shall not include benefit plans providing coverage for specific disease or other limited benefit coverage. (Added 2007, No. 141 (Adj. Sess.), § 1, eff. July 1, 2008; amended 2011, No. 78 (Adj. Sess.), § 2, eff. April 2, 2012.)
2023 Vermont Statutes › Title 8 - Banking and Insurance › Chapter 107 - Health Insurance › § 4088h. Health insurance and the Blueprint for Health

§ 4088h. Health insurance and the Blueprint for Health
(a)(1) A health insurance plan shall be offered, issued, and administered consistent with the Blueprint for Health established in 18 V.S.A. chapter 13, as determined by the Commissioner.
(2) As used in this section, “health insurance plan” means any individual or group health insurance policy, any hospital or medical service corporation or health maintenance organization subscriber contract, or any other health benefit plan offered, issued, or renewed for any person in this State by a health insurer, as defined in 18 V.S.A. § 9402. The term shall include the health benefit plan offered by the State of Vermont to its employees and any health benefit plan offered by any agency or instrumentality of the State to its employees. The term shall not include benefit plans providing coverage for specific disease or other limited benefit coverage unless so directed by the Commissioner.
(b) Health insurers as defined in 18 V.S.A. § 701 shall participate in the Blueprint for Health as specified in 18 V.S.A. § 706. In consultation with the Director of the Blueprint for Health and the Director of Health Care Reform, the Commissioner may establish procedures to exempt or limit the participation of health insurers offering a stand-alone dental plan or specific disease or other limited-benefit coverage. A health insurer shall be exempt from participation if the insurer offers only benefit plans which are paid directly to the individual insured or the insured’s assigned beneficiaries and for which the amount of the benefit is not based upon potential medical costs or actual costs incurred. (Added 2007, No. 204 (Adj. Sess.), § 2; amended 2009, No. 128 (Adj. Sess.), § 15.)
2023 Vermont Statutes › Title 8 - Banking and Insurance › Chapter 107 - Health Insurance › § 4088k. Physical therapy co-payments for certain plans

§ 4088k. Physical therapy co-payments for certain plans
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. chapter 18, subchapter 1, health care services provided by a licensed physical therapist may be subject to a co-payment requirement, provided that any required co-payment amount shall be between 125 and 150 percent of the amount of the co-payment applicable to care and services provided by a primary care provider under the plan. (Added 2018, No. 7 (Sp. Sess.), § 3, eff. Jan. 1, 2020; amended 2019, No. 19, § 2, eff. Jan. 1, 2020.)
2023 Vermont Statutes › Title 8 - Banking and Insurance › Chapter 107 - Health Insurance › § 4088m. Coverage for gender-affirming health care services [Effective January 1, 2024]

§ 4088m. Coverage for gender-affirming health care services [Effective January 1, 2024]
(a) Definitions. As used in this section:
(1) “Gender-affirming health care services” has the same meaning as in 1 V.S.A. § 150.
(2) “Health insurance plan” means Medicaid and any other public health care assistance program, any individual or group health insurance policy, any hospital or medical service corporation or health maintenance organization subscriber contract, or any other health benefit plan offered, issued, or renewed for any person in this State by a health insurer as defined by 18 V.S.A. § 9402. For purposes of this section, health insurance plan includes any health benefit plan offered or administered by the State or any subdivision or instrumentality of the State. The term does not include benefit plans providing coverage for a specific disease or other limited benefit coverage, except that it includes any accident and sickness health plan.
(b) Coverage.
(1) A health insurance plan shall provide coverage for gender-affirming health care services that:
(A) are medically necessary and clinically appropriate for the individual’s diagnosis or health condition; and
(B) are included in the State’s essential health benefits benchmark plan.
(2) Coverage provided pursuant to this section by Medicaid or any other public health care assistance program shall comply with all federal requirements imposed by the Centers for Medicare and Medicaid Services.
(3) Nothing in this section shall prohibit a health insurance plan from providing greater coverage for gender-affirming health care services than is required under this section.
(c) Cost sharing. A health insurance plan shall not impose greater coinsurance, co-payment, deductible, or other cost-sharing requirements for coverage of gender-affirming health care services than apply to the diagnosis and treatment of any other physical or mental condition under the plan. (Added 2023, No. 15, § 3, eff. January 1, 2024.)
2023 Vermont Statutes › Title 8 - Banking and Insurance › Chapter 107 - Health Insurance › § 4089. Services for victims of sexual assault

§ 4089. Services for victims of sexual assault
(a) A health insurer 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 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.
(b) As used in this section:
(1) “Health insurer” shall have the same meaning as in 18 V.S.A. § 9402.
(2) “Sexual assault examination” means either or both of the following:
(A) a physical examination of the patient, documentation of biological and physical findings, and collection of evidence; and
(B) treatment of the patient’s injuries; providing care for sexually transmitted infections; assessing pregnancy risk; discussing treatment options including reproductive health services, screening for the human immunodeficiency virus, and prophylactic treatment when appropriate; and providing instructions and referrals for follow-up care. (Added 2015, No. 34, § 1, eff. Oct. 1, 2015.)
2023 Vermont Statutes › Title 8 - Banking and Insurance › Chapter 107 - Health Insurance › § 4089c. Diabetes treatment

§ 4089c. Diabetes treatment
(a)(1) A health insurer shall provide coverage for the equipment, supplies, and outpatient self-management training and education, including medical nutrition therapy, for the treatment of insulin dependent diabetes, insulin using diabetes, gestational diabetes, and noninsulin using diabetes if prescribed by a health care professional legally authorized to prescribe such items under law. A health insurer may require that such prescriptions be made, and care be given, by a health care professional under contract with the insurer.
(2) Diabetes outpatient self-management training and education required to be covered by this section shall be provided by a certified, registered, or licensed health care professional with specialized training in the education and management of diabetes.
(3) Benefits required to be covered by this section shall be subject to the same dollar limits, deductibles, and coinsurance factors within the provisions of the health insurance policy.
(b) For the purposes of this section, “insurer” means any health insurance company, nonprofit hospital and medical service corporation, and health maintenance organization. The term does not apply to coverage for specified disease or other limited benefit coverage. (Added 1997, No. 14, § 1.)
2023 Vermont Statutes › Title 8 - Banking and Insurance › Chapter 107 - Health Insurance › § 4089d. Coverage; dependent children

§ 4089d. Coverage; dependent children
(a) As used in this section, “health insurance plan” has the same meaning as “group health plan” and shall be subject to the same excepted benefits, in each case, as set forth in 45 C.F.R. § 146.145, as in effect as of December 31, 2017.
(b) 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 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.
(c)(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:
(A) is incapable of self-sustaining employment by reason of a mental or physical disability that has been found to be a disability that qualifies or would qualify the child for benefits using the definitions, standards, and methodology in 20 C.F.R. Part 404, Subpart P;
(B) became so incapable prior to attainment of the limiting age; and
(C) is chiefly dependent upon the employee, member, subscriber, or policyholder for support and maintenance.
(2) Coverage under subdivision (1) of this subsection shall not be denied any person based upon the existence of such a condition; however a health insurance plan may require reasonable periodic proof of a continuing condition no more frequently than once every year.
(d) 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 under subsection (b) of this section as appropriate. To establish entitlement to coverage under this subsection, documentation and certification by the student’s treating physician of the medical necessity of a leave of absence shall be submitted to the insurer or, for self-insured plans, the health plan administrator. The health insurance plan may require reasonable periodic proof from the student’s treating physician that the leave of absence continues to be medically necessary. (Added 1975, No. 237 (Adj. Sess.), § 1, eff. April 7, 1976; amended 1983, No. 165 (Adj. Sess.), § 2; 2005, No. 199 (Adj. Sess.), § 1; 2019, No. 63, § 5, eff. Jan. 1, 2020; 2019, No. 103 (Adj. Sess.), § 27.)
2023 Vermont Statutes › Title 8 - Banking and Insurance › Chapter 107 - Health Insurance › § 4089e. Treatment of inherited metabolic diseases

§ 4089e. Treatment of inherited metabolic diseases
(a) For the purposes of this section:
(1) “Inherited metabolic disease” means a disease caused by an inherited abnormality of body chemistry for which the State screens newborn infants.
(2) “Insurer” means any health insurance company, nonprofit hospital and medical service corporation, managed care organization, and health maintenance organization. The term does not apply to coverage for specified disease or other limited benefit coverage.
(3) “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 intended to be used under the direction of a physician for the dietary treatment of a metabolic disease.
(4) “Medical food” means an amino acid modified preparation that is intended to be used under the direction of a physician for the dietary treatment of an inherited metabolic disease.
(b) An insurer shall provide coverage for medical foods prescribed for medically necessary treatment for an inherited metabolic disease.
(c) Coverage for low protein modified food products prescribed for medically necessary treatment of an inherited metabolic disease shall be at least $2,500.00 during any continuous period of 12 months for any insured individual. (Added 1997, No. 128 (Adj. Sess.), § 1, eff. April 27, 1998.)
2023 Vermont Statutes › Title 8 - Banking and Insurance › Chapter 107 - Health Insurance › § 4089g. Craniofacial disorders

§ 4089g. Craniofacial disorders
(a) A health insurance plan shall provide coverage for diagnosis and medically necessary treatment, including surgical and nonsurgical procedures, for a musculoskeletal disorder that affects any bone or joint in the face, neck, or head and is the result of accident, trauma, congenital defect, developmental defect, or pathology. Subject to subsection (b) of this section, this coverage shall be the same as that provided under the health insurance plan for any other musculoskeletal disorder in the body and may be provided when prescribed or administered by a physician or a dentist. 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.
(b) A health insurance plan may require a referral from a health care provider under contract with the plan.
(c) As used in this section, “health insurance plan” means any health insurance policy or health benefit plan offered by a health insurer as defined in 18 V.S.A. § 9402. Health insurance plan includes any health benefit plan offered or administered by the State, or any subdivision or instrumentality of the State. (Added 1997, No. 95 (Adj. Sess.), § 1.)
2023 Vermont Statutes › Title 8 - Banking and Insurance › Chapter 107 - Health Insurance › § 4089h. Cancellation or nonrenewal of health insurance coverage

§ 4089h. Cancellation or nonrenewal of health insurance coverage
(a) Except as otherwise provided for comprehensive major medical insurance coverage in section 4077 of this chapter, a health insurer shall notify a policyholder of any premium payment due on a policy at least 21 days before the due date. If an insurer does not receive payment by the due date, an insurer shall send a termination notice to the policyholder notifying the policyholder that the insurer will terminate the policy effective on the due date if payment is not received within 14 days from the date of mailing of the termination notice. If an insurer does not receive payment within 14 days from the date of mailing of the termination notice, an insurer may cancel coverage effective on the due date.
(b) As used in this section, “health insurer” means a health insurance company, a hospital or medical service corporation, or a health maintenance organization that issues or renews any individual policy, service contract, or benefit plan in this State. (Added 1997, No. 112 (Adj. Sess.), § 1; amended 2021, No. 25, § 20, eff. May 12, 2021.)
2023 Vermont Statutes › Title 8 - Banking and Insurance › Chapter 107 - Health Insurance › § 4090a. Continuation of group

§ 4090a. Continuation of group
(a) All group health insurance policies, including dental policies, issued by an insurance company or a nonprofit hospital or medical service corporation; self-insured group plans; and prepaid health insurance plans, delivered or issued for delivery in this State, which insure employees or members for dental insurance or hospital and medical insurance on an expense incurred, service basis, or prepaid basis, other than policies covering specific diseases or accidental injuries only, shall provide that any person whose insurance under the group policy would terminate because of the occurrence of a qualifying event as defined in subsection (b) of this section shall be entitled to continue his or her health insurance under that group policy.
(b) For purposes of this subchapter, “qualifying event” means:
(1) loss of employment, including a reduction in hours that results in ineligibility for employer-sponsored coverage;
(2) divorce, dissolution, or legal separation of the covered employee from the employee’s spouse or civil union partner;
(3) a dependent child ceasing to qualify as a dependent child under the generally applicable requirements of the policy; or
(4) death of the covered employee or member.
(c) The provisions of this section shall not apply if:
(1) The deceased person or employee was not insured under the group policy on the date of the qualifying event.
(2) The person is covered by Medicare.
(3) The person is covered by any other group insured or uninsured arrangement which provides dental coverage or hospital and medical coverage for individuals in a group and under which the person was not covered immediately prior to such qualifying event, and no preexisting condition exclusion applies; provided, however, that the person shall remain eligible for continuation coverages which are not available under the insured or uninsured arrangement.
(4) The person has a loss of employment due to misconduct as defined in 21 V.S.A. § 1344.
(d) The continuation required by this section only applies to dental, hospital, and medical benefits.
(e) Notice of the continuation privilege shall be included in each certificate of coverage and shall be provided by the employer to the employee within 30 days following the occurrence of any qualifying event. (Added 1983, No. 165 (Adj. Sess.), § 1; amended 1985, No. 184 (Adj. Sess.), § 1; 2001, No. 121 (Adj. Sess.), § 3, eff. June 5, 2002; 2009, No. 61, § 14, eff. June 2, 2009.)
2023 Vermont Statutes › Title 8 - Banking and Insurance › Chapter 107 - Health Insurance › § 4090b. Continuation; notice; terms

§ 4090b. Continuation; notice; terms
(a) A person electing continuation shall notify the insurer, or the policyholder, or the contractor, or agent for the group if the policyholder did not contract for the policy directly with the insurer, of such election in writing within 60 days after receiving notice following the occurrence of a qualifying event pursuant to subsection 4090a(e) of this title. Notice of election to continue under the group policy shall be accompanied by the initial contribution, which shall include payment for the period from the qualifying event through the end of the month in which the election is made.
(b) Contributions shall be due on a monthly basis in advance to the insurer or the insurer’s agent, and shall not be more than 102 percent of the group rate for the insurance being continued under the group policy on the due date of each payment. (Added 1983, No. 165 (Adj. Sess.), § 1; amended 1985, No. 184 (Adj. Sess.), § 2; 2001, No. 121 (Adj. Sess.), § 4, eff. June 5, 2002; 2009, No. 61, § 15, eff. June 2, 2009.)
2023 Vermont Statutes › Title 8 - Banking and Insurance › Chapter 107 - Health Insurance › § 4090c. Termination of coverage

§ 4090c. Termination of coverage
Continuation of insurance under the group policy shall terminate upon the occurrence of any of the following:
(1) The date 18 months after the date that insurance under the policy would have terminated due to a qualifying event, as defined in subsection 4090a(b) of this title.
(2) The person fails to make timely payment of the required contribution.
(3) The person is covered by Medicare.
(4) The person is covered by any other group insured or uninsured arrangement that provides dental coverage or hospital and medical coverage for individuals in a group, under which the person was not covered immediately prior to the occurrence of a qualifying event, as defined in subsection 4090a(b) of this title, and no preexisting condition exclusion applies; provided, however, that the person shall remain eligible for continuation coverages which are not available under the insured or uninsured arrangement.
(5) The date on which the group policy is terminated or, in the case of an employee, the date the decedent’s or terminated employee’s employer terminates participation under the group policy. If such coverage is replaced by similar coverage under another group policy:
(A) the person shall have the right to become covered under that replacement policy, for the balance of the period that he or she would have remained covered under the prior group policy;
(B) the minimum level of benefits to be provided by the replacement policy shall be the applicable level of benefits of the prior group policy reduced by any benefits payable under that prior group policy; and
(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. (Added 1983, No. 165 (Adj. Sess.), § 1; amended 1985, No. 184 (Adj. Sess.), § 3; 2001, No. 121 (Adj. Sess.), § 5, eff. June 5, 2002; 2009, No. 61, § 16, eff. June 2, 2009.)
2023 Vermont Statutes › Title 8 - Banking and Insurance › Chapter 107 - Health Insurance › § 4090d. Right of conversion

§ 4090d. Right of conversion
All group health insurance policies, issued by an insurance company, a nonprofit hospital or medical service corporation, a self-insured group plan, and prepaid health insurance plans delivered or issued for delivery in this State which insure employees or members for hospital and medical insurance on an expense incurred, service or prepaid basis, other than for specific diseases or for accidental injuries only, shall provide that any person whose insurance under the group policy would terminate because of the death or loss of employment of the employee or member shall be entitled to have a converted policy issued to him or her by the insurer under whose group policy he or she was insured, without evidence of insurability. (Added 1983, No. 165 (Adj. Sess.), § 1; amended 1985, No. 184 (Adj. Sess.), § 4.)