Code of Vermont Rules › Agency 21 - DEPARTMENT OF FINANCIAL REGULATION › Sub-Agency 040 - DIVISION OF HEALTH CARE ADMINISTRATION › Chapter 018 - RULE H-2006-01 - CATAMOUNT HEALTH INSURANCE › Section 21 040 018 - RULE H-2006-01 - CATAMOUNT HEALTH INSURANCE

Current through June,
				2024
Section 1 Purpose
The purpose of this Rule is to set forth the requirements for
				  Catamount Health insurance, as provided in
				  8 V.S.A. §
											4080f
				  and An Act Relating to Health Care Affordability for Vermonters, 2005 Vt. Acts
				  & Resolves No. 191 (Adj. Sess. 2006). Catamount Health insurance shall be
				  sold and administered in accordance with the Act and the policies and purposes
				  of Title 8.
Section 2
				Authority
This Rule is issued pursuant to the authority vested in the
				  Commissioner of the Department of Banking, Insurance, Securities and Health
				  Care Administration by the Act, including, but not limited to,
				  8 V.S.A. §
											4080f,
				  and by other applicable portions of Title 8, including, but not limited to,
				  8 V.S.A. §
											4062.
Section 3 Definitions
As used in this Rule:
(a) "Act" means An Act Relating to Health
				Care Affordability for Vermonters, 2005 Vt. Acts & Resolves No. 191 (Adj.
				Sess. 2006).
(b) "Catamount Health
				insurance" means those health insurance products and plans approved by the
				Commissioner and established under
				8 V.S.A. §
											4080f,
				Act 191, Adj. Session (2006) and this Rule.
(c) "Catamount Health carrier" or "carrier"
				means a carrier that sells, offers, issues or renews Catamount
Health insurance as defined by § 4080f and this Rule. A
				  carrier shall not sell Catamount Health unless the carrier is a registered
				  small group carrier under
				  8 V.S.A. §
												4080a.
(d) "Chronic care" means health services
				provided by a health care professional for an established clinical condition
				that is expected to last a year or more and that requires ongoing clinical
				management attempting to restore the individual to highest function, minimize
				the negative effects of the condition, and prevent complications related to
				chronic conditions. Examples of chronic conditions include, but are not limited
				to, diabetes, hypertension, cardiovascular disease, cancer, asthma, pulmonary
				disease, substance abuse, mental illness, spinal cord injury, and
				hyperlipidemia.
(e) "Chronic care
				management" means a system of coordinated health care interventions and
				communications for individuals with chronic conditions, including significant
				patient self-care efforts, systemic supports for the physician and patient
				relationship, and a plan of care emphasizing prevention of complications,
				utilizing evidence-based practice guidelines, patient empowerment strategies,
				and evaluation of clinical, humanistic, and economic outcomes on an ongoing
				basis with the goal of improving overall health.
(f) "Commissioner" means the Commissioner of
				the Vermont Department of Banking, Insurance, Securities and Health Care
				Administration.
(g) "Community
				rating" means a rating process that produces average rates for those
				individuals insured by Catamount Health insurance for a given policy period.
				Community rating as used in this Rule may allow for premium deviations among
				individuals based on incentives pursuant to rules adopted by the Commissioner
				under
				8 V.S.A. §§
											4080a(h)(2)(B) and
				4080b(h)(2)(B)
				relating to health promotion and disease prevention.
(h) "Credibility" means a measure of the
				degree of statistical significance that can be assigned to the claims
				experience of a Catamount Health plan when it is used as a basis for projecting
				a future rate.
(i) "Creditable
				coverage" includes coverage defined under applicable federal law as creditable
				including: a group health plan, such as one obtained through an employer or
				spouse's employer; health insurance coverage, including individual coverage;
				Medicare and Medicaid, CHAMPUS/TriCare; a medical program of the Indian Health
				Service Act or of a tribal organization; a state health benefits high risk
				pool; the Federal Employees Health Benefits Program; a public health plan; and
				a health benefit plan under section
				5(e) of
				the Peace Corps Act. Subject to federal law, the definition of creditable
				coverage includes any hospital or medical service policy or certificate,
				hospital or medical service plan contract, or HMO contract offered by a health
				insurance issuer, which includes, but is not limited to, comprehensive
				nongroup, small group and large group policies.
(j) "Health care professional" means an
				individual, partnership, corporation, facility (including a hospital) or
				institution licensed or certified or authorized by law to provide professional
				health care services.
(k) "Health
				insurance trend factor" means a projection factor that is an estimate of the
				unit cost increases and utilization increases that are expected to be incurred
				in a health benefits plan. The estimate of unit cost increases and utilization
				increases may include consideration of erosion of deductibles, medical
				technology, general inflation and cost shifting.
(l) "Network" means the network defined by
				the carrier in its Catamount Health policy. Catamount Health networks shall be
				created and managed consistent with the purposes of the Act and other
				applicable law.
(m) "Preventive
				care" means health services provided by health care professionals to identify
				and treat asymptomatic individuals who have developed risk factors or
				preclinical disease, but in whom the disease is not clinically apparent,
				including immunizations and screening, counseling, treatment, and medication
				determined by scientific evidence to be effective in preventing or detecting a
				condition.
(n) "Primary care" means
				health services provided by health care professionals specifically trained for
				and skilled in first-contact and continuing care for individuals with signs,
				symptoms, or health concerns, not limited by problem origin, organ system, or
				diagnosis, and shall include prenatal care and the treatment of mental
				illness.
(o) "Uninsured" means an
				individual who does not qualify for Medicare, Medicaid, the Vermont health
				access plan, or Dr. Dynasaur and had no creditable private insurance or
				employer-sponsored coverage that includes both hospital and physician services
				within 12 months prior to the month of application, or lost creditable private
				health insurance or employer-sponsored coverage during the prior 12 months for
				the following reasons:
(i) the individual's
				private insurance or employer-sponsored coverage ended because of:
(A) loss of employment;
(B) death of the principal insurance
				policyholder;
(C) divorce or
				dissolution of a civil union;
(D)
				no longer qualifying as a dependent under the plan of a parent or caretaker
				relative;
(E) no longer qualifying
				for COBRA, VIPER, or other state continuation coverage; or
(ii) college- or university-sponsored health
				insurance became unavailable to the individual because the individual
				graduated, took a leave of absence, or otherwise terminated studies.
(iii) "Uninsured individual" shall not
				include an individual who would be entitled to Catamount Health coverage
				without being uninsured for 12 months under
				8 V.S.A. §
												4080f(a)(9)(A) if the
				carrier determines, and the Commissioner gives prior approval to such
				determination, that such status was created primarily to obtain access to
				Catamount Health in a manner that is contrary to the intent of the Act. The
				Commissioner shall consult with appropriate legislative committees within 30
				days following any such determinations.
(iv) In order to be considered an "uninsured
				individual", a person shall be a Vermont resident and shall not be claimed as a
				dependent on a tax return by a person who is not a Vermont resident.