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Legislation Signed into Law

2019

Primary Focus: Medical management limitation
Title/Description: An act relating to limiting prior authorization requirements for medication-assisted treatment
Citation: 18 V.S.A. § 4089b; 18 V.S.A. § 4750; 18 V.S.A. § 4754
Summary: This law requires at least one formulation of each MAT drug to be on the lowest tier of the drug formulary. The law eliminates prior authorization for MAT drugs and associated counseling and therapy for commercial plans and mandates report about the impact of prior authorization in Medicaid.
Effective Date: July 1, 2019 and January 1, 2020
Notes: Enacted through SB 43

2015-2016

H 875
Introduced: 3/2016
Sponsor: House Committee on Appropriations
Status: Signed into law 6/2016
Summary: This was an appropriations bill that has one section on mental health parity. It requires the Department of Vermont Health to ensure its clinical utilization review practices with respect to mental health services are consistent with the Federal Parity Law and state parity laws.

S 139
Introduced: 3/2015
Sponsor: Senate Committee on Health and Welfare
Status: Signed into law 6/2015
Summary: Among many other things, this bill repealed a subsection within a section of the insurance law relevant to parity. That section had required some insurance plans to file an annual report that included the following information:

  • Behavioral health patient discharge rates from inpatient care, the average length of stay, and the percentage of those patients who were readmitted
  • Percentage of enrollees receiving behavioral health treatment and number of people denied behavioral health services
  • Number of denials appealed by patients and number of denials appealed by providers
  • Level of patient satisfaction with their behavioral health coverage
Primary Focus: Mandated Benefit: Provider
Title/Description: Health Insurance Coverage, Mental Health and Substance Abuse
Citation: Vt. Stat. Ann. tit. 8, § 4089b
Summary: Vt. Stat. Ann. tit. 8, § 4089b mandates that health insurance plans provide coverage for treatment of a mental condition and:
(1) not establish any rate, term, or condition that places a greater burden on an insured for access to treatment for a mental condition than for access to treatment for other health conditions, including no greater co-payment for primary or specialty mental health care or services than the co-payment applicable to care or services provided by a primary care provider or specialty provider under an insured’s;
(2) not exclude from its network or list of authorized providers any licensed mental health or substance abuse provider located within the geographic coverage area of the health benefit plan if the provider is willing to meet the terms and conditions for participation established by the health insurer; and
(3) make any deductible or out-of-pocket limits required under a health insurance plan comprehensive for coverage of both mental and physical health conditions.
Vt. Stat. Ann. tit. 8, § 4089b also allows health insurance plans to contract with managed care organizations for the provision of mental health services.
Vt. Stat. Ann. tit. 8, § 4089b also provides definitions, discusses eligibility requirements, and requirements for relevant rule adoption.
Effective Date: May 28, 1997
Notes: Amended in 2015.

S 812
Introduced: 1/2016
Sponsor: Rep Lippert
Status: Signed into law 5/2016
Summary: This bill created the Vermont All-Payer Model. The bill requires that the All-Payer Model be in compliance with the Federal Parity Law and state parity laws.

2013-2014

H 107
Introduced: 1/2013
Sponsor: Rep. Fisher
Status: Signed into law 6/2013
Summary: Among many other things, this bill changed the sections of the state law relevant to parity by changing wording in the section about utilization review so that it applies to any plan under the jurisdiction of the Department of Financial Regulations. It also eliminated some obsolete wording in the sections about behavioral health coverage and autism coverage.

2011-2012

H 559
Introduced: 1/2012
Sponsor: Rep. Fisher
Status: Signed into law 5/2012
Summary: Among many other things, this bill changed the state insurance law relative to parity in a number of ways:

  • Requires the Department of Financial Regulation to develop “performance quality indicators” to evaluate how plans and managed care organizations are complying with one of the parity sections of the state insurance law
  • Requires the Commissioner of the Department of Financial Regulation to submit recommendations to the General Assembly about how to distinguish behavioral health primary care services from behavioral health specialty services and issue regulations regarding this as well (which the Department did do)
  • Requires plans to have copayments for behavioral health services that are “no greater” than copayments for other medical services

S 223
Introduced: 1/2012
Sponsor: Sen. Pollina
Status: Signed into law 5/2012
Summary: This bill changed the state insurance law about autism coverage to what it is currently (except for a few minor technical changes that were made in 2013). This section is summarized at the bottom of the page under “Vermont Parity Law,” “Autism Coverage.” This bill also required the Department of Human Services in consultation with Autism Speaks to submit a report to the General Assembly about implementation of this section of the insurance law.

2009-2010

Primary Focus: Mandated Benefit: Provider
Title/Description: Coverage for Diagnosis and Treatment for Early Childhood Developmental Disorders
Citation: Vt. Stat. Ann. tit. 8, § 4088i
Summary: Vt. Stat. Ann. tit. 8, § 4088i mandates that health insurance plans provide coverage for the diagnosis and treatment of early childhood developmental disorders, including applied behavior analysis, for children beginning at birth and continuing until the child reaches age 21. A health insurance plan shall not impose greater coinsurance, co-payment, deductible, or other cost-sharing requirements for coverage of the 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.
Vt. Stat. Ann. tit. 8, § 4088i continues on to discuss the requirements of coverage, such as services must be provided by a licensed provider, the services must be medically necessary, and treatment plan reviews may be implemented.
Effective Date: May 27, 2010
Notes: N/A

S 278
Introduced: 1/2010
Sponsor: Committee on Finance
Status: Signed into law 5/2010
Summary: Among many other things, this bill changed a section of the state insurance law relevant to parity by removing the language that allowed plans to only cover behavioral health services that were provided in-network.

S 262
Introduced: 1/2010
Sponsor: Sen. Carris
Status: Signed into law 5/2010
Summary: This bill added the section of the state insurance law about autism coverage. It has since been amended significantly. Here is how this bill is different than what is currently in the law:

  • Only required coverage through age 6 or when a child enters first grade
  • Had no specific language requiring coverage for applied behavior analysis
  • Did not require coverage by Medicaid plans and other public plans
  • Did not have specific language allowing plans to use prior authorization
  • Did not require coverage for appropriate services provided in a child’s home
  • Did not have any language about how often plans were allowed to review a child’s treatment plan
  • Did not require coverage for services provided by someone under the supervision of a licensed professional
  • Did not list pervasive developmental disorder not otherwise specified as a covered condition
  • Included habilitative and rehabilitative care as a treatment for autism instead of behavioral health treatment
  • Listed and defined autism spectrum disorder instead of “early childhood developmental disorder”
  • Had a different definition of medically necessary that specifically mentioned that it should be based on recommendations or reports from the American Academy of Pediatrics and the American Academy of Child and Adolescent Psychiatry
  • Did not define pharmacy care, psychiatric care, or psychological care

Vermont Parity Law

There are three sections in the state insurance law relevant to parity. They will be summarized below in three parts:

Behavioral Health Coverage

This section requires individual plans, small employer fully-insured plans, large employer fully-insured plans, and any state-administered insurance plans to cover all behavioral health conditions listed in the ICD.

Plans cannot use any financial requirement or quantitative treatment limitation for behavioral health services that “places a greater burden on an insured” for access to care than what is in place for other medical services.

Plans cannot exclude any provider from in-network status if the provider is willing to meet the terms and conditions of being in the network.

There must be only one deductible for all medical care; not one for behavioral health care and another for other medical care.

Plans can use managed care (and separate managed care organizations) for behavioral health services, even if they do not for other medical services, but the managed care practices must follow regulations issued by the Commissioner of the Department of Financial Regulation. Those regulations must ensure that:

  • Timely access to care and an adequate amount of providers are available
  • Plan protocols and utilization review procedures do not reduce access to medically necessary care
  • The amount of plan premiums that are attributed to behavioral health services should be reviewed to determine if it is “excessive, inadequate, unfairly discriminatory, unjust, unfair, inequitable, misleading or contrary to the laws of” Vermont
  • Plans must complete an annual “quality improvement plan” with their managed care organizations to make sure they are using “best practices and evidence-based guidelines” concerning behavioral health services
  • Plans and their managed care organizations will have a list of “active” providers who have in-network status

Before issuing these rules, the Commissioner is required to consult the Commissioner of Mental Health to help design provider incentives for increasing access to care and incorporate “incorporating nationally recognized best practices and evidence-based guidelines into the utilization review” of behavioral health services.

The section specifies that plans are responsible for any actions of their separate managed care organizations and lists some penalties the Commissioner of the Department of Financial Regulation can use in case of a violation of this section or regulations regarding this section:

  • Fines
  • Cease and desist orders
  • Order a plan to correct any violations and end its contract with its managed care organization
  • Revoke or suspend the license of a plan or a managed care organization, or make their continued licensure contingent on conditions put in place by the Commissioner

This section also requires some insurance plans to file an annual report that includes the following information:

  • Behavioral health patient discharge rates from inpatient care, the average length of stay, and the percentage of those patients who were readmitted
  • Percentage of enrollees receiving behavioral health treatment and number of people denied behavioral health services
  • Number of denials appealed by patients and number of denials appealed by providers
  • Level of patient satisfaction with their behavioral health coverage

Utilization Review

This section is mostly about utilization review and requires the Commissioner of the Department of Financial Regulation to issue regulations. Some of the significant requirements are:

  • Plans’ utilization review agents must disclose to patients the criteria used when performing reviews and their credentials
  • Any utilization review or prior authorization that results in a denial of services must include the “evaluation, findings, and concurrence of a mental health professional whose training and expertise is at least comparable to that of the treating clinician”
  • The number of people involved in making utilization review decisions must be specified by the regulations
  • Utilization review decisions cannot be made without talking to the patient’s provider first
  • Review agents are forbidden from having agreements with insurance plans that financially incentivize the agent to deny or reduce benefits

Autism Coverage (Early Childhood Developmental Disorders)

This section requires individual plans, small employer fully-insured plans, large employer fully-insured plans, and Medicaid plans to cover autism services from birth through age 20.

There is no annual maximum for coverage, and the “amount, duration, and frequency” of treatment must be based on whether the treatment is medically necessary.

Financial requirements cannot be any different than those in place for other medical services.

Plans must cover services that take place in a child’s home, as long as they are provided by the appropriate professional for those services.

Plans can review a child’s treatment plan once every 6 months.

Autism spectrum disorder is defined as “one or more pervasive developmental disorders as defined in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders, including autistic disorder, pervasive developmental disorder not otherwise specified, and Asperger’s disorder”

“Early childhood developmental disorder” is defined as “childhood mental or physical impairment or combination of mental and physical impairments that results in functional limitations in major life activities, accompanied by a diagnosis defined by the DSM or the ICD. The term includes autism spectrum disorders, but does not include a learning disability”

Treatment of autism is listed as the following (these are all defined in detail within the law):

It states that the Department of Financial Regulation should “facilitate and encourage” plans to bundle copayments for various autism services.

Get Support

Vermont Insurance Division

Common Violations

In seeking care or services, be aware of the common ways parity rights can be violated.

Common Violations

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