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
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.
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Summary: Among many other things, this bill repealed a subsection within a section of the insurance law relevant to parity.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:
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.
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.
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
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.
There are three sections in the state insurance law relevant to parity. They will be summarized below in three parts:
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:
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:
This section also requires some insurance plans to file an annual report that includes the following information:
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.
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