Introduced by Representatives Smith of Morristown and Fisher of Lincoln
Subject: Vermont health access: buy-in; day care employees
Statement of purpose: This bill would establish a Vermont health access
buy-in program to offer health care coverage to employees of day care facilities and family day care homes.
AN ACT RELATING TO THE VERMONT HEALTH ACCESS BUY-IN PROGRAM FOR DAY CARE FACILITIES AND FAMILY DAY CARE HOMES
It is hereby enacted by the General Assembly of the State of Vermont:
Sec. 1. 33 V.S.A. chapter 19, subchapter 6 is added to read:
Subchapter 6. Vermont Health Access;
Day Care Facilities and Family Day Care Homes
§ 2031. ELIGIBILITY
(a) The director of the office of Vermont health access shall offer health care coverage to employees of licensed day care facilities and registered family day care homes through a health benefit plan administered in connection with the Vermont health access plan (VHAP).
(b) The director shall establish eligibility criteria for enrollment in the health benefit plan required by this subchapter that includes each of the following:
(1) The day care facility or family day care home must be doing business in Vermont.
(2) The day care facility must be licensed pursuant to section 3502 of this title.
(3) The family day care home must be registered pursuant to section 3502 of this title.
(4) The day care facility or family day care home must have employed, on at least 50 percent of its working days during the preceding calendar quarter, at least one and no more than 19 employees. The term includes
self-employed persons. Calculation of the number of employees shall not include a part-time employee who works less than 30 hours per week. The provisions of this section shall continue to apply until the plan anniversary date following the date the employer no longer meets the requirements of this subdivision.
(5) The day care facility or family day care home or its successor in interest must not have offered an insured or self-insured health benefit plan within the past 12 months. A day care facility or family day care home that has been in operation for 12 months or less is eligible if it has not offered health insurance during that time period.
(6) The day care facility or family day care home must pay one-half of the premium for all full-time enrolled employees and for the enrolled spouses and civil union partners age 18 and older of such employees participating in the plans if health care coverage is offered in accordance with subdivision (7) of this subsection or, in the case of a part-time employee, a prorated portion of such employer share of the premium based on the part-time employee’s weekly hours.
(7) A day care facility or family day care home which offers a health benefit plan required by this section may elect to include coverage for spouses and civil union partners who are age 18 and older under the same terms and conditions as for employees.
(8)(A) The day care facility or family day care home must offer to include all of its employees in the plan required by this section.
(B) The day care facility or family day care home must not exclude part-time employees from participation in the plan required by this section and must offer the same coverage under such plans to part-time employees as it offers to full-time employees. The employer must offer to include in the plan required by this subchapter such part-time employees at the rate to be paid by the employer and the employee under subdivision (6) of this subsection. As used in this subdivision, “part-time employee” means any employee who works a minimum of at least 17 and one-half hours per week.
§ 2032. SCOPE OF SERVICES
(a) The director shall establish, by rule, the scope of services covered by the health benefit plan required by this subchapter.
(b) Such scope of services shall be comparable to that included in commercial health benefit plans with the largest non‑Medicaid enrollments in this state offered by health insurers, any hospital or medical service corporation, or health maintenance organizations.
(c) The scope of services covered by the plan required by this subchapter shall include age-appropriate, preventive, clinical services that have demonstrated efficacy. The plan may also include financial or other incentives that have been demonstrated to encourage healthy lifestyles.
(d) The director shall publish a description of the services covered by the health benefit plan required by this subchapter.
(e) The director may reduce, by rule, the scope of services covered by the health benefit plan required by this subchapter upon notice to beneficiaries and expiration of the quarterly premium term so that anticipated revenues are sufficient to pay for anticipated claims.
§ 2033. PREMIUMS; CO-PAYMENTS; DEDUCTIBLES
(a) The director shall establish, by rule, co-payments, coinsurance amounts, deductibles, fees, and other cost‑sharing amounts applicable to the health benefit plan required by this subchapter. Such cost-sharing amounts and fees shall be comparable to those applicable to commercial health benefit plans with the largest non‑Medicaid enrollments in this state offered by health insurers, any hospital or medical service corporation, or health maintenance organizations.
(b) The director shall establish and amend premium amounts so that total revenue is sufficient to pay for the cost of benefits, claims, and program administration, including the cost of reinsurance and such reserves as the director determines, in accordance with health insurance industry rating practices and after consideration of any actuarial opinions solicited by the director, are adequate to account for the program’s administrative costs and other unanticipated costs. The director shall evaluate the adequacy of premiums quarterly and may amend premiums no more frequently than quarterly in order to comply with the provisions of this subchapter.
(c) Premiums established for a health benefit plan required by this subchapter shall be sufficient to provide payments to providers at levels 10 percent greater than the levels paid under the Medicare program. If Medicare does not pay for a service covered under the plan, the director shall establish some other payment structure for such services, determined after consultation with affected providers, that is sufficient to provide reasonable access to care by beneficiaries enrolled in the plan. Beneficiaries of the plan required by this subchapter shall be considered Medicare beneficiaries for purposes of chapter 65 of this title (Medicare balance billing).
(d) The director may adjust premiums, fees, deductibles, coinsurance, co‑payments, and other cost-sharing amounts annually to account for any change in the cost of benefits or other program costs and obligations.
(e) Eligibility for coverage under the health benefit plans required by this subchapter is contingent upon payment by the beneficiary of such premiums, fees, or other financial obligations of the beneficiary required by the plans.
§ 2034. ADMINISTRATION
(a) The director may administer the health benefit plans required by this subchapter through the office of Vermont health access or by contract with a health benefit plan administrator.
(b) Prescription drug coverage offered by the plans required by this subchapter shall be consistent with the standards and procedures applicable to the pharmacy best practices and cost control program established by sections 1996 and 1998 of this title.
(c) A beneficiary aggrieved by an adverse decision of the director may request an independent external review of the decision under section 4089a or 4089f of Title 8, as applicable. Such beneficiary may appeal to the human services board any adverse decision by the director other than decisions subject to an independent external review.
(d) The health care coverage offered pursuant to this subchapter shall not be considered a part of Vermont’s Section 1115 Medicaid waiver for federal fiscal purposes unless the director determines that there are financial advantages to the state and program participants to be part of the Section 1115 waiver, and that such participation does not adversely affect existing benefits provided under the Section 1115 waiver.
(e) No assistance shall be provided under this subchapter with respect to a health care expense that may be covered, in whole or in part, by Title XVIII of the Social Security Act (Medicare) or by any public or private health insurance plan.
(f) Providers participating in the Vermont Medicaid program shall be considered participating providers under the health benefit plans required under this subchapter, unless such providers elect not to participate in such plans.
§ 2035. ENROLLMENT PERIODS; REPORTING
(a) For a 12-month period from the effective date of coverage, a plan required by this subchapter shall limit coverage of preexisting conditions which exist during the six-month period before the effective date of coverage; provided that the plan shall waive any preexisting condition provisions for all individuals and new employees and their spouses or civil union partners, if applicable, who produce evidence of continuous health benefit coverage during the previous nine months substantially equivalent to the coverage offered by the plan. Credit shall be given for prior coverage that occurred without a break in coverage of 90 days or more.
(b) The director shall monitor enrollment in the health benefit plans required by this subchapter on a monthly basis. In the event that premiums and other revenue in any fiscal year are not sufficient to support the payment of benefits, claims, and other program costs for all otherwise eligible individuals under this subchapter, the director shall have the authority to limit enrollments, increase premiums and fees, amend cost-sharing amounts, or take any other administrative actions necessary to ensure that expenditures do not exceed available plan revenues. The director may not reduce reimbursement levels for participating providers under the provisions of this subsection.
(c) The health access oversight committee established by Sec. 13 of No. 14 of the Acts of 1995 shall be responsible for legislative oversight of the implementation and ongoing operation of the plans required by this subchapter. The director shall report on the implementation of the plans, requests for proposal to contract with a third party administrator, and ongoing operation and financial status of the plans at such times and with such information as the committee determines is necessary to fulfill its legislative oversight responsibilities. The committee’s annual report on the Vermont health access plan shall include findings and recommendations concerning the plans required by this subchapter.
§ 2036. VERMONT HEALTH ACCESS BUY‑IN PROGRAM TRUST
(a) The Vermont health access buy-in program trust fund is hereby established as a special fund under subchapter 5 of chapter 7 of Title 32 for the purpose of supporting the cost of paying claims and administering health care benefits to individuals enrolled in the health benefit plans required by this subchapter.
(b) Premiums, fees, and other beneficiary payments, donations, and contributions shall be deposited in the fund. Interest earned on the fund and any remaining balance shall be retained in the fund.
(c) The fund shall be administered by the director of the office of Vermont health access. The office of Vermont health access shall maintain records indicating the amount of monies in the fund at any time. The director may spend monies in the fund only for payment of claims, administration of benefit plans, and other costs associated with the Vermont health access buy-in program. The director may establish reserve accounts in connection with the administration of the health benefit plans required by section 2031 of this title.
(d) The general assembly may appropriate sums from the fund consistent with the purposes for which the fund may be used, to pay for any costs of the agency of human services and its constituent departments, divisions, or offices attributable to administration of the health benefit plans required by section 2031 of this title.
(e) The commissioner of finance and management may transfer monies from other special funds administered by the director of the office of Vermont health access in anticipation of receipts into the Vermont health access buy-in program trust fund, provided that any amounts so transferred shall be repaid before the end of the next fiscal quarter.
The Vermont General Assembly
115 State Street