Download this document in MS Word format


AutoFill Template

H.636

Introduced by   Representative O'Donnell of Vernon

Referred to Committee on

Date:

Subject:  Health; Vermont health access plan; buy-in

Statement of purpose:  This bill proposes to establish a premium-funded program for uninsured individuals to receive health care coverage and to allow individuals eligible for the Vermont health access plan to receive subsidies for employer-sponsored insurance.

AN ACT RELATING TO HEALTH CARE COVERAGE FOR UNINSURED INDIVIDUALS THROUGH THE VERMONT HEALTH ACCESS PLAN

It is hereby enacted by the General Assembly of the State of Vermont:

Sec. 1.  33 V.S.A. subchapter 3 is amended to read:

Subchapter 3.  Vermont Health Access Trust Fund

§ 1971.  DEFINITIONS

As used in this subchapter,:

(1)  “Agency” means the agency of human services.

(2)  “Secretary means the secretary of human servicesApproved group health benefit plan” means an insured or self-insured health benefit plan that satisfies the secretary’s criteria for participation in the premium assistance program under section 1974 of this title.

(3)  “Approved high deductible health insurance plan” means a high deductible health benefit plan with deductible amounts no less than and no greater than the deductible amounts required of a high deductible health insurance plan under Section 223 of the Internal Revenue Code (health savings accounts).

(4)  "Office of Vermont health access" means the office of Medicaid within administering the Medicaid program as a public managed care organization for the agency of human services.

(5)  "Secretary" means the secretary of human services.

* * *

§ 1973.  VERMONT HEALTH ACCESS PLAN

(a)  The department of prevention, assistance, transition, and health access agency of human services shall establish the Vermont health access plan (VHAP) pursuant to a waiver of federal Medicaid law.  The plan shall remain in effect as long as the federal waiver is granted or renewed.

(b)  The purpose of the Vermont health access plan (VHAP) is to provide health care coverage for uninsured or underinsured low income Vermonters. The commissioner of the department of prevention, assistance, transition, and health access agency of human services shall establish rules regarding eligibility and administration of the plan.  The Vermont health access plan shall include a premium assistance program pursuant to section 1974 of this title to provide VHAP beneficiaries with financial assistance to purchase health care coverage offered by the individual’s employer.  The secretary may make participation in the premium assistance program mandatory.

§ 1974.  VHAP PREMIUM ASSISTANCE PROGRAM

(a)  The premium assistance program shall offer financial assistance to individuals eligible for VHAP who have health insurance offered by the individual’s employer in the form of:

(1)  a reduced premium obligation of an eligible individual; and

(2)  in the case of an approved high deductible plan, a reduced deductible payment obligation for the eligible individual.

(b)  Financial assistance to eligible individuals shall be as follows:

(1)  For eligible individuals with household income greater than 150 percent of the federal poverty level and equal to or less than 200 percent of the federal poverty level:

(A)  Premium assistance shall be a $65.00 discount from the monthly cost of participation in or purchase of an approved group health benefit plan with single-person coverage and a $105.00 discount from the monthly cost of participation in or purchase of an approved group health benefit plan with

two-person coverage if both individuals are eligible for VHAP; provided that in no event shall the discount be greater than 60 percent of the eligible individual’s share of group plan coverage; and

(B)  Cost-sharing assistance in connection with an approved high deductible health insurance plan shall be 60 percent of the individual’s deductible expenditures.

(2)  For eligible individuals with household income greater than 200 percent of the federal poverty level and equal to or less than 250 percent of the federal poverty level:

(A)  Premium assistance shall be a $45.00 discount from the monthly cost of participation in or purchase of an approved group health benefit plan with single-person coverage and a $70.00 discount from the monthly cost of participation in or purchase of an approved group health benefit plan with

two-person coverage if both individuals are eligible for VHAP; provided that in no event shall the discount be greater than 40 percent of the eligible individual’s share of group plan coverage; and

(B)  Cost-sharing assistance in connection with an approved high deductible health insurance plan shall be 40 percent of the individual’s deductible expenditures.

(3)  For eligible individuals with household income greater than 250 percent of the federal poverty level and equal to or less than 300 percent of the federal poverty level:

(A)  Premium assistance shall be a $25.00 discount from the monthly cost of participation in or purchase of an approved group health benefit plan with single-person coverage and a $35.00 discount from the monthly cost of participation in or purchase of an approved group health benefit plan with

two-person coverage if both individuals are eligible for VHAP; provided that in no event shall the discount be greater than 20 percent of the eligible individual’s share of group plan coverage; and

(B)  Cost-sharing assistance in connection with an approved high deductible health insurance plan shall be 20 percent of the individual’s deductible expenditures.

(d)  The secretary shall apply the rules applicable to the Vermont health access plan and shall adopt additional rules as necessary for the premium assistance program, including criteria for a group health benefit plan to be approved for participation in the premium assistance program and standards and procedures for participating health insurers to be compensated for the premium discounts, cost-sharing assistance, and other approved costs associated with the premium assistance program.

(e)  Any health insurer or self-insured plan may participate in the program.  The commissioner of banking, insurance, securities, and health care administration, after providing notice and an opportunity to be heard, may require one or more health insurance companies, hospital or medical services corporations, or health maintenance organizations covering at least 15,000 lives in this state to participate in the program if the commissioner determines that such designation is necessary to carry out the purposes of this section. 

(f)  The secretary shall apply to the federal government to include the program authorized by this section as a Medicaid waiver program if the secretary determines that it is cost-effective to do so.

§ 1975.  VERMONT HEALTH ACCESS PLAN; BUY-IN

(a)  The director of the office of Vermont health access shall offer health care coverage to uninsured adults through a health benefit plan administered in connection with the Vermont health access plan (VHAP). 

(b)(1)  In order to be eligible for the health benefit plan, an individual shall be a Vermont resident, be age 18 or older, demonstrate that he or she has been without health insurance coverage for at least 12 months, and have a household income at or below 300 percent of the federal poverty level.

(2)  In determining an individual’s eligibility under subdivision (1) of this subsection, the agency of human services shall apply the rules applicable to the Vermont health access plan, including any exceptions and methods of calculation.

§ 1976.  VHAP BUY-IN; 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 corporations, or health maintenance organizations.

(c)  The scope of services covered by the health benefit plan 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.

(e)  The director may reduce, by rule, the scope of services covered by the health benefit plan upon notice to beneficiaries and expiration of the quarterly premium term so that anticipated revenues are sufficient to pay for anticipated claims.

(f)  For a 12-month period from the effective date of coverage, a plan 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.

§ 1977.  VHAP BUY-IN; 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.  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, hospital or medical service corporations, 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 section.

(c)  Premiums established for a health benefit plan shall be sufficient to provide payments to providers at levels equivalent to 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 plan is contingent upon payment by the beneficiary of such premiums, fees, or other financial obligations of the beneficiary required by the plan.

§ 1978.  VHAP BUY-IN; 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 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 shall have the same grievance and appeal rights as a beneficiary in the Vermont health access program.

(d)  The health care coverage offered 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 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 plan unless such providers elect not to participate in the plan. 

§ 1979.  VHAP BUY-IN; ENROLLMENT PERIODS; REPORTING

(a)  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.

(b)  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.  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.

§ 1980.  VERMONT HEALTH ACCESS BUY‑IN PROGRAM TRUST

              FUND ESTABLISHED

(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 Vermont health access buy-in health benefit plan.

(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 plan.  The director may establish reserve accounts in connection with the administration of the health benefit plan.

(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 plan.

(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.


Sec. 2.  EFFECTIVE DATE

Sec. 1 of this act shall be effective January 1, 2007, except that the agency of human services may engage in rulemaking and upon passage may apply to the Centers on Medicare and Medicaid Services for a waiver amendment.



Published by:

The Vermont General Assembly
115 State Street
Montpelier, Vermont


www.leg.state.vt.us