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S.278

Introduced by   Senator Snelling of Chittenden District (By Request)

Referred to Committee on

Date:

Subject:  Health; access; insurance; reinsurance pool; Medicaid; reimbursement rate; medical malpractice; administration  

Statement of purpose:  This bill proposes to:  (1) require nongroup insurers to provide a health insurance plan for Vermonters which covers basic health benefits at an affordable cost; (2) require every Vermonter to have health coverage and show proof when requesting a state income tax refund or a driver’s license; (3) ensure affordability through a reinsurance pool for the individual and small group markets and through premium subsidies for low income Vermonters; (4) reform the medical malpractice system by making an expression of regret or apology made by or on behalf of a health care provider inadmissible in any civil or administrative proceeding against the provider and making compliance with facility medical practice guidelines admissible in court; (5) require health care providers to report medical errors to patients and the department of health and do root cause analysis of an adverse event; (6) require the department of health to establish a medical error reporting and analysis system, to look for systemic errors and suggest corrective action plans, and to sanction health care facilities that do not report as required; (7) improve Medicaid reimbursement rates to health care professionals; and (8) ingrequire the office of Vermont health access to study and report on an efficient and effective means of covering Medicaid recipients through private insurance plans.

AN ACT RELATING TO AFFORDABLE HEALTH INSURANCE FOR VERMONTERS

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

* * * Package of Basic Health Services * * *

Sec. 1.   8  V.S.A. §4062 is amended to read:

§ 4062. FILING AND APPROVAL OF POLICY FORMS AND PREMIUMS

(a) No policy of health insurance or certificate under a policy not exempted by subdivision 3368(a)(4) of this title shall be delivered or issued for delivery in this state nor shall any endorsement, rider, or application which becomes a part of any such policy, or any proof of insurance form, , or any proof of insurance form, be used, until a copy of the form, premium rates and rules for the classification of risks pertaining thereto have been filed with the commissioner of banking, insurance, securities, and health care administration; nor shall any such form, premium rate or rule be so used until the expiration of thirty days after having been filed, unless the commissioner shall sooner give his or her written approval thereto. The commissioner shall notify in writing the insurer which has filed any such form, premium rate or rule if it contains any provision which is unjust, unfair, inequitable, misleading, or contrary to the law of this state. In such notice, the commissioner shall state that a hearing will be granted within twenty days upon written request of the insurer. In all other cases, the commissioner shall give his or her approval. After the expiration of such thirty days from the filing of any such form, premium rate or rule, or at any time after having given written approval, the commissioner may, after a hearing of which at least twenty days written notice has been given to the insurer using such form, premium rate or rule, withdraw approval on any of the grounds stated in this section. Such disapproval shall be effected by written order of the commissioner which shall state the ground for disapproval and the date, not less than thirty days after such hearing when the withdrawal of approval shall become effective.

 Sec. 1.  8 V.S.A. § 4062d is added to read:

§ 4062d.  Standard Proof of Insurance Form

Sec. 2.   8  V.S.A. §4062d is added to read:

(a)  Every insurer delivering or issuing for delivery in the state in the state a policy of health insurance or certificate under a policy including any endorsement, rider, or application which becomes a part of any such policy, in the state must provide each covered individual with the standard proof of insurance form developed by the commissioner under this section annually by January 31 and upon request.  The proof of insurance proof of insuranceinsurer shall indicate whether the benefits provided are at least equivalent to the package of basic health care services provided in the affordable affordable common benefit plan developed under section 4080b of this title on each proof of insurance.

(b) (b)(1)  Prior to approving a policy or certificate under a policy, the commissioner shall determine if the benefits provided are at least equivalent to the package of basic health care services provided in the affordable affordable common benefit plan developed under section 4080b of this title.  The commissioner shall provide the results of the determination to the insurer with the approval or denial.

(2)  The commissioner shall establish a process by which an individual or employer may submit a health insurance summary plan description, certificate or policy to the department in order to request the standard proof of insurance form.

(c)  The commissioner shall develop a standard proof of insurance form, which shall include language indicating whether the benefits provided are at least equivalent to the package of basic health care services provided in the affordable affordable common benefit plan developed under section 4080b of this title.

 

(d)  As used in this section, health insurance policy means any individual or group health insurance policy, any hospital or medical service corporation or health maintenance organization subscriber contract or any other health benefit plan offered, issued or renewed for any person in this state by a health insurer, as defined by 18 V.S.A. § 9402(7).  The term shall not include disability insurance policies, accident indemnity or expense policies, long-term care insurance policies, student or athletic expense or indemnity policies, Medicare supplemental policies, dental policies and benefit plans providing coverage for specific disease or other limited benefit coverage.

(c) As used in this section, "health insurance policy" means any individual or group health insurance policy, any hospital or medical service corporation or health maintenance organization subscriber contract or any other health benefit plan offered, issued or renewed for any person in this state by a health insurer, as defined by 18 V.S.A. § 9402(7). The term shall not include disability insurance policies, accident indemnity or expense policies, long-term care insurance policies, student or athletic expense or indemnity policies, Medicare supplemental policies, dental policies and benefit plans providing coverage for specific disease or other limited benefit coverage.

 

 

Sec. 22.  8 V.S.A. § 4080b(e) is amended to read:

(e)  A registered nongroup carrier shall offer two or more common health care plans approved by the commissioner.  The commissioner, by rule, shall adopt standards and a process for approval of common health care plans that ensure that consumers may compare the cost of plans offered by carriers.  At least one plan shall be a low-cost The commissioner shall develop an affordable common health care plan that includes a package of basic services and may provide for deductibles, coinsurance arrangements, managed care, cost-containment provisions, and any other term, not inconsistent with the provisions of this title, deemed useful in making the plan affordable.  The basic service plan shall cover at least two physician visits annually and preventive care, including immunizations, annual physical exams, screening, counseling, treatment, and medication determined by scientific evidence to be effective in preventing or detecting disease.  A plan shall be affordable if it costs no more than ten percent of the income of a family at 300 percent of the federal poverty level.  The commissioner shall determinebase the benefits included in the package on the affordability measure, on evidence‑based guidelines for health care services and after a public input process.  If necessary to ensure affordability and notwithstanding provisions in this chapter, the commissioner may approve an affordable common health care plan that does not comply with the coverage requirements in this chapter.  A health maintenance organization may add limitations to a common health care plan if the commissioner finds that the limitations do not unreasonably restrict the insured from access to the benefits covered by the plans.  A registered nongroup carrier may offer additional benefits as riders to the basic benefit package upon approval by the commissioner. 

Sec. 33.  REPEAL

8 V.S.A. § 4080b(n) is repealed.

* * * Premium Assistance Program * * *

Sec. 44.  8 V.S.A. § 4062e is added to read:

§ 4062e.  PREMIUM ASSISTANCE PROGRAM

(a)  Beginning in January 2007, the secretary of human services shall establish the premium assistance program within the office of Vermont health access for the purpose of providing uninsured low and moderate income Vermonters with financial assistance to enroll in or purchase the affordable common health benefit plan developed pursuant to section 4080b of this title.  Financial assistance shall be 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)  The secretary of human services shall determine financial assistance amounts, including premium discounts and cost-sharing, and eligibility after public hearing and an opportunity for comment by interested parties and the public.  At minimum to be eligible, an individual must be a Vermont resident and have family income less than 300 percent of the federal poverty income level for that individual’s family size.

(c)  Annually on or before October 1 of each year, the secretary of human services, in consultation with commissioner of banking, insurance, securities, and health care administration, and the after public hearing and an opportunity for comment by interested parties and the public, shall order the adjustment of the premium discount and cost sharing assistance amounts to account for anticipated cost and utilization trends medical inflationfor the next calendar year.

(d)  The secretary shall adopt rules for the premium assistance program.  Such rules shall include:

(1)  The form and manner of an individual’s application for assistance authorized by this section;

(2)  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; and

(3)  Any other rules necessary to carry out the purposes of this section.

(e)  Any health insurer offering the affordable common benefit plan developed pursuant to section 4080b of this title may participate in the program.

(f)  As used in this section:

(1)  “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).

(2)  “Secretary” means the secretary of the agency of human services.

(g)  The secretary may apply to the federal government to include the program authorized by this section as a Medicaid program or a state children’s health program, if the secretary determines that it is cost-effective to do so.

* * * Individual Proof of Insurance * * *

Sec. 5.  8 V.S.A. § 4062g is added to read:

§ 4062g.  REQUIRED HEALTH INSURANCE

Every individual who resides in Vermont is required to have health coverage that provides at least the coverage of the affordable common benefit plan developed pursuant to section 4080b of this title.

Sec. 56.  23 V.S.A. § 800(a) is amended to read:

(a)  No owner or operator of a motor vehicle required to be licensed shall operate or permit the operation of the vehicle upon the highways of the state without having in effect an automobile liability policy or bond in the amounts of at least $25,000.00 for one person and $50,000.00 for two or more persons killed or injured and $10,000.00 for damages to property in any one accident.  In lieu thereof, evidence of self-insurance in the amount of $115,000.00 must be filed with the commissioner of motor vehicles.  Such financial responsibility shall be maintained and evidenced in a form prescribed by the commissioner.  A junior operator and an operator’s license shall not be issued or renewed without the proof of health insurance pursuant to 8 V.S.A. § 4062d that indicates that the coverage has been certified by the commissioner of banking, insurance, securities and health care administration to be at least equivalent to the basic benefit package required by 8 V.S.A. § 4080b or proof of coverage by Medicaid, the Vermont health access plan or Medicare.  The commissioner may require that evidence of financial responsibility be produced before motor vehicle inspections are performed pursuant to the requirements of 23 V.S.A. § 1222.

Sec. 67.  32 V.S.A. § 5884(d) is added to read:

(d)  Any personal income tax refund balance remaining after debt setoff under subchapter XII or other reduction or adjustment by the commissioner, shall be disbursed to the taxpayer only upon presentation to the commissioner of proof of health insurance of the taxpayer, or in the case of a joint return, proof of health insurance of both taxpayers.  No interest shall accrue on any refund during the period it remains undisbursed under this subsection.  “Proof of health insurance” means presentation to the commissioner of certificate issued by the commissioner of banking, insurance, securities, and health care administration that the taxpayer is covered by health insurance as required under 4062g of Title 8.  All appeals related to issues this subsection shall be to the commissioner of banking, insurance, securities and health care administration.

* * * Small Market Access Reinvestment Trust * * *

Sec. 78.  8 V.S.A. § 4062f is added to read:

§ 4062f.  SMALL MARKET ACCESS REINVESTMENT TRUST

(a)  The commissioner shall establish the small market access reinvestment trust plan for the purpose of lowering the cost of and thereby increasing access to health care coverage in the small group and nongroup health insurance markets.

(b)  The small market access reinvestment trust plan shall include a reinsurance mechanism permitting nongroup and small group carriers to transfer a portion of the incurred expenses over the specified attachment point, in accordance with rules adopted by the commissioner.  Such individuals shall remain enrolled policyholders, members, or subscribers of the carrier’s or insurer’s plan, and shall be subject to the same terms and conditions of coverage, premiums, and cost sharing as any other policyholder, member, or subscriber.

(c)  The commissioner may develop the small market access reinvestment trust plan in a manner that permits the plan to be eligible for a federal grant to administer the plan, including a grant under the federal Trade Adjustment Act.

(d)  The commissioner may adopt rules for the small market access reinvestment trust plan relating to:

(1)  The creation of a private, nonprofit business organization to operate the plan and the appointment of individuals to govern the organization.

(2)  Criteria governing the circumstances under which a small group carrier or a nongroup carrier may transfer a portion of the incurred expenses associated with individuals insured by the carrier to the reinsurance mechanism.

(3)  Eligibility criteria for providing financial support to carriers under the reinsurance mechanism, including carrier expenses eligible for financial support, standards and procedures for the treatment and management of chronic conditions, and any other eligibility criteria established by the commissioner.

(4)  Rules for operation of the reinsurance mechanism and the plan.

(5)  Any other standards or procedures necessary or desirable to carry out the purposes of this section.

(e)  As used in this section:

(1)  “Health insurer” means a health insurance company, nonprofit hospital and medical service corporation, or a health maintenance organization.

(2)  “Nongroup carrier” means a nongroup carrier registered under section 4080b of this title.

(3)  “Plan” means the small market access reinvestment trust plan established by this section.

(4)  “Small group carrier” means a small group carrier registered under section 4080a of this title.

* * * Error Reporting and Medical Malpractice Reform * * *

Sec. 98.  12 V.S.A. § 1912 is added to read:

§ 1912.  EXPRESSION OF REGRET OR APOLOGY BY HEALTH

              CARE PROVIDER INADMISSIBLE

(a)  An expression of regret or apology or an explanation of how a medical error occurred made by or on behalf of a health care provider, including one that is made in writing, orally, or by conduct, that is provided within 14 days of when the provider knew or should have known of the consequences of the error, does not constitute a legal admission of liability for any purpose and shall be inadmissible in any civil or administrative proceeding against the health care provider, including any arbitration or mediation proceeding.

(b)  In any civil or administrative proceeding against a health care provider, including any arbitration or mediation proceeding, the health care provider or any other person who makes an expression of regret, apology, or explanation on behalf of the health care provider, including one that is made in writing, orally, or by conduct, that is provided within 14 days of when the provider knew or should have known of the consequences of the potential adverse outcome may not be examined by deposition or otherwise with respect to the expression of regret, apology, or explanation.

(c)  As used in this section, health care provider means a medical doctor licensed to practice under chapter 23 of Title 26, an osteopathic physician licensed pursuant to subdivision 1750(9) of Title 26, an advance practice registered nurse licensed pursuant to subdivision 1572(4) of Title 26, or a physicians assistant certified pursuant to section 1733 of Title 26 acting within the scope of the license under which the health care provider is practicing.

Sec. 10.  12 V.S.A. § 1913 is added to read:

§ 1913.  ADMISSIBILITY OF PRACTICE GUIDELINES

Practice guidelines duly established by professional organizations of health care providers, by licensed hospitals, or by quality assurance programs recognized by state law shall be admissible as evidence on the question of whether the respondent met or failed to meet the applicable standard of care.

Sec. 11.  18 V.S.A. § 9421 is added to read:

§ 9421.  REPORTING AND NOTIFICATION

(a)  As used in this section:

(1)  “Adverse event” shall include both incidents and serious events.

(2Health care facility shall have the same meaning as in subdivision 9402(7) of this title.

(3Health care worker means an employee, independent contractor, licensee, or other person authorized to provide services in a health care facility.

(4Incident means an event, occurrence, or situation involving the clinical care of a patient in a health care facility which could have injured the patient but did not either cause an unanticipated injury or require the delivery of additional health care services to the patient.  The term does not include a serious event.

(5Serious event means an event, occurrence, or situation involving the clinical care of a patient in a health care facility that results in death or compromises patient safety and results in an unanticipated injury requiring the delivery of additional health care services to the patient.  The term does not include an incident.

(b)  A health care worker who reasonably believes that a serious event or incident has occurred shall report the serious event or incident to the workers health care facility unless the health care worker knows that a report has already been made.  The report shall be made immediately or as soon thereafter as reasonably practicable, but in no event later than 24 hours after the occurrence or discovery of a serious event or incident.

(c)  A medical facility through an appropriate designee shall provide written notification to a patient affected by a serious event or, with the consent of the patient, to an available family member or designee within seven days of the occurrence or discovery of a serious event.  If the patient is unable to give consent, the notification shall be given to an adult member of the immediate family.  If an adult member of the immediate family cannot be identified or located, notification shall be given to the closest adult family member.  For unemancipated patients who are under 18 years of age, the parent or guardian shall be notified in accordance with this subsection.  Notification under this subsection shall not constitute an acknowledgment or admission of liability.

(d)  A health care worker who reports the occurrence of a serious event or incident in accordance with subsection (a) or (b) of this section shall not be subject to any retaliatory action for reporting the serious event or incident and shall have the protections and remedies of section 508 of Title 21.

(e)  Nothing in this section shall limit a medical facilitys ability to take appropriate disciplinary action against a health care worker for failure to meet defined performance expectations or to take corrective action against a licensee for unprofessional conduct, including making false reports or failure to report serious events under this chapter.

(f)  A health care facility shall provide written notification of a serious event or incident to the department of health as soon as is reasonably and practically possible, but no later than 15 working days after discovery of the event.  The report shall be filed in a format specified by the commissioner of health  and shall identify the facility but shall not  include any identifying information for any of the health care professionals, facility employees, or patients involved.  The commissioner may consult with experts and organizations familiar with patient safety when developing the format for reporting and in further defining events in order to be consistent with industry standards.

(g)  Following an incident or serious event, the health care facility shall complete a root cause analysis and develop a corrective action plan.  It shall report the corrective action plan and the findings of the root cause analysis to the department of health within 90 days of the incident or event.

(h)  The commissioner of health shall establish an adverse health event reporting system designed to facilitate quality improvement in the health care system.  The reporting system shall not be designed to punish errors by health care practitioners or health care facility employees.

(i)  The commissioner shall:

(1)  analyze adverse event reports, corrective action plans, and findings of the root cause analyses to determine patterns of systemic failure in the health care system and successful methods to correct these failures.

(2)  communicate to individual facilities the commissioner’s conclusions, if any, regarding an adverse event reported by the facility.

(3)  communicate with relevant health care facilities any recommendations for corrective action resulting from the commissioner’s analysis of submissions from facilities.

(4)  publish an annual report:

(A)  describing, by institution, adverse events reported.

(B)  outlining, in aggregate, corrective action plans and the findings of root cause analyses.

(C)  making recommendations for modifications of state health care operations.

(5)  take steps necessary to determine if adverse event reports, the findings of the root cause analyses, and corrective action plans are filed in a timely manner.  The commissioner may sanction a facility for failure to file a timely adverse event report under this section, failure to conduct a root cause analysis, to implement a corrective action plan, or to provide the findings of a root cause analysis or corrective action plan in a timely fashion.  The sanction may include suspension, revocation, or refusal to renew the license of a facility or the placement of conditions on that license.

 

Sec. 9. * * * Medicaid Reform * * *

Sec. 120.  32 V.S.A. § 307(d) is amended to read:

(d)  The governor’s budget shall include his or her recommendations for an annual budget for Medicaid and all other health care assistance programs administered by the department of prevention, assistance, transition, and health access office of health access.  The governor’s proposed Medicaid budget shall include a proposed annual financial plan, and a proposed five-year financial plan, with the following information and analysis:

(1)  anticipated revenues;

(2)  anticipated expenditures, including anticipated per member per month expenditures for each population category eligible for health care assistance;

(3)  anticipated caseloads, including anticipated caseloads for each population category eligible for health care assistance;

(4)  anticipated utilization;

(5)  health care inflation trends;

(6)  recommendations for funding provider reimbursement at levels sufficient ensure reasonable access to care, and at levels at least equal to Medicare reimbursement to cover the cost of care provided no later than July 1, 2007.  This recommendation shall also include a process that will result in a commensurate decrease in provider charges and plan premiums as Medicaid payments are increased;

(7)  recommendations relating to Medicaid and other program eligibility, the benefit plan, cost-sharing, utilization controls, reimbursement, and any other matter necessary to align anticipated expenditures and revenues; and

(8)  any other recommendations or information affecting the financial sustainability of Medicaid and all other health care assistance programs administered by the department of prevention, assistance, transition, and health access agency of human services.

Sec. 113.  REFORM STUDY

The office of Vermont health access and the department of banking, insurance, securities, and health care administration shall review and study Medicaid, the Vermont health access plan, and Dr. Dynasaur to determine the most efficient and effective method of providing health benefits to eligible individuals by contracting with health insurers for administrative services, medical management services, and benefit packages.  The study shall include a review of the benefits provided by these programs, redundancy in administrative  or medically management services between the office of Vermont health access and private insurers, and eligibility rules regarding divestment of assets.  The office and department shall report to the general assembly by January 1, 2007 with a recommendation on these issues, and a plan for administering Medicaid, the Vermont health access plan, and Dr. Dynasaur through private insurers.

* * * Healthy Lifestyles Insurance Discount * * *

Sec. 141.  8 V.S.A. § 4080a(h) is amended to read:

(h)(1)  A registered small group carrier shall use a community rating method acceptable to the commissioner for determining premiums for small group plans.  Except as provided in subdivision (2) of this subsection, the following risk classification factors are prohibited from use in rating small groups, employees, or members of such groups, and dependents of such employees or members:

(A)  demographic rating, including age and gender rating;

(B)  geographic area rating;

(C)  industry rating;

(D)  medical underwriting and screening;

(E)  experience rating;

(F)  tier rating; or

(G)  durational rating.

(2)(A)  The commissioner shall, by rule, adopt standards and a process for permitting registered small group carriers to use one or more risk classifications in their community rating method, provided that the premium charged shall not deviate above or below the community rate filed by the carrier by more than 20 percent (20%), and provided further that the commissioner’s rules may not permit any medical underwriting and screening.

(B)  The commissioner’s rules shall permit a carrier, including a hospital or medical service corporation, to establish premium discounts or rebates or otherwise modify applicable co-payments or deductibles in return for adherence to programs of health promotion and disease prevention, in accordance with proposed federal regulations relating to bona fide wellness programs, 45 C.F.R. § 146.121(f), as amended.  Under the federal regulations, permissible bona fide wellness programs shall:

(i)  limit any discount, rebate, or waiver of cost sharing to not more than 15 percent of the cost of employee-only coverage, provided that the sum of any rate deviation under subdivision (2)(A) of this subsection plus any premium discount authorized under this subdivision (2)(B) does not exceed 30 percent of the premium;

(ii)  be designed reasonably to promote good health or prevent disease for individuals in the program, and not be used as a subterfuge for imposing higher costs on an individual based on a health factor; and

(iii)  provide that the reward under the program is available to all similarly situated individuals;

(iv)  provide a reasonable alternative standard to obtain the reward to any individual for whom it is unreasonably difficult due to a medical condition to satisfy the otherwise applicable standard for the discount and disclose in all plan materials that describe the discount program the availability of a reasonable alternative standard. 

(C)  The commissioner, in consultation with the commissioner of health, shall adopt by rule:

(i)  standards for approved health promotion and disease prevention programs, based on the best scientific, evidence-based medical practices; and

(ii)  standards and procedures for evaluating an individual’s adherence to programs of health promotion and disease prevention.

(3)  The commissioner may exempt from the requirements of this section an association as defined in section subdivision 4079(2) of this title which:

(A)  offers a small group plan to a member small employer which is community rated in accordance with the provisions of subdivisions (1) and (2) of this subsection.  The plan may include risk classifications in accordance with subdivision (2) of this subsection;

(B)  offers a small group plan that guarantees acceptance of all persons within the association and their dependents; and

(C)  offers one or more of the common health care plans approved by the commissioner under subsection (e) of this section.

(4)  The commissioner may revoke or deny the exemption set forth in subdivision (3) of this subsection if the commissioner determines that:

(A)  because of the nature, size or other characteristics of the association and its members, the employees or members are in need of the protections provided by this section; or

(B)  the association exemption has or would have a substantial adverse effect on the small group market.

Sec. 156.  8 V.S.A. § 4080b(h) is amended to read:

(h)(1)  A registered nongroup carrier shall use a community rating method acceptable to the commissioner for determining premiums for nongroup plans.  Except as provided in subdivision (2) of this subsection, the following risk classification factors are prohibited from use in rating individuals and their dependents:

(A)  demographic rating, including age and gender rating;

(B)  geographic area rating;

(C)  industry rating;

(D)  medical underwriting and screening;

(E)  experience rating;

(F)  tier rating; or

(G)  durational rating.

(2)(A)  The commissioner shall, by rule, adopt standards and a process for permitting registered nongroup carriers to use one or more risk classifications in their community rating method.  After July 1, 1993, provided that the premium charged shall not deviate above or below the community rate filed by the carrier by more than 40 percent (40%) for two years, and thereafter 20 percent (20%).  Such rules may not permit, and provided further that the commissioner’s rules may not permit any medical underwriting and screening and shall give due consideration to the need for affordability and accessibility of health insurance.

(B)  The commissioner’s rules shall permit a carrier, including a hospital or medical service corporation, to establish premium discounts or rebates or otherwise modify applicable copayments or deductibles in return for adherence to programs of health promotion and disease prevention, in accordance with proposed federal regulations relating to bona fide wellness programs, 45 C.F.R. § 146.121(f), as amended.  Under the federal regulations, permissible bona fide wellness programs shall:

(i)  limit any discount, rebate, or waiver of cost sharing to not more than 15 percent of the cost of employee-only coverage, provided that the sum of any rate deviation under subdivision (2)(A) of this subsection plus any premium discount authorized under this subdivision (h)(2)(B) does not exceed 30 percent of the premium;

(ii)  be designed reasonably to promote good health or prevent disease for individuals in the program, and not be used as a subterfuge for imposing higher costs on an individual based on a health factor; and

(iii)  provide that the reward under the program is available to all similarly situated individuals;

(iv)  provide a reasonable alternative standard to obtain the reward to any individual for whom it is unreasonably difficult due to a medical condition to satisfy the otherwise applicable standard for the discount and disclose in all plan materials that describe the discount program the availability of a reasonable alternative standard.   

(C)  The commissioner, in consultation with the commissioner of health, shall adopt by rule:

(i)  standards for approved health promotion and disease prevention programs, based on the best scientific, evidence-based medical practices; and

(ii)  standards and procedures for evaluating an individual’s adherence to programs of health promotion and disease prevention.

Sec. 176.  8 V.S.A. § 4516 is amended to read:

§ 4516.  ANNUAL REPORT TO COMMISSIONER

Annually, on or before the fifteenth day of March 15, a hospital service corporation shall file with the commissioner of banking, insurance, securities, and health care administration a statement sworn to by the president and treasurer of the corporation showing its condition on the thirty-first day of December 31.  The statement shall be in such form and contain such matters as the commissioner shall prescribe.  To qualify for the tax exemption set forth in section 4518 of this title, the statement shall include a certification that the hospital service corporation operates on a nonprofit basis for the purpose of providing an adequate hospital service plan to individuals of the state, both groups and nongroups, without discrimination based on age, gender, geographic area, industry, and medical history, except as allowed by subdivisions 4080a(h)(2)(B) and 4080b(h)(2)(B) of this title.

Sec. 187.  8 V.S.A. § 4588 is amended to read:

§ 4588.  ANNUAL REPORT TO COMMISSIONER

Annually, on or before March 15, a medical service corporation shall file with the commissioner of banking, insurance, securities, and health care administration a statement sworn to by the president and treasurer of the corporation showing its condition on December 31, which shall be in such form and contain such matters as the commissioner shall prescribe.  To qualify for the tax exemption set forth in section 4590 of this title, the statement shall include a certification that the medical service corporation operates on a nonprofit basis for the purpose of providing an adequate medical service plan to individuals of the state, both groups and nongroups, without discrimination based on age, gender, geographic area, industry, and medical history, except as allowed by subdivisions 4080a(h)(2)(B) and 4080b(h)(2)(B) of this title.

Sec. 198.  8 V.S.A. § 5115 is amended to read:

§ 5115.  DUTY OF NONPROFIT HEALTH MAINTENANCE

              ORGANIZATIONS

Any nonprofit health maintenance organization subject to this chapter shall offer nongroup plans to individuals in accordance with section 4080b of this title without discrimination based on age, gender, industry, and medical history, except as allowed by subdivisions 4080a(h)(2)(B) and 4080b(h)(2)(B) of this title.

Sec. 19.  EFFECTIVE DATE

This act shall be effective July 1, 2006, except that Sec. 5 shall be effective September 1, 2006. § 5115. DUTY OF NONPROFIT HEALTH MAINTENANCE ORGANIZATIONS

 



Published by:

The Vermont General Assembly
115 State Street
Montpelier, Vermont


www.leg.state.vt.us