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BILL AS INTRODUCED 2007-2008

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H.555

Introduced by Representative O'Donnell of Vernon

Referred to Committee on

Date:

Subject:  Health; Catamount Health

Statement of purpose:  This bill proposes to provide access to Catamount Health for individuals enrolled in high-deductible health insurance plans.

AN ACT RELATING TO CATAMOUNT HEALTH FOR INDIVIDUALS ON HIGH-DEDUCTIBLE HEALTH INSURANCE PLANS

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

Sec. 1.  8 V.S.A. § 4080f is amended to read:

§ 4080f.  CATAMOUNT HEALTH

(a)  As used in this section:

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(7)  “High-deductible health insurance plan” means a health plan with annual deductible amounts of no less than $2,000.00 for an individual or annual deductible amounts of $4,000.00 for family coverage.

(8)  "Preventive care" means health services provided by health care professionals to identify and treat asymptomatic individuals who have developed risk factors or preclinical disease, but in whom the disease is not clinically apparent, including immunizations and screening, counseling, treatment, and medication determined by scientific evidence to be effective in preventing or detecting a condition.

(8)(9)  “Primary care” means health services provided by health care professionals specifically trained for and skilled in first-contact and continuing care for individuals with signs, symptoms, or health concerns, not limited by problem origin, organ system, or diagnosis, and shall include prenatal care and the treatment of mental illness.

(9)(10)  "Uninsured" means an individual who does not qualify for Medicare, Medicaid, the Vermont health access plan, or Dr. Dynasaur and had no private insurance or employer-sponsored coverage that includes both hospital and physician services within 12 months prior to the month of application, or lost private insurance or employer-sponsored coverage during the prior 12 months for the following reasons:

(A)  the individual's private insurance or employer-sponsored coverage ended because of:

(i)  loss of employment, unless the employer has terminated its employees for the primary purpose of discontinuing employer-sponsored coverage and establishing their eligibility for Catamount Health;

(ii)  death of the principal insurance policyholder;

(iii)  divorce or dissolution of a civil union;

(iv)  no longer qualifying as a dependent under the plan of a parent or caretaker relative; or

(v)  no longer receiving COBRA, VIPER, or other state continuation coverage; or

(B)  college- or university-sponsored health insurance became unavailable to the individual because the individual graduated, took a leave of absence, or otherwise terminated studies.

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(d)(1)  A carrier shall guarantee acceptance of any uninsured individual or an individual enrolled in a high-deductible health insurance plan for any Catamount Health plan offered by the carrier.  A carrier shall also guarantee acceptance of each dependent of an uninsured individual or an individual enrolled in a high-deductible health insurance plan in Catamount Health.  An individual who is eligible for an employer-sponsored insurance plan may not purchase Catamount Health, except as provided for in subdivision (2) of this subsection. Any dispute regarding eligibility shall be resolved by the department in a manner to be determined by rule.

(2)(A)  An individual with income less than or equal to 300 percent of the federal poverty level who is eligible for an employer-sponsored insurance plan may purchase Catamount Health if:

(i)  the individual's employer-sponsored insurance plan is not an approved employer-sponsored plan under section 1974 of Title 33;

(ii)  enrolling the individual in an approved employer-sponsored plan combined with premium assistance under section 1974 of Title 33 offered by the agency of human services is not cost-effective to the state as compared to enrolling the individual in Catamount Health combined with the assistance under subchapter 3a of chapter 19 of Title 33; or

(iii)  the individual is eligible for employer-sponsored insurance premium assistance under section 1974 of Title 33, but is unable to enroll in the employer's insurance plan until the next open enrollment period; or

(iv)  the individual’s employer-sponsored insurance plan is a

high-deductible insurance plan, with or without a health savings account.

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(n)  The commissioner shall encourage hospital and medical service corporations and nonprofit health maintenance organizations doing business in this state to offer Catamount Health.  If necessary to ensure the availability of Catamount Health by October 1, 2007, the commissioner shall require a hospital and medical service corporation and a nonprofit health maintenance organization in this state to offer Catamount Health.  The commissioner may permit one or more health insurers to enter into a joint operating agreement to consolidate the offering of Catamount Health to uninsured Vermonters and Vermonters enrolled in high-deductible health insurance plans.  In connection with a rate decision, the commissioner may make reasonable supplemental orders and may attach reasonable conditions and limitations to such orders as he or she finds, on the basis of competent and substantial evidence, necessary to carry out the purposes of this section.

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Sec. 2.  33 V.S.A. § 1971 is amended to read:

§ 1971.  DEFINITIONS

As used in this subchapter,:

(1)  "Agency" means the agency of human services.

(2)  “High-deductible health insurance plan” means a health plan with annual deductible amounts of no less than $2,000.00 for an individual or annual deductible amounts of $4,000.00 for family coverage.

(3)  "Office of Vermont health access" means the office administering the Medicaid program for the agency of human services and includes the managed care organization established in section 1901 of this title.

(3)(4)  "Secretary" means the secretary of human services.

Sec. 3.  33 V.S.A. § 1973 is amended to read:

§ 1973.  VERMONT HEALTH ACCESS PLAN

(a)  The agency of human services or its designee 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 a federal 1115 demonstration waiver is granted or renewed.

(b)  The purpose of the Vermont health access plan is to provide health care

coverage for uninsured or underinsured low income Vermonters and low income Vermonters enrolled in high-deductible health insurance plans.  The

agency of human services or its designee shall establish rules regarding

eligibility and administration of the plan.

(c)  An individual who has been enrolled in an approved

employer‑sponsored insurance plan with premium assistance under section

1974 of this title shall not be subject to a 12‑month waiting period before

becoming eligible for the Vermont health access plan as provided for in

subdivision 1974(d)(1).  An individual who has been enrolled in a

high-deductible health insurance plan, regardless of whether the plan was an employer-sponsored insurance plan or included a health savings account, shall not be subject to a 12-month waiting period before becoming eligible for the Vermont health access plan.

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Sec. 4.  33 V.S.A. § 1974 is amended to read:

§ 1974.  EMPLOYER-SPONSORED INSURANCE; PREMIUM

              ASSISTANCE

(a)  No later than October 1, 2007, subject to approval by the Centers for Medicare and Medicaid Services, the agency of human services shall establish a premium assistance program to assist individuals eligible for or enrolled in the Vermont health access plan and uninsured individuals with incomes under 300 percent of the federal poverty guidelines and their dependents to purchase an approved employer-sponsored insurance plan if offered to those individuals by an employer.  No later than October 1, 2008, the agency shall establish a premium assistance program to assist individuals enrolled in high-deductible health insurance plans and their dependents to purchase approved

employer-sponsored insurance plans if offered to those individuals by an employer.  The agency shall determine whether to include children who are eligible for Medicaid or Dr. Dynasaur in the premium assistance program at their parent's option.  The agency shall not mandate participation of children in employer-sponsored insurance.

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(c)  Uninsured individuals; premium assistance.

(1)  For the purposes of this subsection:

(A)  "Chronic care" means health services provided by a health care professional for an established clinical condition that is expected to last a year or more and that requires ongoing clinical management attempting to restore the individual to highest function, minimize the negative effects of the condition, and prevent complications related to chronic conditions. Examples of chronic conditions include diabetes, hypertension, cardiovascular disease, cancer, asthma, pulmonary disease, substance abuse, mental illness, spinal cord injury, and hyperlipidemia.

(B)  “High-deductible health insurance plan” means a health plan with annual deductible amounts of no less than $2,000.00 for an individual or an annual deductible amount of $4,000.00 for family coverage.

(C)  "Uninsured" means an individual who does not qualify for Medicare, Medicaid, the Vermont health access plan, or Dr. Dynasaur and had no private insurance or employer-sponsored coverage that includes both hospital and physician services within 12 months prior to the month of application, or lost private insurance or employer-sponsored coverage during the prior 12 months for the following reasons:

(i)  the individual's coverage ended because of:

(I)  loss of employment;

(II)  death of the principal insurance policyholder;

(III)  divorce or dissolution of a civil union;

(IV)  no longer qualifying as a dependent under the plan of a parent or caretaker relative; or

(V)  no longer qualifying for COBRA, VIPER, or other state continuation coverage; or

(ii)  college- or university-sponsored health insurance became unavailable to the individual because the individual graduated, took a leave of absence, or otherwise terminated studies.

(C)(D)  "Vermont resident" means an individual domiciled in Vermont as evidenced by an intent to maintain a principal dwelling place in Vermont indefinitely and to return to Vermont if temporarily absent, coupled with an act or acts consistent with that intent.

(2)  An individual is eligible for premium assistance under this subsection if the individual:

(A)  is an uninsured Vermont resident or a Vermont resident enrolled in a high-deductible health insurance plan;

(B)  has income under 300 percent of the federal poverty level;

(C)  has access to an approved employer-sponsored insurance plan; and

(D)  is 18 or over and is not claimed on a tax return as a dependent of a resident of another state.

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(d)(1)  Participation in an approved employer‑sponsored insurance plan with premium assistance under this section or Catamount Health shall not disqualify an individual from the Vermont health access plan if an approved employer‑sponsored insurance plan or Catamount Health is no longer available to that individual.  

(2)  An individual who has been enrolled in Medicaid, VHAP, Dr. Dynasaur, or any other health benefit plan authorized under Title XIX or Title XX of the Social Security Act or who is enrolled in a high-deductible health insurance plan shall not be subject to a 12‑month waiting period before becoming eligible for premium assistance to purchase an approved employer‑sponsored insurance plan.

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* * * Catamount Health Assistance Program * * *

Sec. 5.  33 V.S.A. § 1981 is amended to read:

§ 1981.  POLICY AND PURPOSE

The Catamount Health assistance program is established to provide uninsured Vermont residents and Vermont residents enrolled in

high-deductible health insurance plans, as defined in section 1982 of this subchapter financial assistance in purchasing Catamount Health, a defined benefit package of primary, preventive, hospital, acute episodic care, and chronic care, including assistance in preventing and managing chronic conditions.

Sec. 6.  33 V.S.A. § 1982 is amended to read:

§ 1982.  DEFINITIONS

As used in this subchapter:

(1)  "Catamount Health" means the health benefit plan offered under section 4080f of Title 8.

(2)  “High-deductible health insurance plan” means a health plan with annual deductible amounts of no less than $2,000.00 for an individual or an annual deductible amount of $4,000.00 for family coverage.

(3)  “Uninsured” means an individual who does not qualify for Medicare, Medicaid, the Vermont health access plan, or Dr. Dynasaur and had no private insurance or employer‑sponsored coverage that includes both hospital and physician services within 12 months prior to the month of application, or lost private insurance or employer‑sponsored coverage during the prior 12 months for the following reasons:

(A)  the individual’s private insurance or employer‑sponsored coverage ended because of:

(i)  loss of employment, unless the employer has terminated its employees for the primary purpose of discontinuing employer‑sponsored coverage and establishing their eligibility for Catamount Health;

 (ii)  death of the principal insurance policyholder;

(iii)  divorce or dissolution of a civil union;

(iv)  no longer qualifying as a dependent under the plan of a parent or caretaker relative; or

(v)  no longer receiving COBRA, VIPER, or other state continuation coverage; or

(B)  college‑ or university‑sponsored health insurance became unavailable to the individual because the individual graduated, took a leave of absence, or otherwise terminated studies.

 (3)(4)  "Vermont resident" means an individual domiciled in Vermont as evidenced by an intent to maintain a principal dwelling place in Vermont indefinitely and to return to Vermont if temporarily absent, coupled with an act or acts consistent with that intent.

Sec. 7.  33 V.S.A. § 1983 is amended to read:

§ 1983.  ELIGIBILITY

(a)(1)  Except as provided in subdivisions (3) and (4) of this subsection, an individual shall be eligible for Catamount Health assistance if the individual is an uninsured Vermont resident without access to an approved

employer-sponsored insurance plan under section 1974 of this title or a Vermont resident enrolled in a high-deductible health insurance plan.

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(b)(1)  An individual receiving benefits under Medicaid, the Vermont health access plan, Dr. Dynasaur, or premium assistance for employer-sponsored insurance under section 1974 of this title or any other health benefit plan authorized under Title XIX or Title XX of the Social Security Act within 12 months of applying for Catamount Health assistance shall not be required to wait 12 months to be eligible.

(2)  An individual who has been enrolled in Catamount Health without assistance shall not be subject to a 12-month waiting period before becoming eligible for assistance under this subchapter.

(3)  An individual who is enrolled in a high-deductible health insurance plan shall not be subject to a 12-month waiting period before becoming eligible for assistance under this subchapter.

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Sec. 8.  2 V.S.A. § 903 is amended to read:

§ 903.  CATAMOUNT HEALTH; REQUEST FOR PROPOSALS

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(b)(1)  Administration without assumption of risk.  No earlier than

October 1, 2009, the commission on health care reform shall evaluate the Catamount Health market to determine whether it is a cost-effective method of providing health care coverage to uninsured Vermonters and Vermonters enrolled in high-deductible health insurance plans, as defined in section 4080f of Title 8, taking into consideration the rates and forms approved by the department of banking, insurance, securities, and health care administration, the costs of administration and reserves, the amount of Catamount Health assistance to be provided to individuals, whether the Catamount Health assistance is sufficient to make Catamount Health affordable to those individuals, and the number of individuals for whom assistance is available given the appropriated amount. Prior to making its determination, the commission shall consider the recommendations of a health care and health insurance consultant selected jointly by the commission and the secretary of administration.

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Sec. 9.  3 V.S.A. § 2222a(c)(9) is amended to read:

§ 2222a.  HEALTH CARE SYSTEM REFORM; IMPROVING QUALITY

                AND AFFORDABILITY

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(c)  Vermont’s health care system reform initiatives include:

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(9)  Catamount Health, established in section 4080f of Title 8, which provides a comprehensive benefit plan with a sliding-scale premium based on


income to uninsured Vermonters and Vermonters enrolled in high-deductible health insurance plans, as defined in section 4080f of Title 8.

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Published by:

The Vermont General Assembly
115 State Street
Montpelier, Vermont


www.leg.state.vt.us