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BILL AS INTRODUCED 2007-2008

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S.182

Introduced by Senator Flanagan of Chittenden District and Senator White of Windham District

Referred to Committee on

Date:

Subject:  Health; Catamount Health  

Statement of purpose:  This bill proposes to provide access to Catamount Health for underinsured individuals and those employed by farms and small businesses.

AN ACT RELATING TO CATAMOUNT HEALTH FOR THE UNDERINSURED

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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(5)  “Farmer shall have the same meaning as in subdivision 3752(7) of Title 32 and shall include an agricultural employee of a farmer.

(6)  “Health care expenses” means amounts paid by the individual for health services and premiums, co-payments, cost-sharing, and other

out-of-pocket payments required by a health insurer or employer-sponsored health benefit plan.

(5)(7)  “Health care professional” means an individual, partnership, corporation, facility, or institution licensed or certified or authorized by law to provide professional health care services.

(6)(8)  “Health service” means any medically necessary treatment or procedure to maintain, diagnose, or treat an individual’s physical or mental condition, including services ordered by a health care professional and medically necessary services to assist in activities of daily living.

(7)(9)  “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)(10)  “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.

(11)  “Small business” means an entity employing three full-time equivalent employees or less.

(12)  “Underinsured” means that an individual or household has spent ten percent of the individual or household’s income on health care expenses.

(9)(13)  “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, is a farmer, is employed by a small business, is self-employed, is employed by a municipality, 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 qualifying for participating in 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 and underinsured individual for any Catamount Health plan offered by the carrier. A carrier shall also guarantee acceptance of each dependent of an uninsured or underinsured individual 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.

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(g)(1)  Approval of rates and forms for Catamount Health shall be pursuant to the process established herein and rules adopted pursuant to this section.  Premium rates shall be actuarially determined considering differences in the demographics of the populations and the different levels and methods of reimbursement for health care professionals, but in no event shall any rate be approved unless the projected administrative costs are limited to nine percent of the premium or less.

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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)  “Secretary” means the secretary of human services. “Farmer” shall have the same meaning as in subdivision 3752(7) of Title 32 and shall include an agricultural employee of a farmer.

(3)  “Health care expenses” means amounts paid by the individual for health services and premiums, co-payments, cost-sharing, and other

out-of-pocket payments required by a health insurer or employer-sponsored health benefit plan.

(3)(4)  “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.

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

(6)  “Small business” means an entity employing three full-time equivalent employees or fewer.

(7)  “Underinsured” shall mean that an individual or household has spent ten percent of the individual or household’s income on health care expenses.

(8)  “Uninsured” means that an individual 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, is a farmer, is employed by a small business, is self-employed, is employed by a municipality, 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 participating in 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.

Sec. 3.  33 V.S.A. § 1974(c) is amended to read:

(c)  Uninsured individuals; premium assistance.

(1)  For the purposes of this subsection:

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(B)  “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)(B)  “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 or underinsured Vermont resident;

(B)  does not qualify for Medicare, Medicaid, the Vermont health access plan, or Dr. Dynasaur;

(B)(C)  has income under 300 percent of the federal poverty level or has spent income in excess of this amount on health care expenses as defined in section 1982 of this title;

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

(D)(E)  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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Sec. 4.  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)  “Farmer” shall have the same meaning as in subdivision 3752(7) of Title 32 and shall include an agricultural employee of a farmer.

(3)  “Health care expenses” means amounts paid by the individual for health services and premiums, co-payments, cost-sharing, and other

out-of-pocket payments required by a health insurer or employer-sponsored health benefit plan.

(4)  “Small business” means an entity employing three full-time equivalent employees or fewer.

(5)  “Underinsured” shall mean that an individual or household has spent ten percent of the individual or household’s income on health care expenses.

(2)(6)  “Uninsured” means that 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, is a farmer, is employed by a small business, is self-employed, is employed by a municipality, 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;

(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 participating in 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.

Sec. 5.  33 V.S.A. § 1983(a)(1) is amended to read:

(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 or underinsured Vermont resident without access to an approved employer-sponsored insurance plan under section 1974 of this title.

Sec. 6.  33 V.S.A. § 1984(d) is added to read:

(d)  For individuals with income at or over 300 percent of the federal poverty guideline, the agency shall establish by rule a mechanism for allowing an individual to spend income in excess of this amount on health care expenses and become eligible for Catamount Health assistance.


Sec. 7.  2 V.S.A. § 902(a)(3)(D) is amended to read:

(D)  determining needed analysis and criteria for implementing a health insurance requirement by January 1, 2011 if less than 96 percent of Vermonters have health insurance by 2010, including methods of enforcement, providing proof of insurance to individuals, and any other criteria necessary for the requirement to be effective in achieving universal health care coverage.  For purposes of this section, an individual shall not be counted as having health insurance if that individual is underinsured as defined in section 1982 of Title 33.

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

§ 903.  CATAMOUNT HEALTH; REQUEST FOR PROPOSALS

(a)  Private carrier assumption of risk option. It is the intent of the general assembly first to provide to carriers and insurers in the private market the opportunity to offer Catamount Health with the assumption of risk. In the event that no private carriers or insurers elect to offer Catamount Health, the commissioner of banking, insurance, securities, and health care administration shall require hospital and medical service corporations and nonprofit health maintenance organizations to offer Catamount Health under subsection 4080f of Title 8.

(b)(1)(a)  Administration without assumption of risk.  No earlier than October 1, 20092008, 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, 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.

(2)(b)  If the commission determines that the market is not cost-effective, the agency of administration shall issue a request for proposals for the administration only of Catamount Health as described in section 4080f of Title 8.  A contract entered into under this subsection shall not include the assumption of risk.  If Catamount Health is administered under this subsection, the agency shall purchase a stop-loss policy for an aggregate claims amount for Catamount Health as a method of managing the state’s financial risk.  The agency shall determine the amount of aggregate stop-loss reinsurance and may purchase additional types of reinsurance if prudent and cost-effective.  The agency may include in the contract the chronic care management program established under section 1903a of Title 33.

(3)(c)  If Catamount Health is offered as a self-insured product, the requirements of section 4080f of Title 8 and subchapter 3a of chapter 19 of Title 33 shall apply to the extent feasible.  The individual contributions set in subchapter 3a of chapter 19 of Title 33 shall be the premium amounts charged to individuals.



Published by:

The Vermont General Assembly
115 State Street
Montpelier, Vermont


www.leg.state.vt.us