Title 8: Banking and Insurance
Chapter 107: HEALTH INSURANCE
8 V.S.A. § 4080f. Catamount health
§ 4080f. Catamount health
(a) As used in this section:
(1) "Carrier" means a registered small group carrier as defined in section 4080a of this title.
(2) "Catamount Health" means the plan for coverage of primary care, preventive care, chronic care, acute episodic care, and hospital services as established in this section to be provided through a health insurance policy, a nonprofit hospital or medical service corporation service contract, or a health maintenance organization subscriber contract which is offered or issued to an individual and which meets the requirements of this section.
(3) "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.
(4) "Chronic care management" means a system of coordinated health care interventions and communications for individuals with chronic conditions, including significant patient self-care efforts, systemic supports for the physician and patient relationship, and a plan of care emphasizing prevention of complications, utilizing evidence-based practice guidelines, patient empowerment and functional capacity development strategies, and evaluation of clinical, humanistic, and economic outcomes on an ongoing basis with the goal of improving overall health.
(5) "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) "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) "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) "Primary care" means health services provided by health care professionals, including naturopathic physicians licensed pursuant to 26 V.S.A. chapter 81, who are 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) "Uninsured" means an individual who does not qualify for Medicare, Medicaid, the Vermont health access plan, or Dr. Dynasaur, and: who had no private insurance or employer-sponsored coverage that includes both hospital and physician services within 12 months prior to the month of application; who has had a nongroup health insurance plan with an annual deductible of no less than $7,500.00 for an individual or an annual deductible of no less than $15,000.00 for two-person or family coverage for at least six months; or who lost private insurance or employer-sponsored coverage during the prior 12 months for any of the following reasons:
(A) The individual's private insurance or employer-sponsored coverage ended because of:
(i) loss of employment, including:
(I) a reduction in hours that results in ineligibility for employer-sponsored coverage, unless the employer has terminated its employees or reduced their hours for the primary purpose of discontinuing employer-sponsored coverage and establishing their eligibility for Catamount Health; or
A self-employed individual who was insured through the nongroup market whose insurance coverage ended as the direct result of either the termination of a business entity owned by the individual or the individual's inability to continue in his or her line of work, if the individual produces satisfactory evidence to the department of Vermont health access of the business termination or certifies by affidavit to the department of Vermont health access that he or she is not employed and is no longer seeking employment in the same line of work; (bb) Subdivision (aa) of this subdivision (II) shall take effect upon issuance by the Centers for Medicare and Medicaid Services of approval of an amendment to the Global Commitment for Health Medicaid Section 1115 Waiver allowing for a self-employment exception to the Catamount Health waiting period, but in no event earlier than July 1, 2011;
(ii) death of the principal insurance policyholder;
(iii) divorce or dissolution of a civil union;
(iv) no longer receiving coverage as a dependent under the plan of a parent or caretaker relative; or
(v) no longer receiving COBRA, VIPER, or other state continuation coverage.
(B) College- or university-sponsored health insurance became unavailable to the individual because the individual graduated, took a leave of absence, decreased enrollment below a threshold set for continued coverage, or otherwise terminated studies.
(C)(i) The individual lost health insurance as a result of domestic violence. The individual shall provide the agency of human services with satisfactory documentation of the domestic violence. The documentation may include a sworn statement from the individual attesting to the abuse, law enforcement or court records, or other documentation from an attorney or legal advisor, member of the clergy, or health care provider, as defined in 18 V.S.A. § 9402. Information relating to the domestic violence, including the individual's statement and corroborating evidence, provided to the agency shall not be disclosed by the agency unless the individual has signed a consent to disclose form. In the event the agency is legally required to release this information without consent of the individual, the agency shall notify the individual at the time the notice or request for release of information is received by the agency and prior to releasing the requested information.
(ii) Subdivision (i) of this subdivision (C) shall take effect upon issuance by the Centers for Medicare and Medicaid Services of approval of an amendment to the Global Commitment for Health Medicaid Section 1115 Waiver allowing for a domestic violence exception to the Catamount Health waiting period.
(b) No person may sell, offer, or renew Catamount Health unless such person is a registered small group carrier and has filed a letter of intent pursuant to this section.
(c)(1) Catamount Health shall provide coverage for primary care, preventive care, chronic care, acute episodic care, and hospital services. The benefits for Catamount Health shall be a preferred provider organization plan with:
(A) a $500.00 deductible for an individual and a $1,000.00 deductible for a family for health services received in network, and a $1,000.00 deductible for an individual and a $2,000.00 deductible for a family for health services received out of network;
(B) 20 percent co-insurance, in and out of network;
(C) a $10.00 office co-payment;
(D) prescription drug coverage without a deductible, $10.00 co-payments for generic drugs, $35.00 co-payments for drugs on the preferred drug list, and $55.00 co-payments for nonpreferred drugs;
(E) out-of-pocket maximums of $1,050.00 for an individual and $2,100.00 for a family for in-network services and $2,100.00 for an individual and $4,000.00 for a family for out-of-network services; and
(F) a waiver of the deductible and other cost-sharing payments for chronic care for individuals participating in chronic care management and for preventive care.
(2) Catamount Health shall provide chronic care management in accordance with the Blueprint for Health established under chapter 13 of Title 18 and shall share the data on enrollees, to the extent allowable under federal law, with the secretary of administration or designee in order to inform the health care reform initiatives under 3 V.S.A. § 2222a.
(3) Notwithstanding sections 4516, 4588, and 5115 of this title, a carrier may use financial or other incentives to encourage healthy lifestyles and patient self-management for individuals covered by Catamount Health. These incentives shall comply with the health promotion and disease prevention program rules adopted by the commissioner under subdivisions 4080a(h)(2)(B) and 4080b(h)(2)(B) of this title.
(4) To the extent Catamount Health provides coverage for any particular type of health service or for any particular medical condition, it shall cover those health services and conditions when provided by any type of health care professional acting within the scope of practice authorized by law. Catamount Health may establish a term or condition that places a greater financial burden on an individual for access to treatment by the type of health care professional only if it is related to the efficacy or cost-effectiveness of the type of service.
(5) Notwithstanding subsections 4513(c), 4584(c), and 5104(b) of this title, the commissioner may establish a pay-for-performance demonstration project for carriers offering Catamount Health.
(6) A health care facility or health care provider who agrees to participate in a Catamount Health network that provides services for a Catamount Health insured shall not balance bill the insured by charging the insured amounts in addition to the reimbursement provided for by the plan's participating provider agreement.
(d)(1) A carrier shall guarantee acceptance of any uninsured individual for any Catamount Health plan offered by the carrier. A carrier shall also guarantee acceptance of each dependent of an uninsured individual in Catamount Health. An individual who is eligible for Medicare may not purchase 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 33 V.S.A. § 1974;
(ii) enrolling the individual in an approved employer-sponsored plan combined with premium assistance under 33 V.S.A. § 1974 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 33 V.S.A. § 1974, but is unable to enroll in the employer's insurance plan until the next open enrollment period.
(B) Decisions by the agency of human services regarding whether an individual's employer-sponsored plan is an approved employer-sponsored plan under 33 V.S.A. § 1974 and decisions by the agency of human services regarding whether enrolling the individual in an approved employer-sponsored plan is cost-effective under 33 V.S.A. § 1974 are matters fully within the discretion of the agency of human services. On appeal pursuant to 3 V.S.A. § 3091, the human services board may overturn the agency's decision only if it is arbitrary or unreasonable.
(3)(A) An individual who loses eligibility for the employer-sponsored premium programs in 33 V.S.A. § 1974 may purchase Catamount Health without being uninsured for 12 months.
(B) An individual whose most recent health care coverage was Medicaid, VHAP, Dr. Dynasaur, any other health benefit plan authorized under Title XIX or Title XX of the Social Security Act, or Catamount Health shall not be subject to a 12-month waiting period before becoming eligible for Catamount Health.
(4) An individual of the age of majority who is claimed on a tax return as a dependent of a resident of another state shall not be eligible to purchase Catamount Health.
(e)(1) For a 12-month period from the earliest date of application, a carrier offering Catamount Health may limit coverage of preexisting conditions which existed during the 12-month period before the earliest date of application, except that such exclusion or limitation shall not apply to chronic care if the individual is participating in a chronic care management program, nor apply to pregnancy. A carrier shall waive any preexisting condition provisions for all individuals and their dependents who produce evidence of continuous creditable coverage during the previous nine months. If an individual has a preexisting condition excluded under a subsequent policy, such exclusion shall not continue longer than the period required under the original contract or 12 months, whichever is less. The carrier shall credit prior coverage that occurred without a break in coverage of 63 days or more. A break in coverage shall be tolled after the earliest date of application, subject to reasonable
time limits, as defined by the commissioner, for the individual to complete the application process. For an eligible individual, as such term is defined in Section 2741 of the Health Insurance Portability and Accountability Act of 1996, a carrier offering Catamount Health shall not limit coverage of preexisting conditions.
(2) Notwithstanding subdivision (1) of this subsection, a carrier offering Catamount Health shall not limit coverage of preexisting conditions for subscribers who apply before November 1, 2008. This subdivision (2) shall not apply to claims incurred prior to the effective date of this section.
(3) Notwithstanding subdivision (1) of this subsection, an individual who was insured in the nongroup market, lost his or her employment, terminated insurance coverage, and had no other private insurance or employer-sponsored coverage that included both hospital and physician services for the 12 months preceding his or her application for Catamount Health shall not be subject to a preexisting condition period upon enrolling in Catamount Health, if the individual:
(A) terminated his or her nongroup coverage within 90 days following the individual's loss of employment; and
(B) applied for Catamount Health within 63 days following the one-year anniversary of terminating his or her nongroup coverage.
(f)(1) Except as provided for in subdivision (2) of this subsection, the carrier shall pay a health care professional the lowest of the health care professional's contracted rate, the health care professional's billed charges, or the rate derived from the Medicare fee schedule, at an amount 10 percent greater than fee schedule amounts paid under the Medicare program in 2006. Payments based on Medicare methodologies under this subsection shall be indexed to the Medicare economic index developed annually by the Centers for Medicare and Medicaid Services. The commissioner may approve adjustments to the amounts paid under this section in accordance with a carrier's pay for performance, quality improvement program, or other payment methodologies in accordance with the Blueprint for Health established under 18 V.S.A. chapter 13.
(2) Payments for hospital services shall be calculated using a hospital-specific cost-to-charge ratio approved by the commissioner, adjusted for each hospital to ensure payments at 100 percent of the hospital's actual cost for services. The commissioner may use individual hospital budgets established under 18 V.S.A. § 9456 to determine approved ratios under this subdivision. Payments under this subdivision shall be indexed to changes in the Medicare payment rules, but shall not be lower than 100 percent of the hospital's actual cost for services. The commissioner may approve adjustments to the amounts paid under this section in accordance with a carrier's pay for performance, quality improvement program, or other payment methodologies in accordance with the Blueprint for Health established under 18 V.S.A. chapter 13.
(3) Payments for chronic care and chronic care management shall meet the requirements in 18 V.S.A. § 702.
(4) If Medicare does not pay for a service covered under Catamount Health, or if the Medicare fee schedule does not set an amount for a service covered under Catamount Health, the commissioner shall establish some other payment amount for such services, determined after consultation with affected health care professionals and insurers.
(5) A carrier offering Catamount Health shall renegotiate existing contracts with health care professionals as necessary in order to pay the reimbursements provided for in this subsection.
(6) All provisions of this subsection shall apply notwithstanding subsections 4513(c), 4584(c), and 5104(b) of this title.
(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.
(2) No rate or form shall be approved if it contains any provision which is unjust, unfair, inequitable, misleading, or contrary to the law of this state. A rate shall be approved if it is sufficient not to threaten the financial safety and soundness of the insurer, reflects efficient and economical management, provides Catamount Health at the most reasonable price consistent with actuarial review, is not unfairly discriminatory, and complies with the other requirements of this section.
(h) With each rate filing, a carrier shall file a certification by a member of the American Academy of Actuaries of the carrier's compliance with this section. The requirements for certification shall be as the commissioner by rule prescribes.
(i) Catamount Health shall be offered with a rate structure which at least differentiates among single-person, two-person, and family rates, and the rates shall be guaranteed for 12 months from the date the individual enrolls.
(j) A carrier offering Catamount Health shall use a community rating method acceptable to the commissioner for determining premiums for Catamount Health plans. Catamount Health plans shall constitute a separate market and shall be rated as a distinct pool, separate from other individual or group insurance products. For Catamount Health, the following risk classification factors are prohibited from use in rating individuals and their dependents:
(1) demographic rating, including age and gender rating;
(2) geographic area rating;
(3) industry rating;
(4) medical underwriting and screening;
(5) experience rating;
(6) tier rating; or
(7) durational rating.
(k) Catamount Health shall be considered an individual health insurance plan, health benefit plan, health insurance contract, and health insurance policy for purposes of Vermont law, but shall not be subject to section 4080b of this title.
( l ) Catamount Health shall not be sold prior to October 1, 2007. Rates and forms may be filed and approved prior to that date, and marketing and sales targeted to an effective date of October 1, 2007 shall be allowed in the discretion of the commissioner.
(m) A letter of intent, proposed rates, and proposed forms shall be filed consistent with the requirements of this section and the rules adopted pursuant to this section.
(1) Forms shall be filed initially and upon any change. Forms may not be used unless and until approved as described in this section. The department shall notify the carrier within 45 days whether the form meets the requirements set by statute and rule.
(2) Rates shall be filed prior to use and thereafter at least annually on a schedule and in a manner established by rule. The department shall notify the carrier within 45 days whether the rates meet the requirements set by statute and rule.
(3) In any notice denying approval of a rate or form, the commissioner shall state that a hearing will be granted within 20 days upon written request of the insurer, provided that the written request for hearing is filed with the department within 30 days of the notice of disapproval. After the expiration of 30 days from the filing of any such form or premium rate, or at any time after having given written approval, the commissioner may, after a hearing of which at least 20 days' written notice has been given to the insurer using such form or premium rate, 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 30 days after such hearing when the withdrawal of approval shall become effective.
(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. 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.
(o) With approval of the commissioner, a carrier may discontinue sales of Catamount Health upon at least six months' prior written notice to the commissioner. Following such notice, if there are any individuals who continue to be covered by Catamount Health for whom the carrier does not have approved premium rates, the commissioner may approve premium rates adjusted by the average Vermont nongroup trends for cost and utilization for the previous six months. (Added 2005, No. 191 (Adj. Sess.), § 15; No. 190 (Adj. Sess.), § 1; amended 2007, No. 70, §§ 1-7; No. 71, § 13, eff. June 5, 2007; 2007, No. 174 (Adj. Sess.), § 22; 2007, No. 203 (Adj. Sess.), §§ 6, 11; 2009, No. 61, § 19, eff. April 1, 2010; 2009, No. 67 (Adj. Sess.), § 64, eff. July 1, 2011; , No. 128 (Adj. Sess.), § 37; No. 156 (Adj. Sess.), §§ E.309.5, I.12; 2011, No. 63, § E.301.4; 2011, No. 96 (Adj. Sess.), § 2, eff. Oct. 1, 2012.)