VermontH.312025-2026 SessionHouseWALLET

An act relating to claim edit standards and prior authorization requirements

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Bill Overview

Analyzed Economic Effects

2 provisions identified: 1 benefits, 0 costs, 1 mixed.

No prior approval for primary care orders

Health plans cannot require prior authorization for care ordered by your in-network primary care provider. This does not apply to prescription drugs. It also does not apply to care provided out of network. A primary care provider means a provider contracted and enrolled with your plan as a primary care provider. The rule takes effect March 5, 2025, and plans must follow it as soon as reasonably practicable, and no later than January 1, 2026.

Insurers get exceptions to claim edit rules

Beginning January 1, 2026, insurers can depart from Vermont’s standard claim edit rules in limited cases. They may do this to follow State or federal laws or coverage mandates, to handle new billing codes, or for edits the payer decides are more favorable to providers. They can also do it for services provided outside Vermont unless the insurer and that provider agree to use Vermont’s standards. Any such edits must include input from Vermont and national providers, follow nationally recognized standards approved by the Commissioner of Financial Regulation, and be posted on the plan’s website or similar notices.

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Sponsors & Cosponsors

Sponsor

Alyssa Black
Democratic • House

Cosponsors

There are no cosponsors for this bill.

Roll Call Votes

No roll call votes available for this bill.

Actions Timeline

House message: Governor approved bill on March 5, 2025
3/11/2025Senate
Signed by Governor on March 5, 2025
3/11/2025House
Delivered to the Governor on February 28, 2025
2/28/2025House
Senate Message: Passed in concurrence
2/26/2025House
Read 3rd time & passed in concurrence
2/25/2025Senate
Unfinished Business/Third Reading
2/25/2025Senate
New Business/Third Reading
2/21/2025Senate
Reported favorably by Senator Lyons for Committee on Health and Welfare, read 2nd time and 3rd reading ordered
2/19/2025Senate
Favorable report by Committee on Health and Welfare
2/19/2025Senate
Second Reading
2/19/2025Senate
Favorable report by Committee on Health and Welfare
2/18/2025Senate
Second Reading
2/18/2025Senate
Entered on Notice Calendar
2/18/2025Senate
Read 1st time & referred to Committee on Health and Welfare
2/6/2025Senate
Read third time and passed
2/4/2025House
Action Calendar: Third Reading
2/4/2025House
Third Reading ordered
1/31/2025House
Rep. Black of Essex reported for the Committee on Health Care
1/31/2025House
Read second time
1/31/2025House
Action Calendar: Favorable
1/31/2025House
On Notice Calendar
1/30/2025House
Read first time and referred to the Committee on Health Care
1/14/2025House

Bill Text

As Enacted (ACT 3)
3/7/2025
PDF
As Passed by Both Chambers
2/27/2025
PDF
As Passed by Both Chambers (Unofficial)
2/27/2025
PDF
As Passed by the House
2/6/2025
PDF
As Passed by the House (Unofficial)
2/6/2025
PDF
As Introduced
1/13/2025
PDF

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