An act relating to updating and reorganizing the health insurance statutes in 8 V.S.A. chapter 107
Sponsored By: Virginia "Ginny" V Lyons (Democratic)
Signed by Governor
Your PRIA Score
Personalized for You
How does this bill affect your finances?
Sign up for a PRIA Policy Scan to see your personalized alignment score for this bill and every other piece of legislation we track. We analyze your financial profile against policy provisions to show you exactly what matters to your wallet.
Bill Overview
Analyzed Economic Effects
47 provisions identified: 33 benefits, 1 costs, 13 mixed.
Autism and developmental care to age 21
Plans must cover evidence‑based diagnosis and treatment for early childhood developmental disorders from birth until age 21. This includes applied behavior analysis when supervised by a board‑certified behavior analyst, if medically necessary. Plans may use prior authorization and set reasonable review schedules, and cost‑sharing must be in line with other benefits. Medicaid follows federal CMS rules.
Better cancer screening and treatment coverage
Beginning September 1, 2025, plans must cover colorectal screening with no copay, deductible, or coinsurance. Screening mammograms and needed follow‑up breast imaging are covered at no cost when done at accredited facilities; HSA plan rules still apply. Plans must cover growth‑factor injections used with chemo and treat oral cancer drugs no worse than IV cancer drugs for costs. Plans must also cover medically accepted off‑label cancer drugs and routine costs for approved cancer clinical trials at named centers, with rules for out‑of‑state trials.
Mental health and addiction care parity
Your plan must treat mental health and substance use care the same as medical care. It cannot add extra limits, higher costs, or unfair network rules for these services. At least one FDA‑approved substance use disorder medicine must be on the lowest cost tier if the plan covers drugs. The state enforces these rules.
Public review of health insurance rates
Insurers must file major medical rate requests with the Green Mountain Care Board. The Board has 90 days to approve, modify, or deny (plus up to 30 days if information is missing). Filings must explain big increases (over 10%) and show how much of premiums goes to prescription drugs. The Board posts filings and takes public comments.
Some benefits protected from creditors
Up to $200 per month of your health insurance benefits is protected from creditors during a covered disability. That is up to $2,400 a year. This does not protect lump‑sum dismemberment payments and does not apply to suits for necessities from the disability period.
New limits and options for drug costs
Health plans cannot set a yearly dollar cap on prescription drugs. Your yearly drug spending is capped at the IRS minimums for self-only and family coverage. In high‑deductible plans, drug coverage starts only after you meet the federal HDHP deductible. Starting September 1, 2025, if you were in a bronze plan for two years and hit last year’s drug cap, you are auto‑reenrolled in a bronze plan with an equal or lower drug limit unless you opt out. The Board can approve some bronze plans with different drug limits, but at least two standard bronze plans must keep the statutory limit.
Insurers can’t use discretionary clauses
Health, disability income, and life policies cannot give insurers special power to interpret the contract. Any such clause is void. This protects your right to fair review under the policy.
Tighter rules on short‑term health plans
Short‑term limited‑duration health policies cannot be renewed and must end within three months. You cannot be covered by short‑term policies for more than three months in any 12‑month period. Issuers generally need a certificate of authority and must include large, clear disclosures. The Commissioner sets registration, financial, marketing, and filing standards.
At least 40 home health visits
Major medical plans must cover care from nonprofit Medicare‑certified home health agencies. You get at least 40 covered home health visits per person in any year or 12‑month period. Insurers may require proof of insurability and cannot charge more than for other care. This rule does not require coverage for people eligible for Medicare.
Better Medigap access and fairer rates
Insurers that sell Medigap to age‑eligible people must also offer the same plans to people eligible by disability, with at least a six‑month sign‑up window. Medigap premiums must use community rating, with little or no medical underwriting. Large Medigap insurers face extra review if they seek a composite rate hike over 3%, with public notice and potential hearings; an intervenor fee is capped at $2,500. The state also provides public education on Medigap and Medicare Advantage to help people compare costs and networks.
Coverage for gender‑affirming health care
Health plans and Medicaid cover medically necessary, clinically appropriate gender‑affirming care listed in the state benchmark. Plans cannot charge more for this care than for other treatments. Public programs must also follow federal CMS rules.
Coverage for prosthetics and craniofacial care
Plans must cover prosthetic devices at least as well as Medicare and cover needed repair or replacement, with no worse cost‑sharing than similar services. Plans must also cover diagnosis and medically necessary treatment of certain face, neck, or head musculoskeletal disorders on the same basis as other body sites. For certain dental procedures that require general anesthesia due to a child’s age, documented phobia, exceptional medical needs, or developmental disabilities, plans must cover the facility and anesthesia (not the dental work itself).
Diabetes supplies and quit‑tobacco meds covered
If prescribed, your plan covers diabetes equipment, supplies, and outpatient training by qualified professionals. Plans and Medicaid also cover at least one three‑month supply per year of FDA‑approved tobacco‑cessation medicines; over‑the‑counter products count if prescribed. Usual drug copays may apply where allowed.
Fair access and pricing for individual plans
Nonprofit HMOs must offer individual (nongroup) plans and cannot deny offers based on age, gender, industry, or medical history except where the law allows. Insurers cannot unfairly charge different premiums or pay different benefits to people with the same risk. The HMO requirement starts September 1, 2025.
Hearing aids covered in large plans
Large‑group employer plans must cover a hearing aid for each ear when prescribed, plus services and batteries. Plans can limit replacements to one per ear every three years unless a provider says you need them sooner. You may choose a pricier model and pay the difference. Cost‑sharing cannot be worse than for other nonprimary care items.
Insurers can’t count Medicaid eligibility
Insurers cannot refuse or reduce your benefits because you may qualify for Medicaid. Insurers must follow Vermont’s Medicaid recovery rules. The state enforces these protections.
Lower costs for reproductive and assault care
Plans cover abortion and related care without copays, deductibles, or coinsurance, except to keep HSA rules for high‑deductible plans and for Medicaid services. If your plan covers drugs, it must cover FDA‑approved contraceptives and devices, with at least one product per method at no cost, plus clinical services and follow‑up at no cost. Insurers cannot charge copays or coinsurance for listed sexual assault exam services. If you lack coverage or it does not pay the full cost, the State pays for forensic and sexual assault exams and related counseling. State payment begins September 1, 2025.
Major plans join Blueprint for Health
All major medical plans must follow Vermont’s Blueprint for Health. Insurers must take part in the state care‑coordination model, which can change how your care is arranged and accessed.
Midwife and home birth coverage
If your plan covers maternity care, it must also cover services by licensed midwives and certified nurse midwives. Care is covered in hospitals, other facilities, or at home, within the midwife’s scope. Midwifery services cannot have higher cost‑sharing than similar maternity benefits. These rules also apply to state public programs.
More paths to group health coverage
Out‑of‑state employers defined as large groups at home can buy large‑group coverage for Vermont workers if more than 25 employees live and work in Vermont. Associations can offer group coverage only if they met strict formation and governance rules, including at least 100 people at incorporation, one year of existence, non‑insurance purpose, and bylaws with annual meetings and dues. These rules can expand group plan options while setting guardrails.
More time before your policy cancels
For major medical plans, insurers must give at least 21 days’ notice before a premium is due and a grace period of at least one month with coverage in force. For other health policies, they must give 21 days’ notice and wait 14 days after a termination notice before canceling if not paid.
Protections when your employer changes insurers
When your employer switches group insurers, the old insurer stays liable for claims that already accrued. The new insurer must offer you replacement coverage, credit deductibles and waiting periods you already met, and avoid stricter preexisting‑condition limits than either plan. The law coordinates any extensions of benefits between the two insurers.
Stronger coverage for kids and dependents
A newborn is covered from birth for at least 60 days at no extra premium; to keep coverage, notify the plan and pay any added premium within 60 days after birth. Plans that cover children must keep covering them to age 26. Coverage must continue past the limiting age for unmarried disabled dependents who became disabled before that age and rely on the policyholder. If a medical support order applies, insurers must enroll the child quickly, can collect premiums from the effective date, and are liable if they fail to enroll after notice. Adopted and placed children get the same coverage as natural children, and either parent can get information, file claims, and appeal denials.
Stronger health policy contract protections
Individual policies must show key terms clearly, use readable print, and allow a free‑look return (30 days if Medicare‑eligible by age, 10 days for others). Policies must include standard protections like incontestability after three years, grace periods, claim and proof timelines, and limits on lawsuits. Standard clauses must follow approved wording and be easy to find. If policy language conflicts with these rules, the law controls and cannot be worse for you.
Stronger rights at local pharmacies
Beginning September 1, 2025, insurers and PBMs must let Vermont retail pharmacies fill your prescriptions and pay them at the same level as others. They cannot force mail‑order or raise your costs for choosing a local pharmacy, or switch your pharmacy without your consent. These retail pharmacy protections also apply to Medicaid and other state health programs. Plans must not count third‑party coupons or assistance toward your drug deductible or out‑of‑pocket totals, with limits for generics and HSA plans.
Equal coverage for civil union families
Insurers must give civil union partners the same dependent coverage as married couples. For Vermont residents working for out‑of‑state employers, coverage cannot treat civil unions or same‑sex marriages differently, as federal law allows. Treating civil unions differently is unfair discrimination. These rules take effect September 1, 2025.
Licensing and safeguards for mental health reviewers
People who decide payment for mental health care must hold a state review‑agent license. The Commissioner sets decision time limits, requires disclosure of review rules and reviewer credentials within 10 business days on request, and bars pay‑for‑denial incentives. A comparable mental health professional must concur on denials that affect payment, and reviewers must talk with the treating provider before deciding. The license costs $200 to start and $200 each year to renew, and violations can bring fines up to $5,000.
Tax-exempt health plans must certify fairness
Starting September 1, 2025, hospital and medical service corporations must certify in their annual sworn statement that they operate as nonprofits and provide adequate plans without discrimination by age, gender, area, industry, or medical history (with limited statutory exceptions). The certification is due by March 1 with the annual filing to the Commissioner. This certification is required to keep their tax‑exempt status.
Insurers must join Blueprint for Health
Starting September 1, 2025, insurers that sell health coverage in Vermont must take part in the Blueprint for Health. The Commissioner can exempt insurers that only sell stand‑alone dental, very limited benefit plans, or certain direct‑pay plans. This aims to coordinate care statewide while limiting the rule for narrow products.
Independent outside review of claim denials
After you finish your plan’s internal appeal, you can ask for an independent external review when the service would cost the plan at least $100. The request costs $25 per case, capped at $75 per year, and the fee can be waived for financial hardship. If the reviewer overturns the denial, the insurer pays the fee and must follow the decision.
Keep coverage during college medical leave
If your dependent is a full‑time college student over 18, the plan must keep coverage during a medically necessary leave. Coverage can continue up to 24 months or until it would otherwise end. A treating provider’s certification is required, and periodic proof may be requested.
Kids’ vaccine coverage can’t drop
Insurers must keep at least the same level of pediatric vaccine coverage they had on May 1, 1993. Plans cannot cut children’s vaccine benefits below that floor.
Policy ownership and age‑limit rules
Someone with an insurable interest can buy and own a policy on another person and receive the benefits it provides. If a policy has an age‑limit date and you paid a premium covering that date, coverage runs through the paid period. If the correct age would have ended coverage, the insurer’s liability is limited to refunding premiums for the uncovered period on request.
Vermont standards can apply across states
If a Vermont insurer sells a policy for delivery in another state and that state does not review it, Vermont can require the policy to meet Vermont’s contract standards. Policies from out‑of‑state insurers sold in Vermont may follow their home‑state rules only if those terms are not worse for you than Vermont law.
Fines for intentional insurance law violations
The Insurance Commissioner can fine up to $750 for intentional violations of this law or an order. The Commissioner can also suspend or revoke an insurer’s or agent’s license.
No misleading ads in health insurance
Companies and agents cannot use misleading ads to sell health insurance or PBM services. The Insurance Commissioner can order them to stop and suspend or revoke licenses for intentional violations.
New $150 filing fees and rules for insurers
Beginning September 1, 2025, hospital and medical service corporations must pay a nonrefundable $150 fee with each contract, certificate, amendment, or rate filing. Each filing must include a plain‑language summary of any rate increase and follow a public comment process. Fees are payable to the Commissioner or the Green Mountain Care Board, as appropriate. The Commissioner sets filing procedures by rule.
Fairer contract and plan terms
Insurers cannot use your signed application against you unless a copy is attached to your policy; if you ask after a renewal or reinstatement, they must send it within 15 days. The Commissioner may let insurers omit or modify inapplicable standard provisions, but only with approval. Blanket policies (like some student or group travel plans) must follow fair claims rules and can’t use worse suit limits. The chapter clarifies that most required benefits apply to major medical plans (not Medicaid), and it defines key terms used across the health insurance rules.
No rebates on Exchange and individual plans
The law bans insurers from offering rebates, premium refunds, perks, or other advantages for individual and small‑group policies and for plans on Vermont’s health insurance marketplace. For marketplace plans, insurers cannot include agent commissions in plan rates. The marketplace may pay agents outside of insurance rates. Limited exceptions remain, like returning dividends, abating premiums from surplus, and interest up to 6% on bona fide obligations.
Higher copays for chiro and PT visits
Plans must cover needed chiropractic services, with therapies limited to physiotherapy and rehab exercises, and may require referrals. If you have a silver or bronze plan, copays for chiropractic or physical therapy visits can be 125% to 150% of your primary care copay. This can raise your per‑visit costs in those plan levels.
Some policies are outside these rules
These sections do not apply to some policy types, like workers’ compensation, liability insurance, reinsurance, certain blanket or group policies, and some life or annuity contracts with only accident or sickness riders. If your policy is one of these, these specific consumer protections do not apply.
No rebates or perks in group plans
Insurers cannot offer rebates, paid jobs, or other perks to sell group policies. This does not cover small‑group marketplace plans. Insurers may pay commissions to licensed agents or brokers, but they must clearly disclose to the buyer any commission or fee paid to a non‑employee agent or broker. They may still return dividends or abate premiums from surplus.
Appeal rights and claim process rules
Anyone harmed by an Insurance Commissioner order can appeal to the Washington County Superior Court. The order usually does not take effect during the appeal, unless the court orders otherwise. Either party can appeal again to the Vermont Supreme Court. Also, when an insurer sends or accepts claim forms or investigates a claim, that alone does not waive the insurer’s defenses.
External review records kept confidential
Beginning September 1, 2025, records and internal materials from independent external reviews of health and mental health coverage decisions are confidential. They are not open to public records requests. This protects privacy but limits public access.
More plans now count as health insurance
Starting September 1, 2025, Vermont treats more products as health insurance. Short‑term limited‑duration policies, student health plans, and Medicare supplement plans are included. Medicaid and other State programs paid with federal funds remain excluded unless federal law and the Legislature allow them.
Old health insurance chapter repealed
The State repeals its prior health insurance chapter and replaces it with this reorganized framework. This updates and consolidates health insurance law in Vermont.
Stronger oversight and compliance for insurers
Insurers must follow federal rules, including HIPAA, the Affordable Care Act, and the No Surprises Act, with state enforcement and referrals when needed. The Green Mountain Care Board must consider non‑confidential quality‑improvement results for mental health and substance use care. Each policy or rate filing must include a $150 nonrefundable fee to fund reviews.
Free Policy Watch
You just read the policy. Now see what it costs you.
Pick a topic. PRIA runs your household against live legislation and sends you a free personalized readout.
Pick a topic to get started
Sponsors & Cosponsors
Sponsor
Virginia "Ginny" V Lyons
Democratic • Senate
Cosponsors
Ann E Cummings
Democratic • Senate
Roll Call Votes
No roll call votes available for this bill.
Actions Timeline
Senate Message: Signed by Governor 5/1/2025
5/2/2025HouseSigned by Governor on May 1, 2025
5/2/2025SenateDelivered to Governor on April 25, 2025
4/25/2025SenateSenate Message: House proposal of amendment concurred in
4/18/2025HouseAs passed by Senate and House
4/17/2025SenateHouse proposal of amendment concurred in
4/17/2025SenateHouse proposal of amendment; text
4/17/2025SenateUnfinished Business/House Proposal of Amendment
4/17/2025SenateNew Business/House Proposal of Amendment
4/16/2025SenateHouse proposal of amendment
4/15/2025SenateEntered on Notice Calendar
4/15/2025SenateHouse message: House passed bill in concurrence with proposal(s) of amendment
4/11/2025SenateRead third time and passed in concurrence with proposal of amendment
4/9/2025HouseAction Calendar: Third Reading
4/9/2025HouseThird Reading ordered
4/8/2025HouseReport of Committee on Health Care agreed to
4/8/2025HouseRep. Cina of Burlington reported for the Committee on Health Care
4/8/2025HouseRead second time
4/8/2025HouseAction Calendar: Favorable with Amendment
4/8/2025HouseNotice Calendar: Favorable with Amendment
4/4/2025HouseRead first time and referred to the Committee on Health Care
2/13/2025HouseRead 3rd time & passed
2/12/2025SenateNew Business/Third Reading
2/12/2025SenateReported favorably by Senator Hardy for Committee on Finance, read 2nd time and 3rd reading ordered
2/11/2025SenateFavorable report by Committee on Finance
2/11/2025Senate
Bill Text
As Enacted (ACT 11)
5/7/2025
As Passed by Both Chambers
4/25/2025
As Passed by Both Chambers (Unofficial)
4/25/2025
House Proposal of Amendment
4/11/2025
House Proposal of Amendment (Unofficial)
4/11/2025
As Passed by the Senate
2/18/2025
As Passed by the Senate (Unofficial)
2/18/2025
As Introduced
1/28/2025
Related Bills
H.519 — An act relating to Vermont State Employees' Retirement System Group G membership
S.163 — An act relating to the role of advanced practice providers in hospital care
H.927 — An act relating to technical corrections for the 2026 legislative session
H.723 — An act relating to posting of land
H.626 — An act relating to sexual extortion, voyeurism, and disclosure of sexually explicit images without consent
H.917 — An act relating to military affairs
Take It Personal
Get Your Personalized Policy View
Take the PRIA Score to see how policy affects your household, then upgrade to PRIA Full Coverage for year-round monitoring.
Already have an account? Sign in