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
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87 provisions identified: 50 benefits, 7 costs, 30 mixed.
Disability insurance payments protected from creditors
Creditors generally cannot seize up to $200 per month in health insurance benefits paid during a covered disability. This monthly protection does not apply to claims for necessities contracted for during that disability. Creditors also cannot seize a lump-sum insurance payment for loss of a limb or another insured loss.
Coverage protects patients needing prosthetic limbs
Plans must cover devices replacing all or part of an arm or leg at least as broadly as Medicare. Coverage includes medically necessary repairs and replacements. Plans may cover the most appropriate medically necessary model and require prior approval as they do for other benefits. Patient costs cannot be less favorable than those for other nonprimary-care items and services.
Dependent coverage protects young adults and students
Plans covering dependent children must make coverage available until the child turns 26. This requirement excludes specified-disease and other limited-benefit plans and does not require coverage for a dependent child’s own child. Plans covering full-time college dependents beyond age 18 must keep coverage during a medically necessary leave. That protection lasts up to 24 months or the plan’s normal coverage end date, whichever comes first. Students must provide medical documentation and certification; plans can request reasonable periodic proof.
Developmental care coverage for children under 21
Plans must cover evidence-based diagnosis and medically necessary treatment of early childhood developmental disorders from birth until age 21. Covered treatment includes applied behavior analysis and may include behavioral, pharmacy, psychiatric, psychological, and therapy services. Behavior analysis requires a nationally board-certified analyst or a licensed health professional providing or supervising care within their legal scope. Natural-environment services require an appropriately licensed professional or the required direct supervision; treatment amounts depend on medical need and may require prior approval. Major medical benefits need not exceed federal essential health benefits, and public-program coverage must follow federal requirements.
Disabled adult children keep dependent coverage
Plans cannot end dependent coverage at their age limit for an unmarried child meeting the federal disability standard. The disability must have prevented self-supporting employment before the child reached that limit. The child must chiefly rely on the covered person for support and maintenance. Plans can request reasonable proof that the condition continues, but no more than once a year.
Equal coverage for mental health treatment
Plans must cover mental health and substance use treatment without greater financial or access burdens than other health care. Mental health copayments cannot exceed the matching primary-care or specialist copayment, and deductibles and out-of-pocket limits must combine physical and mental care. Plans cannot exclude licensed local providers willing to meet their participation terms. Plans covering prescriptions must put at least one FDA-approved substance use medicine in each therapeutic class on the lowest-cost tier. Managed-care arrangements must follow rules protecting timely, appropriate access.
Group plans protect coverage and spending
Beginning September 1, 2025, group policies cannot limit coverage because of preexisting conditions. They cannot impose annual or lifetime dollar limits on essential health benefits, including out-of-network care. Annual cost sharing for self-only coverage follows the federal limit; the limit for other group coverage is twice that amount. If no federal limit is set, the prior self-only limit increases with Vermont’s average per-person health insurance premium.
Health coverage for newborns and adopted children
Plans covering dependent children must cover newborns from birth, including treatment for diagnosed birth defects and abnormalities. No notice or extra premium is required for at least 60 days; continued coverage can require notice and payment. Plans must allow at least 60 days after birth for that notice and payment. Children under 18 placed for adoption receive the same coverage as natural dependent children, even before adoption is final. A preexisting condition alone cannot restrict coverage when adoption or placement happens while the parent is eligible for the plan.
Medical food coverage for inherited disorders
Plans must cover prescribed, medically necessary medical foods for inherited metabolic disorders included in Vermont's newborn screening program. Coverage for prescribed low-protein modified food products must be at least $2,500 during any continuous 12-month period.
Parents can secure ordered child coverage
When an eligible parent must provide ordered child coverage, insurers cannot deny enrollment because of unmarried parents, tax status, or residence. Enrollment must be processed within 10 days after application and notice; coverage starts three days after mailing notice or upon receipt, whichever comes first. Coverage continues unless the order ends, comparable coverage starts by disenrollment, or the employer ends dependent coverage for everyone. For unpaid premiums, insurers must notify the required parties and restore coverage retroactively if paid within 45 days; failure to enroll makes insurers liable for covered expenses. Either parent can obtain benefit information, submit claims, and appeal without the other’s approval; authorized providers and agencies can also act, with payment sent to the entitled recipient.
Required coverage for gender-affirming care
Plans must cover medically necessary, clinically appropriate gender-affirming care included in Vermont's essential health benefits benchmark. Plans can cover additional services beyond that benchmark. Cost sharing cannot be higher than for treatment of other physical or mental conditions. These protections also apply to Medicaid and other state or local public health assistance programs, subject to federal requirements.
Cancer trial coverage with referral rules
The Commissioner must require routine-cost coverage for qualifying approved cancer trials at University of Vermont Medical Center, Dartmouth-Hitchcock's Norris Cotton Cancer Center, or qualifying hospital-affiliated providers. For an out-of-state trial, you must notify your plan before participating. Coverage requires no available trial at the named centers, a provider-supported subsequent trial, or an approved out-of-network referral supported by your provider. Plans may require in-network follow-up unless your cancer provider says that is not in your best interest. The requirement also applies to Medicaid and other Vermont-administered public health assistance programs.
Claim protections and lawsuit time limits
For policies subject to these required terms, nonfraudulent application mistakes generally cannot void coverage or defeat losses beginning after three years. After three years, an earlier health condition generally cannot defeat a claim unless a named or specifically described exclusion remains active. Fraud is not protected. Insurers can require reasonable examinations at their expense during pending claims and conduct lawful autopsies. Lawsuits must wait until 60 days after written proof and must begin within three years after proof is due.
Keep group coverage with required payments
People insured on the event date can continue group medical and dental coverage after job loss, reduced hours, divorce, separation, dependent aging-out, or death. They must elect in writing within 60 days of notice and pay initially through the election month. Later monthly payments are due in advance and cannot exceed 102% of the group rate. Continuation generally lasts up to 18 months; Medicare coverage and job loss for misconduct exclude eligibility. Coverage can end sooner for nonpayment, Medicare, qualifying other group coverage, or an end to the group policy or employer participation.
Health policy wording must protect patients
Listed optional policy terms must use statutory wording or approved wording that is no less favorable, subject to statutory exceptions. These terms cover occupation, age, other insurance, earnings, unpaid premiums, cancellation, state-law compliance, and losses tied to illegal occupations or felonies. Standard terms that conflict with a policy’s coverage must be removed or changed with the Commissioner’s approval. Required home-jurisdiction terms in out-of-state insurers’ Vermont policies cannot be less favorable; Vermont insurers issuing elsewhere can use terms allowed there. For policies subject to the standard-term rules, Vermont law overrides conflicting wording that gives covered people worse terms.
Stronger rights in insurance claim disputes
Vermont health, disability-income, and life insurance contracts cannot reserve insurer discretion to interpret terms or use review standards inconsistent with Vermont law. Those clauses are void. Application statements bind you only when a copy is attached to or endorsed on the policy. Others need your written consent to change your application; clearly marked administrative-only insurer entries are allowed. A false application statement bars recovery only when it materially affected the insurer’s acceptance of the risk or the hazard assumed.
Advance premium notices and termination protections
Insurers must notify the policyholder or other responsible party at least 21 days before a premium is due. For policies ending automatically after nonpayment, valid claims for covered losses before the grace period ends remain payable. An insurer’s conduct treating coverage as active can also preserve liability for losses before written termination notice. Under these rules, termination cannot take effect before midnight at the end of the 14th day after notice is mailed.
Anesthesia coverage for qualifying dental patients
Plans must cover hospital or surgery-center charges and general anesthesia for qualifying dental care, but not the dental work itself. Coverage includes children age seven or younger whose complex needs cannot be safely treated as outpatients. Children age 12 or younger qualify with documented phobias, mental conditions, or psychiatric disabilities, complex urgent needs, and expected better results than local anesthesia. People with exceptional medical circumstances or developmental disabilities placing them at serious risk also qualify. Anesthesia requires a licensed anesthesiologist or certified registered nurse anesthetist; plans may require prior approval and specified qualified dental providers.
Association plan enrollment and financial safeguards
Association and qualifying trust policies must cover all statutorily eligible members, employees, and dependents unless they reject coverage in writing. The Commissioner must adopt association plan rules covering licenses, financial reserves, solvency, and pricing. These rules operate as far as federal law permits, and association plans remain subject to Vermont's additional statutory requirements.
Asthma medicines without prior approval
Plans must cover at least one readily available asthma controller medicine in each drug class and form of administration. These medicines cannot require prior authorization. A medicine qualifies as readily available when it is not on a national drug shortage list.
Benefits continue during disability and hospitalization
Group plans must extend benefits when the employer or member is totally disabled on the date coverage ends. The minimum extension is 12 months for major medical coverage and 90 days for other hospital or medical expense coverage. Ending a policy does not stop benefits payable for an ongoing covered loss-of-time period or hospital stay. The law does not require dental benefits to be extended.
Coverage and cost protections for remote care
Plans must cover medically necessary, appropriate care by secure live video or audio-only phone as they cover in-person care. This includes qualifying video dental care and covered home health services by phone; patient costs cannot exceed in-person costs. Video visits cannot face stricter visit limits, though plans can require network providers. Phone reimbursement cannot require an existing patient-provider relationship, and Medicaid phone coverage applies only as federal rules permit. Equivalent billing codes receive equal provider payment, except for applicable value-based contracts and third-party video vendor contracts.
Coverage protections for cancer patients
Beginning September 1, 2025, plans must cover prostate screenings recommended by the CDC or your health professional, on terms at least as favorable as other cancer screenings. Plans must cover medically necessary growth cell stimulating factor injections prescribed with chemotherapy. Prescribed oral cancer drugs must have financial terms no worse than injected or intravenous cancer drugs. Plans, Medicaid, and other Vermont public health programs must cover medically accepted cancer drug uses, including evidence-supported off-label uses, and needed administration services. FDA-contraindicated uses are excluded; the same lawful limits, deductibles, and coinsurance used for comparable screenings or drugs still apply.
Coverage protections when group insurers change
When similar group coverage replaces an old plan, the new insurer must offer coverage to people covered or eligible under either plan. It must credit similar deductibles and waiting periods already satisfied under the old plan. It must also follow required benefit-extension and preexisting-condition protections, subject to the law’s limits on extension coverage. The old insurer remains responsible for accrued claims and required extensions; the new insurer does not pay those obligations.
Diabetes coverage and capped insulin costs
Plans must cover prescribed diabetes equipment, supplies, outpatient education, and medical nutrition therapy. This includes insulin-dependent, insulin-using, noninsulin-using, and gestational diabetes. Training must come from a certified, registered, or licensed professional with specialized diabetes training. Total prescription insulin costs cannot exceed $100 per 30-day supply, even before you meet your deductible. The cap applies regardless of the amount, type, or number of insulin drugs prescribed.
Equal charges for childhood developmental care
Health plans cannot charge more for diagnosing or treating early childhood developmental disorders than for other physical or mental conditions. This protection covers copayments, coinsurance, deductibles, and other cost sharing.
Equal couple coverage for cross-border workers
Coverage for Vermont residents working for employers based outside Vermont cannot distinguish among civil unions, same-sex marriages, and opposite-sex marriages. This equal-treatment requirement applies to the extent federal law permits.
Equal coverage for eye care patients
Plans covering eye care must cover in-network licensed optometrists and ophthalmologists working within their legal scope. Patient costs for an optometrist cannot exceed costs for the same service from an ophthalmologist; provider payment must be equal. Insurers must allow optometrists to participate to the same extent as ophthalmologists. Neither profession’s participation can depend on offering discounted materials or joining another plan. These rules also cover Medicaid and other Vermont public health programs, except for the supplier-choice protections.
Equal coverage for naturopathic primary care
Plans must cover otherwise covered, medically necessary services from Vermont-licensed naturopathic doctors working within their legal scope. Naturopathic doctors providing primary care must be recognized as primary care doctors. Plans cannot apply more restrictive or unfairly discriminatory patient costs, service limits, or review rules. Network contracting and out-of-network payment rules may match those for other primary care doctors. These protections also apply to Medicaid and other Vermont public health assistance programs.
Fewer forced drug trials for patients
Plans cannot make continuously enrolled members fail on the same drug more than once. Failure includes stopping because of poor effectiveness, reduced effect, or an adverse event. Members or treating professionals can request exceptions for likely harm, expected ineffectiveness, prior failed trials, or stability on another drug. Exceptions also cover likely harm to adherence, other conditions, or daily functioning, and must follow applicable prior-approval deadlines. For substance use disorder prescriptions, plans cannot require documented drug trials before approval at all.
Free preventive care and protected vaccines
Group policies cannot charge copayments, coinsurance, or deductibles for preventive services covered by the law’s listed federal guidelines. These include services rated A or B by the U.S. Preventive Services Task Force and recommended routine vaccines. Federal health agency guidelines also cover preventive care for children, teens, and women. High-deductible plans must follow this rule only when it preserves health savings account eligibility. Vermont insurers also cannot reduce children’s vaccine coverage below the level they provided on May 1, 1993.
Medicare supplement access without health screening
Medicare supplement insurers must use approved community rates and cannot use medical underwriting or health screening. Risk classifications cannot change those rates, though separate community rates are allowed for age-based and disability-based Medicare eligibility. Insurers offering policies to age-eligible buyers must offer the same policies to disability-eligible buyers. Disability-based buyers get an initial enrollment period of at least six months and any additional periods offered to age-based buyers. The disability access requirement excludes people eligible for Medicare because of end stage renal disease.
Midwife coverage includes home births
Plans providing maternity benefits must cover services within the scope of a Vermont-licensed midwife or certified nurse midwife. Covered services can take place at home, in a hospital, or in another health facility. Cost sharing cannot exceed charges for similar benefits. The requirement also applies to Medicaid and other Vermont public health assistance programs.
No copays for covered assault exams
Health plans cannot charge copayments or coinsurance for covered sexual assault examination services listed in an insurer’s crime-victim-services agreement. Deductibles and other cost sharing are also barred to the extent federal law permits.
Patients can choose beyond mail-order pharmacies
Insurers and pharmacy benefit managers cannot require exclusive use of mail-order pharmacies or the benefit manager’s affiliated pharmacies. Plan designs cannot force mail-order use or raise plan or patient costs because someone chooses not to use it. This includes charging the patient the full drug price for declining mail order.
Patients keep pharmacy and prescription choices
Insurers and pharmacy benefit managers cannot change your prescription order or chosen pharmacy without consent; legally required lower-cost substitutions remain. They cannot require a designated pharmacy to send administered medicines to you for transport or directly to a care site. Pharmacy networks and dispensing rules cannot be stricter than, or conflict with, applicable laws or Vermont pharmacy rules and guidance. Insurers and managers must follow legal drug definitions and pharmacy standards, rather than impose conflicting classifications, claim penalties, or pharmacy directions. Specified pharmacy protections also apply to Medicaid and other Vermont public health programs, except subsection (c) of the referenced pharmacy law.
Payment supports remote addiction treatment
For remote substance use disorder treatment starting at a health facility, insurers and Vermont’s health access department must ensure payment to both sites. Payment covers the distant provider and the facility where the patient receives care. Both sites need not receive payment when providers at both sites work for the same entity.
Required health benefits have coverage limits
The subchapter’s required benefits generally apply only to major medical plans, not Vermont Medicaid. Exceptions apply when the law specifically says otherwise or federal law requires a different result. Benefits can have cost sharing, coverage limits, treatment guidelines, and service reviews consistent with state rules and guidance. Insurers can require contracted licensed providers, but must meet network adequacy requirements.
Short-term health coverage has tighter limits
Short-term health policies cannot be renewed. Insurers cannot issue coverage that gives a person more than three months of short-term coverage in any 12-month period. The law does not provide replacement coverage or set its cost.
Tighter rules for association health plans
Association health plans must meet federal formation standards in effect on January 19, 2017, to be issued, offered, or renewed. Associations seeking group coverage need at least 100 people when formed and at least one year serving purposes beyond insurance. They must meet meeting, dues, voting, and representation rules and remain independent of insurer control. Members must share a purpose not mainly based on business or customer ties. Coverage is limited to eligible association-linked members, employees, and dependents; insurance solicitation cannot be the main way to recruit members.
Abortion coverage with limited cost exceptions
Plans must cover abortion and abortion-related care without cost sharing or additional charges. Coverage is also required in Medicaid and other Vermont state or local public health assistance programs. The no-cost-sharing rule does not apply to Medicaid. High-deductible plans have an exception to the extent free coverage would disqualify them from health savings account eligibility.
Birth control coverage and yearlong supplies
Plans must cover outpatient contraception and sterilization, with no greater financial burden than other care; prescription products require prescription-drug coverage. For women, at least one prescribed option per FDA-identified method, plus related clinical and follow-up services, must have no cost sharing. Plans must defer to the provider's medical-necessity choice; voluntary sterilization is free of cost sharing except when that would defeat health savings account eligibility. Plans and Vermont public programs, including Medicaid, must cover prescribed supplies intended to last 12 months. Providers choose dispensing all at once or over the year, and dispensing providers or entities are paid per unit.
Blanket group coverage protections and exceptions
Blanket insurance covers specified groups, such as passengers, students, teachers, hazard-exposed employees, and volunteers, within federal limits. It is supplemental to major medical coverage or covers risks other than payment of health care costs; similar groups need Commissioner approval. Blanket policies paying health care costs must follow applicable insurance rules and cannot use less favorable claims terms than permitted. Individual applications and certificates are unnecessary, and benefits generally go to the insured person, a beneficiary, or the estate. Nongroup and small-group requirements do not apply, and the Commissioner may waive requirements unrelated to the risks or duration covered.
Cancer screening coverage without added charges
Plans must cover colorectal screening under current national recommendations for average-risk people and treating-provider recommendations for high-risk people. High risk includes family history, genetic syndromes, prior cancer or polyps, chronic digestive disease, and other provider-identified risks. Contracted screening and related tissue removal, laboratory, professional, facility, and anesthesia services cannot have cost sharing or extra charges. Plans must also fully cover screening mammograms, recommended medically necessary breast imaging, and additional imaging for inconclusive results or dense tissue at accredited facilities. The breast-imaging no-cost rule has an exception when it would defeat a high-deductible plan's health savings account eligibility.
Chiropractic coverage with copayment limits
Plans must cover clinically necessary care within a Vermont-licensed chiropractic physician's scope of practice. Add-on treatments are limited to physiotherapy methods and rehabilitation exercises. Plans need not cover internal-organ conditions arising from abdominal or chest-organ dysfunction and may require a contracted-provider referral. In silver- and bronze-level qualified or reflective plans, chiropractic copayments may be 125–150% of the primary-care copayment.
Claim deadlines and timely benefit payments
Policies subject to the required claim terms generally require written claim notice within 20 days and proof within 90 days. Insurers must provide claim forms within 15 days; without forms, you can submit written proof describing the loss. Deadlines allow delays when timely submission was not reasonably possible. Late proof is subject to the statutory one-year limit, except when the claimant lacks legal capacity. Nonperiodic benefits are payable immediately after adequate proof; periodic benefits must be paid at least monthly.
Clear policies and equal family coverage
Individual policies must clearly state terms, exceptions, and reductions in uniform type of at least 10 points. They may cover eligible family members under application and dependency rules, including children up to an age no higher than 26. Policies covering spouses or family members must offer equivalent dependent coverage to civil-union partners. Most individual policies must allow 10 days to cancel for a premium refund, or 30 days for people eligible for Medicare by age. Specified single-premium, nonrenewable accident-only or medical-cost-only policies are exempt from that cancellation notice requirement.
Coverage for Canadian prescription purchases
Plans must cover prescription drugs bought and used in Canada, or legally reimported into the United States. Coverage must use the same benefit terms as U.S. purchases. For mail or internet purchases, plans may require accreditation by IMPAC or a similar organization.
Coverage for face and neck disorders
Plans must cover diagnosis and medically necessary treatment of qualifying bone or joint disorders in the face, neck, or head. Coverage must match other musculoskeletal disorders and include surgical and nonsurgical treatment prescribed or administered by a physician or dentist. The disorder must result from accident, trauma, a congenital or developmental defect, or disease. Conditions primarily affecting gums, teeth, or the tooth-bearing jaw ridge are excluded. Plans may require a referral from a contracted provider.
Drug spending caps and coupon credit
Plans must cap yearly prescription drug spending at the federal minimum deductible amount for self-only or family coverage. The supplied text does not give those dollar amounts. Insurers and pharmacy benefit managers must count qualifying coupons, discounts, and assistance toward deductibles and out-of-pocket limits. When a generic or interchangeable biological product exists, third-party help counts only after access through prior authorization, step therapy, or exceptions and appeals. For high-deductible plans, this credit applies only when it preserves health savings account eligibility.
Drug spending protections with deductible requirements
Health plans cannot impose annual dollar limits on prescription drug benefits. Annual prescription out-of-pocket limits follow the federal minimum deductible amounts for self-only and family coverage. High-deductible plans generally cannot provide drug benefits before the applicable federal minimum annual deductible is met. Federal law allows some drugs to be covered before that point. After the deductible is met, the prescription out-of-pocket limit applies.
Home health visits and maternity coverage
Major medical plans must cover maternity and childbirth care and qualifying home health care. Home health coverage must include at least 40 agency visits per person per calendar year or continuous 12-month period. Four hours of home health aide care count as one visit. Home care must be professionally designed and supervised and replace otherwise-needed hospital or skilled nursing admission, with cost sharing no higher than other physical or mental care. The requirement excludes Medicare-eligible individuals, and insurers may require evidence of insurability.
Large-group plans must cover hearing aids
Non-excluded large-group plans must cover a hearing aid for each ear, related professional services, and prescribed batteries. A hearing care professional must prescribe, fit, and dispense the aid. Plans may limit coverage to one aid per ear every three years unless earlier replacement is medically necessary. Coverage is otherwise limited only by medical necessity, with cost sharing no less favorable than other nonprimary-care services. You can choose an aid above plan limits and pay the extra cost.
Late premium grace periods protect coverage
Required policy terms keep coverage active during grace periods for premiums due after the first premium. Minimum periods are 7 days for weekly premiums, 10 days for monthly premiums, and 31 days for other policies. Acceptance of a missed renewal premium provides for reinstatement. When an application and conditional receipt are required, reinstatement occurs by the 45th day unless the insurer gives earlier written disapproval.
Worker coverage access with premium responsibilities
Insurers cannot exclude part-time workers working at least 17.5 hours weekly from the group they would join if full-time. They must offer the same benefits, using full employer-employee contributions, prorated contributions, or payment entirely by the employee. Out-of-state employers can buy Vermont large-group coverage for eligible Vermont employees if more than 25 certificate holders live and principally work in Vermont. The employer must also qualify as a large group at home and under the federal Affordable Care Act.
Fair treatment in health insurance pricing
Health insurers cannot unfairly charge people with substantially the same health risk different premiums or give them different benefits. Different rates, benefits, and rules for evaluating applicants remain allowed for group, family expense, and blanket plans.
Limits on direct pharmacy sales pitches
Pharmacies and pharmacy benefit managers generally cannot directly contact health plan members to sell prescription items. Contact is allowed with written permission given to the supplier or ordering health professional. It is also allowed to arrange delivery of an item already furnished. A supplier can contact someone about another prescription item after providing at least one item within the past 15 months.
Protection from misleading health insurance ads
Beginning September 1, 2025, companies, insurance agents, brokers, and pharmacy benefit managers cannot use materially misleading ads or sales pitches. The insurance commissioner can order them to stop after at least 10 days’ notice and a hearing. Intentionally violating that order can lead to license suspension or loss after notice and a hearing. The commissioner can also fine intentional violations of the health insurance chapter or related orders up to $750. Those violations can also lead to suspension or loss of an insurer’s or agent’s license.
Drug coverage safeguards and generic-level costs
Plans cannot make coverage depend on using a drug not FDA-indicated for your diagnosed condition under professional treatment. Your health professional can still prescribe a drug for an off-label use. Plans must apply the same patient cost-sharing rules to interchangeable biological products as to generic drugs. The law does not set the dollar amount of those generic-drug costs.
Group members get clear coverage terms
Group policies must meet minimum standards for claim notices, proof of loss, payment timing, and time to bring legal action. The policy and specified applications form the entire contract; absent fraud, application statements are representations, not guarantees. A statement can defeat coverage or reduce benefits only if included in a written application attached to the policy. Insurers must provide coverage certificates identifying benefits and recipients, with one certificate allowed per family, and permit eligible additions under policy terms. Insurers collecting association dues must disclose that arrangement to members.
Insurers can pay for pharmacist services
Insurers can pay or reimburse for pharmacist services within the pharmacist’s legal scope when the plan covers the service. This permission does not require a plan to cover additional services. The law does not set a payment amount.
Medicare shoppers get clearer coverage information
The Department of Financial Regulation must work with insurers, advocates, and the Health Care Advocate on public Medicare education. The information must explain Medicare supplement and Medicare Advantage benefits and limits. It must address coverage, costs, and provider networks.
One cost-sharing charge for remote reviews
Plans must reimburse health and dental services provided through secure transmission of medical information for later specialist review. The connection must comply with federal health privacy rules, and the distant provider must have relevant specialty training. Plans can apply no more than one cost-sharing requirement, to either the local or distant provider, not both.
Owning health coverage for another person
A person with a proper insurable interest can apply for and own a health policy covering someone else. The policy owner can receive the policy’s payments, benefits, and rights.
Policyholders keep contract and payment rights
Health policies generally must include standard contract terms, restrict agent changes or waivers, and use substitute wording only when equally favorable. Life benefits go to the named beneficiary, or the estate without an effective designation; other benefits generally go to the insured. Beneficiaries can be changed unless the designation is irrevocable, and direct provider payment remains subject to written directions or timely requests. After renewal or reinstatement, a covered person or policy assignee can request the application in writing. The insurer must send it within 15 days or cannot use it as evidence in a proceeding about that policy.
Premium notices and time to pay
Insurers must give at least 21 days’ notice before a premium is due. Major medical plans must allow at least one month to pay each premium after the first. Coverage stays active during that period, and valid claims for covered losses before it ends remain payable. Major medical termination requires 21 days’ notice and cannot take effect before the day after the grace period ends. Other policies must give 14 days from mailing a nonpayment termination notice to pay, avoiding cancellation effective on the premium due date.
Retail pharmacy access and drug notices
Insurers and pharmacy benefit managers must let Vermont-licensed retail pharmacists fill prescriptions on the same terms as other pharmacies. Equal treatment includes reimbursement and the quantity or days' supply, including comparisons with mail-order and affiliated pharmacies. Participating network pharmacies must be allowed to provide services within their lawful scope. Insurers must notify members about drug coverage changes at least once each calendar year. They must also provide access to their own or their pharmacy benefit manager's preferred drug list.
Workers receive notices when coverage changes
Employers must include continuation-rights notices in coverage certificates and notify employees within 30 days after a qualifying event. Events include job loss, reduced hours, divorce, a dependent aging out, or death. When a group policy ends, insurers must provide termination forms and ask the policyholder to explain end dates and later claims. If members contributed toward coverage, the notice must warn about continuing to collect those payments after termination. The collecting entity may become solely liable for the corresponding benefits.
Insurers face federal health-rule enforcement
Vermont insurers, hospital and medical service corporations, health maintenance organizations, and providers must follow applicable federal health requirements. These include HIPAA, the Affordable Care Act, and the No Surprises Act. The Financial Regulation Commissioner enforces them within the Commissioner’s authority and can refer surprise-billing cases as provided by law.
Vermont oversight for some out-of-state policies
The insurance commissioner can require a Vermont-based insurer to meet specified Vermont standards for a policy delivered outside Vermont. This applies when the other state’s insurance official says the policy is not subject to approval or disapproval there. The applicable standards are in 8 V.S.A. §§ 4029–4031.
Insurers must follow Medicaid recovery rules
Insurers offering, selling, issuing, or renewing health coverage in Vermont must follow the state’s Medicaid recovery rules. The requirement also covers insurers that must be licensed or registered with Vermont’s Department of Financial Regulation. The insurance commissioner enforces these rules within the commissioner’s authority.
Claim processing preserves insurer defense rights
An insurer does not give up its right to defend a claim just by acknowledging receipt of notice. Providing or accepting proof-of-loss forms, or investigating the claim, also does not by itself surrender that right.
Physical therapy copays tied to primary care
Silver- and bronze-level qualified health plans and their matching reflective plans may charge copays for licensed physical therapists. If charged, the copay must be 125% to 150% of the plan’s primary-care copay. Your payment therefore depends on your plan’s primary-care copay.
Insurance reimbursement barred for specified services
Health insurance plans cannot reimburse services provided under 16 V.S.A. § 2959a. This provision does not specify a household payment obligation or the resulting effect on access or costs.
More insurers must join health program
Health insurers doing business in Vermont must participate in the Blueprint for Health as state law provides. The law removes express authority to exclude or limit participation for stand-alone dental and certain limited-benefit insurers. It also removes the express exemption for insurers paying only direct benefits not based on medical costs. No direct household cost or coverage change is specified.
Short-term health plans face stricter limits
Short-term health policies must expire no more than three months after their original start date. Providers need a certificate of authority from the insurance commissioner unless exempt under 8 V.S.A. § 3368(a)(4). The commissioner must set registration rules and require approval filings for rates, forms, and ads, plus consumer-protection and market-stability requirements. Policies, contracts, and applications must prominently explain included and excluded benefits and consumer protections in at least 14-point type. The commissioner supplies the disclosure language.
Coverage for medicines to quit tobacco
Plans must cover at least one three-month supply each year of FDA-approved medicine to help you quit tobacco. Coverage includes over-the-counter medicines when a licensed health care professional prescribes them. Plans may still charge the usual prescription copayment.
Eye care choices and charge protections
Plans cannot restrict or penalize eye care professionals for choosing suppliers or labs they find better for cost, quality, timing, or selection. Providers must tell consumers about resulting extra costs; this supplier-choice protection does not apply to Medicaid. Plan-set fees apply only to services or materials reimbursed as covered services. Noncovered charges cannot exceed the provider’s usual rate, and reimbursement for covered items must be reasonable rather than token.
Fair payment for athletic trainer care
Plans cannot deny payment solely because a licensed athletic trainer provides a service they would cover from another professional. The service must be within the trainer's lawful scope and already covered by the plan. Cost sharing, limits, practice rules, and review requirements cannot collectively be more restrictive or unfairly discriminatory. Insurers may require the trainer to have a contract with them.
Independent coverage appeals carry small fees
After required internal appeals, you can seek written independent review when a qualifying decision involves at least $100 in plan spending. Eligible disputes include medical necessity, provider choice, experimental treatment, off-label drugs, medically based preexisting-condition decisions, and adverse surprise-billing decisions. The fee is $25 per request, capped at $75 yearly, with reductions or waivers available for financial circumstances. The insurer pays other review costs and your fee if its payment denial is reversed; the written decision binds the insurer. Vermont Medicaid services and Department of Corrections services for incarcerated people are excluded.
Medicare supplement reviews can carry charges
Vermont’s insurance commissioner can deny Medicare supplement increases or approve different amounts; approved increases must meet legal standards. Insurers covering at least 5,000 Vermont lives trigger notice to the state aging and disability department for average increases above 3%. Coverage changes with comparable cost or access effects also trigger notice. After the required independent analysis, a hearing is required when the specified requested and recommended average increases differ by at least two percentage points; nonproprietary filings are public on request. Affected policyholders may be charged reasonable intervention costs up to $2,500, with the maximum subject to good-cause waiver or inflation adjustment.
Mental health accountability and qualified-provider rules
Insurers remain fully responsible when a managed care organization provides or administers their mental health coverage. Violations are unfair insurance practices; after notice and a hearing opportunity, the Commissioner can order corrections or contract termination. The Commissioner can also impose penalties, stop violations, or suspend or revoke licenses. Coverage under the referenced treatment rule requires licensed or certified mental health professionals or approved facilities. Substance use treatment requires approved counselors, other providers, or institutions meeting state qualification standards.
Paid coverage continues past age limits
Coverage continues through a period for which an insurer accepted a premium, even when an age cutoff falls within or before it. Any cancellation right still applies. If age was misstated and coverage was unavailable when payment was accepted, liability is limited to a requested premium refund. The refund covers the period without coverage.
Licensed oversight of mental health denials
People and companies reviewing mental health payments case by case in Vermont must obtain a state review-agent license. State standards must require qualified clinical review, review criteria on request, provider contact before adverse decisions, reconsideration, and confidentiality. Review agents cannot receive incentive or contingent fees tied to reducing services. They pay $200 for the registration year and $200 for each annual renewal. Violations can bring fines of up to $5,000 each.
Clearer premium filings, fees for insurers
Insurers making required rate filings must submit and publicly post a plain-language explanation that justifies requested premium increases. They must give the Green Mountain Care Board drug-spending details, specialty-tier drug lists, and pharmacy benefit manager information. These details include drugs’ share of premiums by category and yearly changes in monthly spending per member. Detailed provider payments are required on request; the outpatient drug share under the medical benefit is required if available. Filing entities pay a nonrefundable $150 for each covered policy, contract, form, rate, or rule filing—not a direct household charge.
Health plan sales rewards face limits
For plans under 33 V.S.A. § 1811 and other group plans, unlisted rebates and sales rewards cannot be offered or accepted. For § 1811 plans, insurers cannot pay sales commissions or include related service costs in rates; employee pay cannot favor particular plans. The Vermont Health Benefit Exchange can arrange compensation outside rates or through its statutory payment methods. For other group plans, licensed agents and brokers can be paid, but purchasers must be told amounts paid to nonemployee salespeople. Allowed exceptions include specified dividends, savings, unused premium deposits, premium reductions from surplus, and genuine premium-payment obligations charging no more than 6% yearly interest.
State review of insurance rates
Beginning September 1, 2025, covered insurers must file policy forms, rates, and risk-classification rules before using policies; statutory exemptions remain. The Green Mountain Care Board generally has 90 days to decide major medical rates, with up to 30 extra days for late or incomplete materials. The Commissioner generally has 30 days for other filings, which are deemed approved unless acted on or found incomplete. The law sets a $150 fee per policy, contract, form, or rate filing. Insurers offering major medical plans must participate in Vermont's Blueprint for Health and offer and manage plans consistently with it.
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
5/2/2025SenateSigned 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
4/18/2025SenateAs 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
4/11/2025HouseRead 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)Opens in a new window
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
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