§ 1806. Qualified health benefit plans

(a) Prior to contracting with a health insurer to offer a qualified health benefit plan, the Commissioner shall determine that making the plan available through the Vermont Health Benefit Exchange is in the best interests of individuals and qualified employers in this State. In determining the best interests, the Commissioner shall consider affordability; promotion of high-quality care, prevention, and wellness; promotion of access to health care; participation in the State’s health care reform efforts; and such other criteria as the Commissioner, in the Commissioner’s discretion, deems appropriate.

(b)(1) A qualified health benefit plan shall provide the following benefits:

(A) The essential benefits package required by Section 1302(a) of the Affordable Care Act and any additional benefits required by the Secretary of Human Services by rule after consultation with the Advisory Committee established in section 402 of this title and after approval from the Green Mountain Care Board established in 18 Vt. Stat. Ann. chapter 220.

(B) Notwithstanding subdivision (1)(A) of this subsection (b), a health insurer or a stand-alone dental insurer, including a nonprofit dental service corporation, may offer a plan that provides only limited dental benefits, either separately or in conjunction with a qualified health benefit plan, if it meets the requirements of Section 9832(c)(2)(A) of the Internal Revenue Code and provides pediatric dental benefits meeting the requirements of Section 1302(b)(1)(J) of the Affordable Care Act. Said plans may include child-only policies or family policies. If permitted under federal law, a qualified health benefit plan offered in conjunction with a stand-alone dental plan providing pediatric dental benefits meeting the requirements of Section 1302(b)(1)(J) of the Affordable Care Act shall be deemed to meet the requirements of this subsection.

(2) At least the bronze level of coverage as defined by Section 1302 of the Affordable Care Act and the cost-sharing limitations for individuals provided in Section 1302 of the Affordable Care Act, as well as any more restrictive cost-sharing requirements specified by the Secretary of Human Services by rule after consultation with the Advisory Committee established in section 402 of this title and after approval from the Green Mountain Care Board established in 18 Vt. Stat. Ann. chapter 220.

(3) For qualified health benefit plans offered to employers, a deductible that meets the limitations provided in Section 1302 of the Affordable Care Act and any more restrictive deductible requirements specified by the Secretary of Human Services by rule after consultation with the Advisory Committee established in section 402 of this title and after approval from the Green Mountain Care Board established in 18 Vt. Stat. Ann. chapter 220.

(c) A qualified health benefit plan shall meet the following minimum prevention, quality, and wellness requirements:

(1) standards for marketing practices, network adequacy, essential community providers in underserved areas, appropriate services to enable access for underserved individuals or populations, accreditation, quality improvement, and information on quality measures for health benefit plan performance, as provided in Section 1311 of the Affordable Care Act and any more restrictive requirements provided by 8 Vt. Stat. Ann. chapter 107;

(2) quality and wellness standards, including a requirement for joint quality improvement activities with other plans, as specified in rule by the Secretary of Human Services, after consultation with the Commissioners of Health and of Financial Regulation and with the Advisory Committee established in section 402 of this title; and

(3) standards for participation in the Blueprint for Health as provided in 18 Vt. Stat. Ann. chapter 13.

(d) A health insurer offering a qualified health benefit plan shall use the uniform enrollment forms and descriptions of coverage provided by the Commissioners of Vermont Health Access and of Financial Regulation.

(e)(1) A health insurer offering a qualified health benefit plan shall comply with the following insurance and consumer information requirements:

(A)(i) obtain premium approval through the rate review process provided in 8 Vt. Stat. Ann. chapter 107; and

(ii) submit to the Commissioner of Financial Regulation a justification for any premium increase before implementation of that increase and prominently post this information on the health insurer’s website.

(B) Offer at least one qualified health benefit plan at the silver level and at least one qualified health benefit plan at the gold level that meet the requirements of Section 1302 of the Affordable Care Act and any additional requirements specified by the Secretary of Human Services by rule. In addition, a health insurer may choose to offer one or more qualified health benefit plans at the platinum level that meet the requirements of Section 1302 of the Affordable Care Act and any additional requirements specified by the Secretary of Human Services by rule.

(C) Charge the same premium rate for a health benefit plan without regard to whether the plan is offered through the Vermont Health Benefit Exchange and without regard to whether the plan is offered directly from the carrier or through an insurance agent.

(D) Provide accurate and timely disclosure of information to the public and to the Vermont Health Benefit Exchange relating to claims denials, enrollment data, rating practices, out-of-network coverage, enrollee and participant rights provided by Title I of the Affordable Care Act, and other information as required by the Commissioner of Vermont Health Access or by the Commissioner of Financial Regulation. The Commissioner of Financial Regulation shall define, by rule, the acceptable time frame for provision of information in accordance with this subdivision.

(E) Provide information in a timely manner to an individual, upon request, regarding the cost-sharing amounts for that individual’s health benefit plan.

(2) A health insurer offering a qualified health benefit plan shall comply with all other insurance requirements for health insurers as provided in 8 Vt. Stat. Ann. chapter 107 and as specified by rule by the Commissioner of Financial Regulation.

(f) Consistent with Section 1311(e)(1)(B) of the Affordable Care Act, the Vermont Health Benefit Exchange shall not exclude a health benefit plan:

(1) on the basis that the plan is a fee-for-service plan;

(2) through the imposition of premium price controls by the Vermont Health Benefit Exchange; or

(3) on the basis that the health benefit plan provides for treatments necessary to prevent patients’ deaths in circumstances the Vermont Health Benefit Exchange determines are inappropriate or too costly.

(g) The Vermont Health Benefit Exchange shall clearly indicate to any prospective purchaser of a bronze-level plan, and of other plans as appropriate, the potential for significant out-of-pocket costs, in addition to the premium, associated with the plan. (Added 2011, No. 48, § 4; amended 2011, No. 171 (Adj. Sess.), §§ 2a, 2h; 2021, No. 20, § 297.)