Vermont Statutes Title 8 Sec. 5104
Terms Used In Vermont Statutes Title 8 Sec. 5104
- Commissioner: means the Commissioner of Financial Regulation. See
- Evidence: Information presented in testimony or in documents that is used to persuade the fact finder (judge or jury) to decide the case for one side or the other.
- Evidence of coverage: means any certificate, agreement, or contract issued to a member setting out the coverage to which the member is entitled and the rates for that coverage. See
- Health maintenance organization: means any person who furnishes, either directly or through arrangements with others, comprehensive health care services to an enrolled member in return for periodic payments; the amounts of said payments are agreed upon prior to the time during which the health care services may be furnished; and who is obligated to the member to arrange for or to provide directly available and accessible health care services. See
- Member: means any individual who has entered into a contract with a health maintenance organization for health care services or for services related to but not limited to processing, administering, or the payment of claims for health care services or on whose behalf such an arrangement has been made. See
- Person: includes individuals, partnerships, associations, trusts, and corporations. See
- Provider: means any physician, hospital, or other institution, organization, or other person who furnishes health care services. See
- State: when applied to the different parts of the United States may apply to the District of Columbia and any territory and the Commonwealth of Puerto Rico. See
§ 5104. Filing and approval of rates and forms; supplemental orders
(a)(1) A health maintenance organization that has received a certificate of authority under section 5102 of this title shall file and obtain approval of all policy forms and rates as provided in sections 4062 and 4062a of this title. This requirement shall include the filing of administrative retentions for any business in which the organization acts as a third party administrator or in any other administrative processing capacity. The Commissioner or the Green Mountain Care Board, as appropriate, may request and shall receive any information that the Commissioner or the Board deems necessary to evaluate the filing. In addition to any other information requested, the Commissioner or the Board shall require the filing of information on costs for providing services to the organization’s Vermont members affected by the policy form or rate, including Vermont claims experience, and administrative and overhead costs allocated to the service of Vermont members. Prior to approval, there shall be a public comment period pursuant to section 4062 of this title. A health maintenance organization shall file a summary of rate filings pursuant to section 4062 of this title.
(2) The Commissioner or the Board shall refuse to approve the form of evidence of coverage, filing, or rate if it contains any provision that is unjust, unfair, inequitable, misleading, or contrary to the law of the State or plan of operation, or if the rates are excessive, inadequate, or unfairly discriminatory, fail to protect the organization’s solvency, or fail to meet the standards of affordability, promotion of quality care, and promotion of access pursuant to section 4062 of this title. No evidence of coverage shall be offered to any potential member unless the person making the offer has first been licensed as an insurance agent in accordance with chapter 131 of this title.
(b) In connection with a rate decision, the Board may also make reasonable supplemental orders and may attach reasonable conditions and limitations to such orders as the Board finds, on the basis of competent and substantial evidence, necessary to ensure that benefits and services are provided at reasonable cost under efficient and economical management of the organization. The Commissioner and, except as otherwise provided by 18 V.S.A. §§ 9375 and 9376, the Green Mountain Care Board shall not set the rate of payment or reimbursement made by the organization to any physician, hospital, or health care provider. (Added 1979, No. 117 (Adj. Sess.); amended 1991, No. 166 (Adj. Sess.), § 15; 1993, No. 30, § 8, eff. May 21, 1993; 1993, No. 235 (Adj. Sess.), § 10b; 2011, No. 48, § 15d, eff. Jan. 1, 2012; 2011, No. 171 (Adj. Sess.), § 25a, eff. May 16, 2012; 2013, No. 79, § 5k, eff. Jan. 1, 2014.)