State Codes and Statutes

Statutes > Vermont > Title-33 > Chapter-19 > 1974

§ 1974. Employer-sponsored insurance, premium assistance

(a) No later than October 1, 2007, subject to approval by the Centers for Medicare and Medicaid Services, the agency of human services shall establish a premium assistance program to assist individuals eligible for or enrolled in the Vermont health access plan and uninsured individuals with incomes under 300 percent of the federal poverty guidelines and their dependents to purchase an approved employer-sponsored insurance plan if offered to those individuals by an employer. The agency shall determine whether to include children who are eligible for Medicaid or Dr. Dynasaur in the premium assistance program at their parent's option. The agency shall not mandate participation of children in employer-sponsored insurance.

(b) VHAP-eligible premium assistance.

(1) For individuals enrolled in or who apply for enrollment in the Vermont health access plan on or after October 1, 2007 who have access to an approved employer-sponsored insurance plan, the premium assistance program shall provide:

(A) A subsidy of premiums or cost-sharing amounts based on the household income of the eligible individual to ensure that the individual is obligated to make out-of-pocket expenditures for premiums and cost-sharing amounts which are substantially equivalent to or less than the premium and cost-sharing obligations on an annual basis under the Vermont health access plan.

(B) Supplemental benefit coverage equivalent to the benefits offered by the Vermont health access plan.

(2) In consultation with the department of banking, insurance, securities, and health care administration, the agency shall develop criteria for approving employer-sponsored health insurance plans to ensure the plans provide comprehensive and affordable health insurance when combined with the assistance under this section. At minimum, an approved employer-sponsored insurance plan shall conform to the following standards:

(A) The benefits covered by the plan must be substantially similar to the benefits covered under the certificates of coverage offered by the typical benefit plans issued by the four health insurers with the greatest number of covered lives in the small group and association market in this state.

(B) The plan shall include appropriate coverage of chronic conditions in a manner consistent with statewide participation by health insurers in the Vermont blueprint for health, and in accordance with the standards established in section 702 of Title 18.

(3) The agency shall determine whether it is cost-effective to the state to enroll an individual in an approved employer-sponsored insurance plan with the premium assistance under this subsection as compared to enrolling the individual in the Vermont health access plan. If the agency determines that it is cost-effective, the individual shall be required to enroll in the approved employer-sponsored plan as a condition of continued assistance under this section or coverage under the Vermont health access plan, except that dependents who are children of eligible individuals shall not be required to enroll in the premium assistance program. Notwithstanding this requirement, an individual shall be provided benefits under the Vermont health access plan until the next open enrollment period offered by the employer or insurer. The agency shall not consider the medical history, medical conditions, or claims history of any individual for whom cost-effectiveness is being evaluated.

(4) An individual who is or becomes eligible for Medicare shall not be eligible for premium assistance under this subsection.

(5) Decisions regarding plan approval and cost-effectiveness are matters fully within the agency's discretion. On appeal pursuant to section 3091 of Title 3, the human services board may overturn the agency's decision only if it is arbitrary or unreasonable.

(6) Notwithstanding any other provision of law, when an individual is enrolled in Catamount Health solely under the high deductible standard outlined in subdivision 4080f(a)(9) of Title 8, the individual shall not be eligible for premium assistance for the 12-month period following the date of enrollment in Catamount Health.

(c) Uninsured individuals; premium assistance.

(1) For the purposes of this subsection:

(A) "Chronic care" means health services provided by a health care professional for an established clinical condition that is expected to last a year or more and that requires ongoing clinical management attempting to restore the individual to highest function, minimize the negative effects of the condition, and prevent complications related to chronic conditions. Examples of chronic conditions include diabetes, hypertension, cardiovascular disease, cancer, asthma, pulmonary disease, substance abuse, mental illness, spinal cord injury, and hyperlipidemia.

(B) "Uninsured" means an individual who does not qualify for Medicare, Medicaid, the Vermont health access plan, or Dr. Dynasaur and had no private insurance or employer-sponsored coverage that includes both hospital and physician services within 12 months prior to the month of application, or lost private insurance or employer-sponsored coverage during the prior 12 months for the following reasons:

(i) the individual's private insurance or employer-sponsored coverage ended because of:

(I) loss of employment, including a reduction in hours that results in ineligibility for employer-sponsored coverage, unless the employer has terminated its employees or reduced their hours for the primary purpose of discontinuing employer-sponsored coverage and establishing their eligibility for Catamount Health;

(II) death of the principal insurance policyholder;

(III) divorce or dissolution of a civil union;

(IV) no longer receiving coverage as a dependent under the plan of a parent or caretaker relative; or

(V) no longer receiving COBRA, VIPER, or other state continuation coverage.

(ii) College- or university-sponsored health insurance became unavailable to the individual because the individual graduated, took a leave of absence, decreased enrollment below a threshold set for continued coverage, or otherwise terminated studies.

(iii)(I) The individual lost health insurance as a result of domestic violence. The individual shall provide the agency of human services with satisfactory documentation of the domestic violence. The documentation may include a sworn statement from the individual attesting to the abuse, law enforcement or court records, or other documentation from an attorney or legal advisor, member of the clergy, or health care provider, as defined in section 9402 of Title 18. Information relating to the domestic violence, including the individual's statement and corroborating evidence, provided to the agency shall not be disclosed by the agency unless the individual has signed a consent to disclose form. In the event the agency is legally required to release this information without consent of the individual, the agency shall notify the individual at the time the notice or request for release of information is received by the agency and prior to releasing the requested information.

(II) Subdivision (I) of this subdivision (B)(iii) shall take effect upon issuance by the Centers for Medicare and Medicaid Services of approval of an amendment to the waiver set forth in subsection (f) of this section allowing for a domestic violence exception to the premium assistance program waiting period.

(C) "Vermont resident" means an individual domiciled in Vermont as evidenced by an intent to maintain a principal dwelling place in Vermont indefinitely and to return to Vermont if temporarily absent, coupled with an act or acts consistent with that intent.

(2) An individual is eligible for premium assistance under this subsection if the individual:

(A) is an uninsured Vermont resident;

(B) has income less than or equal to 300 percent of the federal poverty level;

(C) has access to an approved employer-sponsored insurance plan; and

(D) is 18 or over and is not claimed on a tax return as a dependent of a resident of another state.

(3) The premium assistance program under this subsection shall provide a subsidy of premiums or cost-sharing amounts based on the household income of the eligible individual, with greater amounts of financial assistance provided to eligible individuals with lower household income and lesser amounts of assistance provided to eligible individuals with higher household income. Until an approved employer-sponsored plan is required to meet the standard in subdivision (4)(B)(ii) of this subsection, the subsidy shall include premium assistance and assistance to cover cost-sharing amounts for chronic care health services covered by the Vermont health access plan that are related to evidence-based guidelines for ongoing prevention and clinical management of the chronic condition specified in the blueprint for health in section 702 of Title 18. Notwithstanding any other provision of law, when an individual is enrolled in Catamount Health solely under the high deductible standard outlined in subdivision 4080f(a)(9) of Title 8, the individual shall not be eligible for premium assistance for the 12-month period following the date of enrollment in Catamount Health.

(4) In consultation with the department of banking, insurance, securities, and health care administration, the agency shall develop criteria for approving employer-sponsored health insurance plans to ensure the plans provide comprehensive and affordable health insurance when combined with the assistance under this section. At minimum, an approved employer-sponsored insurance plan shall include:

(A) covered benefits to be substantially similar, as determined by the agency, to the benefits covered under Catamount Health; and

(B)(i) until January 1, 2009 or when statewide participation in the Vermont blueprint for health is achieved, appropriate coverage of chronic conditions in a manner consistent with statewide participation by health insurers in the Vermont blueprint for health, and in accordance with the standards established in section 702 of Title 18;

(ii) after statewide participation is achieved, coverage of chronic conditions substantially similar to Catamount Health.

(5) The agency shall determine whether it is cost-effective to the state to require the individual to purchase the approved employer-sponsored insurance plan with premium assistance under this subsection instead of Catamount Health established in section 4080f of Title 8 with assistance under subchapter 3a of chapter 19 of this title. If providing the individual with assistance to purchase Catamount Health is more cost-effective to the state than providing the individual with premium assistance to purchase the individual's approved employer-sponsored plan, the state shall provide the individual the option of purchasing Catamount Health with assistance for that product. An individual may purchase Catamount Health and receive Catamount Health assistance until the approved employer-sponsored plan has an open enrollment period, but the individual shall be required to enroll in the approved employer-sponsored plan in order to continue to receive any assistance. The agency shall not consider the medical history, medical conditions, or claims history of any individual for whom cost-effectiveness is being evaluated.

(6) Decisions regarding plan approval and cost-effectiveness are matters fully within the agency's discretion. On appeal pursuant to section 3091 of Title 3, the human services board may overturn the agency's decision only if it is arbitrary or unreasonable.

(d)(1) Participation in an approved employer-sponsored insurance plan with premium assistance under this section or Catamount Health shall not disqualify an individual from the Vermont health access plan if an approved employer-sponsored insurance plan or Catamount Health is no longer available to that individual.

(2) An individual who has been enrolled in Medicaid, VHAP, Dr. Dynasaur, or any other health benefit plan authorized under Title XIX or Title XX of the Social Security Act shall not be subject to a 12-month waiting period before becoming eligible for premium assistance to purchase an approved employer-sponsored insurance plan.

(3) Enrollment in Catamount Health, with or without premium assistance, shall not disqualify an individual for premium assistance in connection with an approved employer-sponsored insurance plan.

(e) If the emergency board determines that the funds appropriated for either of the premium assistance programs under this section are insufficient to meet the projected costs of enrolling new program participants into the appropriate program, the emergency board shall suspend new enrollment in that program or restrict enrollment to eligible lower income individuals. This subsection does not affect eligibility for the Vermont health access plan or purchase of Catamount Health.

(f) The agency of human services shall request federal approval for an amendment to the Global Commitment for Health Medicaid Section 1115 waiver for the premium assistance program authorized by this section.

(g)(1) Of the amount appropriated in No. 215 of the Act of the 2005 Adj. Sess. (2006) for the employer-sponsored insurance premium assistance program established by this section, no more than $250,000.00 may be expended for start-up and initial administrative expenses until the report as required by subdivision (2) of this subsection has been received and approved.

(2) No additional amounts appropriated in No. 215 of the Act of the 2005 Adj. Sess. (2006) for the employer-sponsored premium assistance program may be made after November 15, 2006 without approval of a majority of the combined membership of the joint fiscal committee and the health access oversight committee at a joint meeting upon receipt of a report from the agency, which must include the following:

(A) a plan for the additional expenditures;

(B) a survey to determine whether and how many individuals currently enrolled in VHAP, including those eligible as caretakers, are potentially eligible for employer-sponsored premium assistance under this section;

(C) the sliding-scale premium and cost-sharing assistance amounts provided under the premium assistance program to individuals;

(D) a description and estimate of benefits offered by the Vermont health access plan that are likely to be provided as supplemental benefits for the employer-sponsored premium assistance program enrollees;

(E) a plan for covering dependent children through the premium assistance program; and

(F) the anticipated budgetary impact of an employer-sponsored insurance premium assistance program for fiscal year 2008, including savings attributable to enrolling current VHAP enrollees in the premium assistance program established under this section, the start-up and administrative costs of the program, and the cost of providing the subsidy to these enrollees.

(h) The agency shall report monthly to the joint fiscal committee, the health access oversight committee, and the commission on health care reform with the number of individuals enrolled in the premium assistance program, the income levels of the individuals, a description of the range and types of employer-sponsored plans that have been approved, the percentage of premium and cost-sharing amounts paid by employers whose employees participate in the premium assistance program, and the net savings or cost of the program.

(i) The health access oversight committee shall monitor the development, implementation, and ongoing operation of the employer-sponsored premium assistance program under this section.

Subsection (j) effective until April 1, 2010; see also subsection (j) set out below.

(j) The premium contributions for individuals shall be as follows:

(1) Monthly premiums for each individual who is eligible for the Vermont health access plan shall be the same as charged in the health access plan.

(2) Monthly premiums for each individual who is not eligible for the Vermont health access plan shall be:

(A) Income less than or equal to 175 percent of FPL: $60.00 per month.

(B) Income greater than 175 percent and less than or equal to 200 percent of FPL: $65.00 per month.

(C) Income greater than 200 percent and less than or equal to 225 percent of FPL: $110.00 per month.

(D) Income greater than 225 percent and less than or equal to 250 percent of FPL: $135.00 per month.

(E) Income greater than 250 percent and less than or equal to 275 percent of FPL: $160.00 per month.

(F) Income greater than 275 percent and less than or equal to 300 percent of FPL: $185.00 per month.

Subsection (j) effective April 1, 2010; see also subsection (j) set out above.

(j) The premium contributions for individuals shall be as follows:

(1) Monthly premiums for each individual who is eligible for premium assistance under subsection (b) of this section shall be the same as charged in the Vermont health access plan.

(2) Monthly premiums for each individual who is not eligible for the Vermont health access plan shall be the same as the premiums established in subsections 1984(b) and (c) of this title. (Added 2005, No. 191 (Adj. Sess.), § 13; amended 2007, No. 70, §§ 10-14; No. 71, § 12; 2007, No. 174 (Adj. Sess.), § 24; No. 192 (Adj. Sess.), § 6.016.1; No. 203 (Adj. Sess.), § 9, eff. June 10, 2008; 2009, No. 61, § 20, eff. April 1, 2010.)

State Codes and Statutes

Statutes > Vermont > Title-33 > Chapter-19 > 1974

§ 1974. Employer-sponsored insurance, premium assistance

(a) No later than October 1, 2007, subject to approval by the Centers for Medicare and Medicaid Services, the agency of human services shall establish a premium assistance program to assist individuals eligible for or enrolled in the Vermont health access plan and uninsured individuals with incomes under 300 percent of the federal poverty guidelines and their dependents to purchase an approved employer-sponsored insurance plan if offered to those individuals by an employer. The agency shall determine whether to include children who are eligible for Medicaid or Dr. Dynasaur in the premium assistance program at their parent's option. The agency shall not mandate participation of children in employer-sponsored insurance.

(b) VHAP-eligible premium assistance.

(1) For individuals enrolled in or who apply for enrollment in the Vermont health access plan on or after October 1, 2007 who have access to an approved employer-sponsored insurance plan, the premium assistance program shall provide:

(A) A subsidy of premiums or cost-sharing amounts based on the household income of the eligible individual to ensure that the individual is obligated to make out-of-pocket expenditures for premiums and cost-sharing amounts which are substantially equivalent to or less than the premium and cost-sharing obligations on an annual basis under the Vermont health access plan.

(B) Supplemental benefit coverage equivalent to the benefits offered by the Vermont health access plan.

(2) In consultation with the department of banking, insurance, securities, and health care administration, the agency shall develop criteria for approving employer-sponsored health insurance plans to ensure the plans provide comprehensive and affordable health insurance when combined with the assistance under this section. At minimum, an approved employer-sponsored insurance plan shall conform to the following standards:

(A) The benefits covered by the plan must be substantially similar to the benefits covered under the certificates of coverage offered by the typical benefit plans issued by the four health insurers with the greatest number of covered lives in the small group and association market in this state.

(B) The plan shall include appropriate coverage of chronic conditions in a manner consistent with statewide participation by health insurers in the Vermont blueprint for health, and in accordance with the standards established in section 702 of Title 18.

(3) The agency shall determine whether it is cost-effective to the state to enroll an individual in an approved employer-sponsored insurance plan with the premium assistance under this subsection as compared to enrolling the individual in the Vermont health access plan. If the agency determines that it is cost-effective, the individual shall be required to enroll in the approved employer-sponsored plan as a condition of continued assistance under this section or coverage under the Vermont health access plan, except that dependents who are children of eligible individuals shall not be required to enroll in the premium assistance program. Notwithstanding this requirement, an individual shall be provided benefits under the Vermont health access plan until the next open enrollment period offered by the employer or insurer. The agency shall not consider the medical history, medical conditions, or claims history of any individual for whom cost-effectiveness is being evaluated.

(4) An individual who is or becomes eligible for Medicare shall not be eligible for premium assistance under this subsection.

(5) Decisions regarding plan approval and cost-effectiveness are matters fully within the agency's discretion. On appeal pursuant to section 3091 of Title 3, the human services board may overturn the agency's decision only if it is arbitrary or unreasonable.

(6) Notwithstanding any other provision of law, when an individual is enrolled in Catamount Health solely under the high deductible standard outlined in subdivision 4080f(a)(9) of Title 8, the individual shall not be eligible for premium assistance for the 12-month period following the date of enrollment in Catamount Health.

(c) Uninsured individuals; premium assistance.

(1) For the purposes of this subsection:

(A) "Chronic care" means health services provided by a health care professional for an established clinical condition that is expected to last a year or more and that requires ongoing clinical management attempting to restore the individual to highest function, minimize the negative effects of the condition, and prevent complications related to chronic conditions. Examples of chronic conditions include diabetes, hypertension, cardiovascular disease, cancer, asthma, pulmonary disease, substance abuse, mental illness, spinal cord injury, and hyperlipidemia.

(B) "Uninsured" means an individual who does not qualify for Medicare, Medicaid, the Vermont health access plan, or Dr. Dynasaur and had no private insurance or employer-sponsored coverage that includes both hospital and physician services within 12 months prior to the month of application, or lost private insurance or employer-sponsored coverage during the prior 12 months for the following reasons:

(i) the individual's private insurance or employer-sponsored coverage ended because of:

(I) loss of employment, including a reduction in hours that results in ineligibility for employer-sponsored coverage, unless the employer has terminated its employees or reduced their hours for the primary purpose of discontinuing employer-sponsored coverage and establishing their eligibility for Catamount Health;

(II) death of the principal insurance policyholder;

(III) divorce or dissolution of a civil union;

(IV) no longer receiving coverage as a dependent under the plan of a parent or caretaker relative; or

(V) no longer receiving COBRA, VIPER, or other state continuation coverage.

(ii) College- or university-sponsored health insurance became unavailable to the individual because the individual graduated, took a leave of absence, decreased enrollment below a threshold set for continued coverage, or otherwise terminated studies.

(iii)(I) The individual lost health insurance as a result of domestic violence. The individual shall provide the agency of human services with satisfactory documentation of the domestic violence. The documentation may include a sworn statement from the individual attesting to the abuse, law enforcement or court records, or other documentation from an attorney or legal advisor, member of the clergy, or health care provider, as defined in section 9402 of Title 18. Information relating to the domestic violence, including the individual's statement and corroborating evidence, provided to the agency shall not be disclosed by the agency unless the individual has signed a consent to disclose form. In the event the agency is legally required to release this information without consent of the individual, the agency shall notify the individual at the time the notice or request for release of information is received by the agency and prior to releasing the requested information.

(II) Subdivision (I) of this subdivision (B)(iii) shall take effect upon issuance by the Centers for Medicare and Medicaid Services of approval of an amendment to the waiver set forth in subsection (f) of this section allowing for a domestic violence exception to the premium assistance program waiting period.

(C) "Vermont resident" means an individual domiciled in Vermont as evidenced by an intent to maintain a principal dwelling place in Vermont indefinitely and to return to Vermont if temporarily absent, coupled with an act or acts consistent with that intent.

(2) An individual is eligible for premium assistance under this subsection if the individual:

(A) is an uninsured Vermont resident;

(B) has income less than or equal to 300 percent of the federal poverty level;

(C) has access to an approved employer-sponsored insurance plan; and

(D) is 18 or over and is not claimed on a tax return as a dependent of a resident of another state.

(3) The premium assistance program under this subsection shall provide a subsidy of premiums or cost-sharing amounts based on the household income of the eligible individual, with greater amounts of financial assistance provided to eligible individuals with lower household income and lesser amounts of assistance provided to eligible individuals with higher household income. Until an approved employer-sponsored plan is required to meet the standard in subdivision (4)(B)(ii) of this subsection, the subsidy shall include premium assistance and assistance to cover cost-sharing amounts for chronic care health services covered by the Vermont health access plan that are related to evidence-based guidelines for ongoing prevention and clinical management of the chronic condition specified in the blueprint for health in section 702 of Title 18. Notwithstanding any other provision of law, when an individual is enrolled in Catamount Health solely under the high deductible standard outlined in subdivision 4080f(a)(9) of Title 8, the individual shall not be eligible for premium assistance for the 12-month period following the date of enrollment in Catamount Health.

(4) In consultation with the department of banking, insurance, securities, and health care administration, the agency shall develop criteria for approving employer-sponsored health insurance plans to ensure the plans provide comprehensive and affordable health insurance when combined with the assistance under this section. At minimum, an approved employer-sponsored insurance plan shall include:

(A) covered benefits to be substantially similar, as determined by the agency, to the benefits covered under Catamount Health; and

(B)(i) until January 1, 2009 or when statewide participation in the Vermont blueprint for health is achieved, appropriate coverage of chronic conditions in a manner consistent with statewide participation by health insurers in the Vermont blueprint for health, and in accordance with the standards established in section 702 of Title 18;

(ii) after statewide participation is achieved, coverage of chronic conditions substantially similar to Catamount Health.

(5) The agency shall determine whether it is cost-effective to the state to require the individual to purchase the approved employer-sponsored insurance plan with premium assistance under this subsection instead of Catamount Health established in section 4080f of Title 8 with assistance under subchapter 3a of chapter 19 of this title. If providing the individual with assistance to purchase Catamount Health is more cost-effective to the state than providing the individual with premium assistance to purchase the individual's approved employer-sponsored plan, the state shall provide the individual the option of purchasing Catamount Health with assistance for that product. An individual may purchase Catamount Health and receive Catamount Health assistance until the approved employer-sponsored plan has an open enrollment period, but the individual shall be required to enroll in the approved employer-sponsored plan in order to continue to receive any assistance. The agency shall not consider the medical history, medical conditions, or claims history of any individual for whom cost-effectiveness is being evaluated.

(6) Decisions regarding plan approval and cost-effectiveness are matters fully within the agency's discretion. On appeal pursuant to section 3091 of Title 3, the human services board may overturn the agency's decision only if it is arbitrary or unreasonable.

(d)(1) Participation in an approved employer-sponsored insurance plan with premium assistance under this section or Catamount Health shall not disqualify an individual from the Vermont health access plan if an approved employer-sponsored insurance plan or Catamount Health is no longer available to that individual.

(2) An individual who has been enrolled in Medicaid, VHAP, Dr. Dynasaur, or any other health benefit plan authorized under Title XIX or Title XX of the Social Security Act shall not be subject to a 12-month waiting period before becoming eligible for premium assistance to purchase an approved employer-sponsored insurance plan.

(3) Enrollment in Catamount Health, with or without premium assistance, shall not disqualify an individual for premium assistance in connection with an approved employer-sponsored insurance plan.

(e) If the emergency board determines that the funds appropriated for either of the premium assistance programs under this section are insufficient to meet the projected costs of enrolling new program participants into the appropriate program, the emergency board shall suspend new enrollment in that program or restrict enrollment to eligible lower income individuals. This subsection does not affect eligibility for the Vermont health access plan or purchase of Catamount Health.

(f) The agency of human services shall request federal approval for an amendment to the Global Commitment for Health Medicaid Section 1115 waiver for the premium assistance program authorized by this section.

(g)(1) Of the amount appropriated in No. 215 of the Act of the 2005 Adj. Sess. (2006) for the employer-sponsored insurance premium assistance program established by this section, no more than $250,000.00 may be expended for start-up and initial administrative expenses until the report as required by subdivision (2) of this subsection has been received and approved.

(2) No additional amounts appropriated in No. 215 of the Act of the 2005 Adj. Sess. (2006) for the employer-sponsored premium assistance program may be made after November 15, 2006 without approval of a majority of the combined membership of the joint fiscal committee and the health access oversight committee at a joint meeting upon receipt of a report from the agency, which must include the following:

(A) a plan for the additional expenditures;

(B) a survey to determine whether and how many individuals currently enrolled in VHAP, including those eligible as caretakers, are potentially eligible for employer-sponsored premium assistance under this section;

(C) the sliding-scale premium and cost-sharing assistance amounts provided under the premium assistance program to individuals;

(D) a description and estimate of benefits offered by the Vermont health access plan that are likely to be provided as supplemental benefits for the employer-sponsored premium assistance program enrollees;

(E) a plan for covering dependent children through the premium assistance program; and

(F) the anticipated budgetary impact of an employer-sponsored insurance premium assistance program for fiscal year 2008, including savings attributable to enrolling current VHAP enrollees in the premium assistance program established under this section, the start-up and administrative costs of the program, and the cost of providing the subsidy to these enrollees.

(h) The agency shall report monthly to the joint fiscal committee, the health access oversight committee, and the commission on health care reform with the number of individuals enrolled in the premium assistance program, the income levels of the individuals, a description of the range and types of employer-sponsored plans that have been approved, the percentage of premium and cost-sharing amounts paid by employers whose employees participate in the premium assistance program, and the net savings or cost of the program.

(i) The health access oversight committee shall monitor the development, implementation, and ongoing operation of the employer-sponsored premium assistance program under this section.

Subsection (j) effective until April 1, 2010; see also subsection (j) set out below.

(j) The premium contributions for individuals shall be as follows:

(1) Monthly premiums for each individual who is eligible for the Vermont health access plan shall be the same as charged in the health access plan.

(2) Monthly premiums for each individual who is not eligible for the Vermont health access plan shall be:

(A) Income less than or equal to 175 percent of FPL: $60.00 per month.

(B) Income greater than 175 percent and less than or equal to 200 percent of FPL: $65.00 per month.

(C) Income greater than 200 percent and less than or equal to 225 percent of FPL: $110.00 per month.

(D) Income greater than 225 percent and less than or equal to 250 percent of FPL: $135.00 per month.

(E) Income greater than 250 percent and less than or equal to 275 percent of FPL: $160.00 per month.

(F) Income greater than 275 percent and less than or equal to 300 percent of FPL: $185.00 per month.

Subsection (j) effective April 1, 2010; see also subsection (j) set out above.

(j) The premium contributions for individuals shall be as follows:

(1) Monthly premiums for each individual who is eligible for premium assistance under subsection (b) of this section shall be the same as charged in the Vermont health access plan.

(2) Monthly premiums for each individual who is not eligible for the Vermont health access plan shall be the same as the premiums established in subsections 1984(b) and (c) of this title. (Added 2005, No. 191 (Adj. Sess.), § 13; amended 2007, No. 70, §§ 10-14; No. 71, § 12; 2007, No. 174 (Adj. Sess.), § 24; No. 192 (Adj. Sess.), § 6.016.1; No. 203 (Adj. Sess.), § 9, eff. June 10, 2008; 2009, No. 61, § 20, eff. April 1, 2010.)


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State Codes and Statutes

Statutes > Vermont > Title-33 > Chapter-19 > 1974

§ 1974. Employer-sponsored insurance, premium assistance

(a) No later than October 1, 2007, subject to approval by the Centers for Medicare and Medicaid Services, the agency of human services shall establish a premium assistance program to assist individuals eligible for or enrolled in the Vermont health access plan and uninsured individuals with incomes under 300 percent of the federal poverty guidelines and their dependents to purchase an approved employer-sponsored insurance plan if offered to those individuals by an employer. The agency shall determine whether to include children who are eligible for Medicaid or Dr. Dynasaur in the premium assistance program at their parent's option. The agency shall not mandate participation of children in employer-sponsored insurance.

(b) VHAP-eligible premium assistance.

(1) For individuals enrolled in or who apply for enrollment in the Vermont health access plan on or after October 1, 2007 who have access to an approved employer-sponsored insurance plan, the premium assistance program shall provide:

(A) A subsidy of premiums or cost-sharing amounts based on the household income of the eligible individual to ensure that the individual is obligated to make out-of-pocket expenditures for premiums and cost-sharing amounts which are substantially equivalent to or less than the premium and cost-sharing obligations on an annual basis under the Vermont health access plan.

(B) Supplemental benefit coverage equivalent to the benefits offered by the Vermont health access plan.

(2) In consultation with the department of banking, insurance, securities, and health care administration, the agency shall develop criteria for approving employer-sponsored health insurance plans to ensure the plans provide comprehensive and affordable health insurance when combined with the assistance under this section. At minimum, an approved employer-sponsored insurance plan shall conform to the following standards:

(A) The benefits covered by the plan must be substantially similar to the benefits covered under the certificates of coverage offered by the typical benefit plans issued by the four health insurers with the greatest number of covered lives in the small group and association market in this state.

(B) The plan shall include appropriate coverage of chronic conditions in a manner consistent with statewide participation by health insurers in the Vermont blueprint for health, and in accordance with the standards established in section 702 of Title 18.

(3) The agency shall determine whether it is cost-effective to the state to enroll an individual in an approved employer-sponsored insurance plan with the premium assistance under this subsection as compared to enrolling the individual in the Vermont health access plan. If the agency determines that it is cost-effective, the individual shall be required to enroll in the approved employer-sponsored plan as a condition of continued assistance under this section or coverage under the Vermont health access plan, except that dependents who are children of eligible individuals shall not be required to enroll in the premium assistance program. Notwithstanding this requirement, an individual shall be provided benefits under the Vermont health access plan until the next open enrollment period offered by the employer or insurer. The agency shall not consider the medical history, medical conditions, or claims history of any individual for whom cost-effectiveness is being evaluated.

(4) An individual who is or becomes eligible for Medicare shall not be eligible for premium assistance under this subsection.

(5) Decisions regarding plan approval and cost-effectiveness are matters fully within the agency's discretion. On appeal pursuant to section 3091 of Title 3, the human services board may overturn the agency's decision only if it is arbitrary or unreasonable.

(6) Notwithstanding any other provision of law, when an individual is enrolled in Catamount Health solely under the high deductible standard outlined in subdivision 4080f(a)(9) of Title 8, the individual shall not be eligible for premium assistance for the 12-month period following the date of enrollment in Catamount Health.

(c) Uninsured individuals; premium assistance.

(1) For the purposes of this subsection:

(A) "Chronic care" means health services provided by a health care professional for an established clinical condition that is expected to last a year or more and that requires ongoing clinical management attempting to restore the individual to highest function, minimize the negative effects of the condition, and prevent complications related to chronic conditions. Examples of chronic conditions include diabetes, hypertension, cardiovascular disease, cancer, asthma, pulmonary disease, substance abuse, mental illness, spinal cord injury, and hyperlipidemia.

(B) "Uninsured" means an individual who does not qualify for Medicare, Medicaid, the Vermont health access plan, or Dr. Dynasaur and had no private insurance or employer-sponsored coverage that includes both hospital and physician services within 12 months prior to the month of application, or lost private insurance or employer-sponsored coverage during the prior 12 months for the following reasons:

(i) the individual's private insurance or employer-sponsored coverage ended because of:

(I) loss of employment, including a reduction in hours that results in ineligibility for employer-sponsored coverage, unless the employer has terminated its employees or reduced their hours for the primary purpose of discontinuing employer-sponsored coverage and establishing their eligibility for Catamount Health;

(II) death of the principal insurance policyholder;

(III) divorce or dissolution of a civil union;

(IV) no longer receiving coverage as a dependent under the plan of a parent or caretaker relative; or

(V) no longer receiving COBRA, VIPER, or other state continuation coverage.

(ii) College- or university-sponsored health insurance became unavailable to the individual because the individual graduated, took a leave of absence, decreased enrollment below a threshold set for continued coverage, or otherwise terminated studies.

(iii)(I) The individual lost health insurance as a result of domestic violence. The individual shall provide the agency of human services with satisfactory documentation of the domestic violence. The documentation may include a sworn statement from the individual attesting to the abuse, law enforcement or court records, or other documentation from an attorney or legal advisor, member of the clergy, or health care provider, as defined in section 9402 of Title 18. Information relating to the domestic violence, including the individual's statement and corroborating evidence, provided to the agency shall not be disclosed by the agency unless the individual has signed a consent to disclose form. In the event the agency is legally required to release this information without consent of the individual, the agency shall notify the individual at the time the notice or request for release of information is received by the agency and prior to releasing the requested information.

(II) Subdivision (I) of this subdivision (B)(iii) shall take effect upon issuance by the Centers for Medicare and Medicaid Services of approval of an amendment to the waiver set forth in subsection (f) of this section allowing for a domestic violence exception to the premium assistance program waiting period.

(C) "Vermont resident" means an individual domiciled in Vermont as evidenced by an intent to maintain a principal dwelling place in Vermont indefinitely and to return to Vermont if temporarily absent, coupled with an act or acts consistent with that intent.

(2) An individual is eligible for premium assistance under this subsection if the individual:

(A) is an uninsured Vermont resident;

(B) has income less than or equal to 300 percent of the federal poverty level;

(C) has access to an approved employer-sponsored insurance plan; and

(D) is 18 or over and is not claimed on a tax return as a dependent of a resident of another state.

(3) The premium assistance program under this subsection shall provide a subsidy of premiums or cost-sharing amounts based on the household income of the eligible individual, with greater amounts of financial assistance provided to eligible individuals with lower household income and lesser amounts of assistance provided to eligible individuals with higher household income. Until an approved employer-sponsored plan is required to meet the standard in subdivision (4)(B)(ii) of this subsection, the subsidy shall include premium assistance and assistance to cover cost-sharing amounts for chronic care health services covered by the Vermont health access plan that are related to evidence-based guidelines for ongoing prevention and clinical management of the chronic condition specified in the blueprint for health in section 702 of Title 18. Notwithstanding any other provision of law, when an individual is enrolled in Catamount Health solely under the high deductible standard outlined in subdivision 4080f(a)(9) of Title 8, the individual shall not be eligible for premium assistance for the 12-month period following the date of enrollment in Catamount Health.

(4) In consultation with the department of banking, insurance, securities, and health care administration, the agency shall develop criteria for approving employer-sponsored health insurance plans to ensure the plans provide comprehensive and affordable health insurance when combined with the assistance under this section. At minimum, an approved employer-sponsored insurance plan shall include:

(A) covered benefits to be substantially similar, as determined by the agency, to the benefits covered under Catamount Health; and

(B)(i) until January 1, 2009 or when statewide participation in the Vermont blueprint for health is achieved, appropriate coverage of chronic conditions in a manner consistent with statewide participation by health insurers in the Vermont blueprint for health, and in accordance with the standards established in section 702 of Title 18;

(ii) after statewide participation is achieved, coverage of chronic conditions substantially similar to Catamount Health.

(5) The agency shall determine whether it is cost-effective to the state to require the individual to purchase the approved employer-sponsored insurance plan with premium assistance under this subsection instead of Catamount Health established in section 4080f of Title 8 with assistance under subchapter 3a of chapter 19 of this title. If providing the individual with assistance to purchase Catamount Health is more cost-effective to the state than providing the individual with premium assistance to purchase the individual's approved employer-sponsored plan, the state shall provide the individual the option of purchasing Catamount Health with assistance for that product. An individual may purchase Catamount Health and receive Catamount Health assistance until the approved employer-sponsored plan has an open enrollment period, but the individual shall be required to enroll in the approved employer-sponsored plan in order to continue to receive any assistance. The agency shall not consider the medical history, medical conditions, or claims history of any individual for whom cost-effectiveness is being evaluated.

(6) Decisions regarding plan approval and cost-effectiveness are matters fully within the agency's discretion. On appeal pursuant to section 3091 of Title 3, the human services board may overturn the agency's decision only if it is arbitrary or unreasonable.

(d)(1) Participation in an approved employer-sponsored insurance plan with premium assistance under this section or Catamount Health shall not disqualify an individual from the Vermont health access plan if an approved employer-sponsored insurance plan or Catamount Health is no longer available to that individual.

(2) An individual who has been enrolled in Medicaid, VHAP, Dr. Dynasaur, or any other health benefit plan authorized under Title XIX or Title XX of the Social Security Act shall not be subject to a 12-month waiting period before becoming eligible for premium assistance to purchase an approved employer-sponsored insurance plan.

(3) Enrollment in Catamount Health, with or without premium assistance, shall not disqualify an individual for premium assistance in connection with an approved employer-sponsored insurance plan.

(e) If the emergency board determines that the funds appropriated for either of the premium assistance programs under this section are insufficient to meet the projected costs of enrolling new program participants into the appropriate program, the emergency board shall suspend new enrollment in that program or restrict enrollment to eligible lower income individuals. This subsection does not affect eligibility for the Vermont health access plan or purchase of Catamount Health.

(f) The agency of human services shall request federal approval for an amendment to the Global Commitment for Health Medicaid Section 1115 waiver for the premium assistance program authorized by this section.

(g)(1) Of the amount appropriated in No. 215 of the Act of the 2005 Adj. Sess. (2006) for the employer-sponsored insurance premium assistance program established by this section, no more than $250,000.00 may be expended for start-up and initial administrative expenses until the report as required by subdivision (2) of this subsection has been received and approved.

(2) No additional amounts appropriated in No. 215 of the Act of the 2005 Adj. Sess. (2006) for the employer-sponsored premium assistance program may be made after November 15, 2006 without approval of a majority of the combined membership of the joint fiscal committee and the health access oversight committee at a joint meeting upon receipt of a report from the agency, which must include the following:

(A) a plan for the additional expenditures;

(B) a survey to determine whether and how many individuals currently enrolled in VHAP, including those eligible as caretakers, are potentially eligible for employer-sponsored premium assistance under this section;

(C) the sliding-scale premium and cost-sharing assistance amounts provided under the premium assistance program to individuals;

(D) a description and estimate of benefits offered by the Vermont health access plan that are likely to be provided as supplemental benefits for the employer-sponsored premium assistance program enrollees;

(E) a plan for covering dependent children through the premium assistance program; and

(F) the anticipated budgetary impact of an employer-sponsored insurance premium assistance program for fiscal year 2008, including savings attributable to enrolling current VHAP enrollees in the premium assistance program established under this section, the start-up and administrative costs of the program, and the cost of providing the subsidy to these enrollees.

(h) The agency shall report monthly to the joint fiscal committee, the health access oversight committee, and the commission on health care reform with the number of individuals enrolled in the premium assistance program, the income levels of the individuals, a description of the range and types of employer-sponsored plans that have been approved, the percentage of premium and cost-sharing amounts paid by employers whose employees participate in the premium assistance program, and the net savings or cost of the program.

(i) The health access oversight committee shall monitor the development, implementation, and ongoing operation of the employer-sponsored premium assistance program under this section.

Subsection (j) effective until April 1, 2010; see also subsection (j) set out below.

(j) The premium contributions for individuals shall be as follows:

(1) Monthly premiums for each individual who is eligible for the Vermont health access plan shall be the same as charged in the health access plan.

(2) Monthly premiums for each individual who is not eligible for the Vermont health access plan shall be:

(A) Income less than or equal to 175 percent of FPL: $60.00 per month.

(B) Income greater than 175 percent and less than or equal to 200 percent of FPL: $65.00 per month.

(C) Income greater than 200 percent and less than or equal to 225 percent of FPL: $110.00 per month.

(D) Income greater than 225 percent and less than or equal to 250 percent of FPL: $135.00 per month.

(E) Income greater than 250 percent and less than or equal to 275 percent of FPL: $160.00 per month.

(F) Income greater than 275 percent and less than or equal to 300 percent of FPL: $185.00 per month.

Subsection (j) effective April 1, 2010; see also subsection (j) set out above.

(j) The premium contributions for individuals shall be as follows:

(1) Monthly premiums for each individual who is eligible for premium assistance under subsection (b) of this section shall be the same as charged in the Vermont health access plan.

(2) Monthly premiums for each individual who is not eligible for the Vermont health access plan shall be the same as the premiums established in subsections 1984(b) and (c) of this title. (Added 2005, No. 191 (Adj. Sess.), § 13; amended 2007, No. 70, §§ 10-14; No. 71, § 12; 2007, No. 174 (Adj. Sess.), § 24; No. 192 (Adj. Sess.), § 6.016.1; No. 203 (Adj. Sess.), § 9, eff. June 10, 2008; 2009, No. 61, § 20, eff. April 1, 2010.)


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