Current through February, 2024
Section 1 Purpose
The purpose of this Rule is to set forth the requirements for
Catamount Health insurance, as provided in
8 V.S.A. §
4080f
and An Act Relating to Health Care Affordability for Vermonters, 2005 Vt. Acts
& Resolves No. 191 (Adj. Sess. 2006). Catamount Health insurance shall be
sold and administered in accordance with the Act and the policies and purposes
of Title 8.
Section 2
Authority
This Rule is issued pursuant to the authority vested in the
Commissioner of the Department of Banking, Insurance, Securities and Health
Care Administration by the Act, including, but not limited to,
8 V.S.A. §
4080f,
and by other applicable portions of Title 8, including, but not limited to,
8 V.S.A. §
4062.
Section 3 Definitions
As used in this Rule:
(a) "Act" means An Act Relating to Health
Care Affordability for Vermonters, 2005 Vt. Acts & Resolves No. 191 (Adj.
Sess. 2006).
(b) "Catamount Health
insurance" means those health insurance products and plans approved by the
Commissioner and established under
8 V.S.A. §
4080f,
Act 191, Adj. Session (2006) and this Rule.
(c) "Catamount Health carrier" or "carrier"
means a carrier that sells, offers, issues or renews Catamount
Health insurance as defined by § 4080f and this Rule. A
carrier shall not sell Catamount Health unless the carrier is a registered
small group carrier under
8 V.S.A. §
4080a.
(d) "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, but are not limited
to, diabetes, hypertension, cardiovascular disease, cancer, asthma, pulmonary
disease, substance abuse, mental illness, spinal cord injury, and
hyperlipidemia.
(e) "Chronic care
management" means a system of coordinated health care interventions and
communications for individuals with chronic conditions, including significant
patient self-care efforts, systemic supports for the physician and patient
relationship, and a plan of care emphasizing prevention of complications,
utilizing evidence-based practice guidelines, patient empowerment strategies,
and evaluation of clinical, humanistic, and economic outcomes on an ongoing
basis with the goal of improving overall health.
(f) "Commissioner" means the Commissioner of
the Vermont Department of Banking, Insurance, Securities and Health Care
Administration.
(g) "Community
rating" means a rating process that produces average rates for those
individuals insured by Catamount Health insurance for a given policy period.
Community rating as used in this Rule may allow for premium deviations among
individuals based on incentives pursuant to rules adopted by the Commissioner
under
8 V.S.A. §§
4080a(h)(2)(B) and
4080b(h)(2)(B)
relating to health promotion and disease prevention.
(h) "Credibility" means a measure of the
degree of statistical significance that can be assigned to the claims
experience of a Catamount Health plan when it is used as a basis for projecting
a future rate.
(i) "Creditable
coverage" includes coverage defined under applicable federal law as creditable
including: a group health plan, such as one obtained through an employer or
spouse's employer; health insurance coverage, including individual coverage;
Medicare and Medicaid, CHAMPUS/TriCare; a medical program of the Indian Health
Service Act or of a tribal organization; a state health benefits high risk
pool; the Federal Employees Health Benefits Program; a public health plan; and
a health benefit plan under section
5(e) of
the Peace Corps Act. Subject to federal law, the definition of creditable
coverage includes any hospital or medical service policy or certificate,
hospital or medical service plan contract, or HMO contract offered by a health
insurance issuer, which includes, but is not limited to, comprehensive
nongroup, small group and large group policies.
(j) "Health care professional" means an
individual, partnership, corporation, facility (including a hospital) or
institution licensed or certified or authorized by law to provide professional
health care services.
(k) "Health
insurance trend factor" means a projection factor that is an estimate of the
unit cost increases and utilization increases that are expected to be incurred
in a health benefits plan. The estimate of unit cost increases and utilization
increases may include consideration of erosion of deductibles, medical
technology, general inflation and cost shifting.
(l) "Network" means the network defined by
the carrier in its Catamount Health policy. Catamount Health networks shall be
created and managed consistent with the purposes of the Act and other
applicable law.
(m) "Preventive
care" means health services provided by health care professionals to identify
and treat asymptomatic individuals who have developed risk factors or
preclinical disease, but in whom the disease is not clinically apparent,
including immunizations and screening, counseling, treatment, and medication
determined by scientific evidence to be effective in preventing or detecting a
condition.
(n) "Primary care" means
health services provided by health care professionals specifically trained for
and skilled in first-contact and continuing care for individuals with signs,
symptoms, or health concerns, not limited by problem origin, organ system, or
diagnosis, and shall include prenatal care and the treatment of mental
illness.
(o) "Uninsured" means an
individual who does not qualify for Medicare, Medicaid, the Vermont health
access plan, or Dr. Dynasaur and had no creditable private insurance or
employer-sponsored coverage that includes both hospital and physician services
within 12 months prior to the month of application, or lost creditable private
health 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:
(A) loss of employment;
(B) death of the principal insurance
policyholder;
(C) divorce or
dissolution of a civil union;
(D)
no longer qualifying as a dependent under the plan of a parent or caretaker
relative;
(E) no longer qualifying
for COBRA, VIPER, or other state continuation coverage; or
(ii) college- or university-sponsored health
insurance became unavailable to the individual because the individual
graduated, took a leave of absence, or otherwise terminated studies.
(iii) "Uninsured individual" shall not
include an individual who would be entitled to Catamount Health coverage
without being uninsured for 12 months under
8 V.S.A. §
4080f(a)(9)(A) if the
carrier determines, and the Commissioner gives prior approval to such
determination, that such status was created primarily to obtain access to
Catamount Health in a manner that is contrary to the intent of the Act. The
Commissioner shall consult with appropriate legislative committees within 30
days following any such determinations.
(iv) In order to be considered an "uninsured
individual", a person shall be a Vermont resident and shall not be claimed as a
dependent on a tax return by a person who is not a Vermont resident.
Section 4 Notice of
Intent to Sell
A carrier intending to sell Catamount Health insurance shall
submit a notice of intent to sell to the Commissioner no later than 30 days
from the effective day of this Rule. Such letter shall identify the carrier and
the anticipated dates the carrier intends to file for approval of Catamount
Health rates and forms.
Section
5 Form Filings
(a) Carriers shall
file all Catamount Health forms for approval by the Commissioner prior to
use.
(b) Forms, as used in this
Rule, shall include the following:
(i) all
product forms, including but not limited to, policy forms, member handbooks,
certificates, endorsements, riders, and applications;
(ii) materials intended to be publicly
disseminated regarding chronic care management programs; and
(iii) materials intended to be publicly
disseminated regarding wellness discount programs.
(c) No form shall be approved if it contains
any provision which is unjust, unfair, inequitable, misleading, contrary to the
law of this state or otherwise fails to comply with the requirements of the Act
or
8 V.S.A. §
4080f.
(d) The carrier shall file for approval with
the Commissioner the following documents prior to or contemporaneously with the
filing of other forms under Section
5. The
Commissioner shall approve such filings if in compliance with the goals of the
Act and subject to such terms and conditions as he or she may prescribe.
(i) A chronic care management plan pursuant
to Section 7 of this Rule.
(ii) A
health care professional payment plan pursuant to Section 8 of this Rule.
(A) Health care professional payment plans
shall be filed for approval when a Catamount Health carrier seeks to modify the
methodology employed by the carrier to pay participating health care
professionals. If amounts of the payment are the only modifications to the
payment plan, no new filing is required.
(iii) A plan for determining eligibility
pursuant to Section 10 of this Rule.
(iv) A cost containment plan consistent with
the purposes of the Act.
(e) The Commissioner shall notify the carrier
within 45 days from receipt of the filing whether the submission is approved or
denied.
(f) Except as expressly
provided to the contrary by this Rule, form filings shall be subject to the
same rules and procedures applicable to other health insurance product
filings.
Section 6
Benefit Design
(a) Catamount Health benefit
design, as reflected in a carrier's form filings, shall be approved by the
Commissioner in accordance with the standards and procedures in
8 V.S.A. §
4080f,
and other applicable law including
8 V.S.A. §
4062.
(b) All Catamount Health insurance plans
shall include coverage for primary care, preventive care, chronic care, acute
episodic care and hospital services. Such coverage shall be provided consistent
with the purposes of the Act.
(c)
The following out of pocket costs shall apply to Catamount Health policies.
Catamount Health policies shall have:
(i) an
annual deductible of $ 250.00 for an individual and a $ 500.00 deductible for a
family for health services received in network, and a $ 500.00 deductible for
an individual and a $ 1,000.00 deductible for a family for health services
received out of network;
(A) A family
deductible shall be satisfied when one insured, or a combination of insureds,
satisfies the annual family deductible during the policy period.
(ii) 20% co-insurance for covered
services received, other than office visits with a co-payment or prescription
drugs, regardless of whether services are provided within or outside the
carrier's network;
(iii) a $ 10.00
office co-payment per individual, per visit;
(iv) prescription drug coverage with no
deductible, however carriers may impose up to a $ 10.00 co-payment for generic
drugs, $ 30.00 co-payment for drugs on the carrier's preferred drug list, and a
$ 50.00 co-payment for nonpreferred drugs;
(A) Prescription drug payments shall not
count toward out of pocket maximums.
(v) annual out of pocket maximums shall be $
800.00 for an individual, $ 1,600.00 for a family for in-network services and $
1,500.00 for an individual and $ 3,000.00 for a family for out-of-network
services.
(A) A family out pocket maximum
shall be satisfied when one insured, or a combination of insureds, satisfies
the annual family out of pocket maximum during the policy period.
(d) Carriers shall waive
deductibles and other cost-sharing payments for chronic care if the individual
is actively participating in a chronic care management program.
(e) Carriers shall waive deductibles and
other cost-sharing payments for preventive care, provided such services are
obtained in network. However, if preventive care services are not available in
network, the carrier shall waive deductibles and other cost-sharing payments
for preventive care services obtained outside of network.
(f) Preexisting Condition Limitation
(i) A Catamount Health carrier may limit
coverage of a preexisting condition which existed during the 12-month period
before the effective date of coverage, except that such exclusion or limitation
shall not apply to chronic care provided such individual is participating in a
chronic care management program.
(A)
Participation in a chronic care management program shall mean that the
individual has enrolled or has indicated a willingness to become enrolled in a
chronic care management program and is in substantial compliance with the
requirements of the program.
(1) For the
purposes of this subsection, if an individual has indicated a willingness to
become enrolled in a chronic care management program, a carrier may place
reasonable time limits for the insured to become enrolled in the program. If
the insured fails to meet these time limits, the carrier shall not be required
to waive the preexisting condition limitation. In no event shall the carrier
require the individual become enrolled in the chronic care management program
in less than 15 business days.
(B) A Catamount Health carrier shall offer a
chronic care management program to an insured if such a program is generally
available to the carrier's other insureds (whether through Catamount Health or
otherwise) with the same chronic condition.
(C) Consistent with other applicable state
and federal laws, qualifying participation in a chronic care management program
shall not be premised on an individual achieving a specified health status, but
it may be premised on specific participation obligations. If an individual's
health reasonably prevents specified participation, a carrier shall make
reasonable alternative accommodations or credit the insured with participation
in the chronic care management program.
(ii) A carrier shall waive any preexisting
condition provisions for all individuals and their covered dependents who
produce evidence of continuous creditable coverage during the previous nine
months. The carrier shall credit coverage that occurred without a break in
coverage of 63 days or more.
(iii)
For an "eligible individual", as that term is defined by Section 2741 of Title
XXVII of the Public Health Service Act, as amended if amended, a carrier
offering Catamount Health shall not limit coverage of a preexisting
condition.
Section
7 Chronic Care Management
(a)
Catamount Health carriers shall provide insureds access to chronic care
management programs. Such programs shall be subject to approval by the
Commissioner. Chronic care management programs shall be consistent with the
purposes of the Act, including the use of criteria substantially similar to the
chronic care management program established under
18 V.S.A. §
702 and 33 V.S.A. § 1903a, as
amended.
(b) As directed by the
Commissioner, Catamount Health carriers shall share data about their chronic
care management programs, to the extent allowable by federal and state law,
with the Vermont Secretary of Administration or designee in order to support
health care reform initiatives under
3 V.S.A. §
2222a
and related legislation.
Section
8 Health Care Professional Relationships
(a) Consistent with
8 V.S.A. §
4080f,
benefits shall be delivered through a preferred provider organization ("PPO")
plan. Catamount Health carriers shall define their PPO within the parameters of
commonly accepted industry practices, but such definition shall be consistent
with the purposes of the Act.
(b)
Subject to subsection (i) below, Catamount Health products may not limit the
type of licensed health care professional offering a covered benefit, so long
as that health care professional is operating within the scope of his or her
practice authorized by law.
(i) Catamount
Health products may impose a greater financial burden on an individual's access
to treatment by the type of health care professional only if it is related to
the efficacy or cost effectiveness of the services, subject to the approval of
the Commissioner. As appropriate, the Commissioner may consult with the Vermont
Department of Health to establish whether limits are appropriately premised on
the efficacy and cost effectiveness of the services.
(ii) Catamount Health carriers may impose
credentialing criteria, consistent with the Act, on all participating health
care professionals to ensure that minimum quality standards are met.
(c) Health care professional
payments for care shall be made consistent with the Act. The carriers shall
file a health care professional payment plan consistent with the provisions of
this section, and subject to approval of the Commissioner under Section
5.
(i) Catamount Health carriers shall negotiate
payment agreements with health care professionals that are consistent with the
Act.
(ii) If Catamount Health
carriers and health care professionals cannot agree on a payment agreement, the
Commissioner shall prescribe the provisions of the agreement in
dispute.
(iii) Nothing in this
subsection shall be construed to mean that carriers or the Department may
mandate health care professionals participate in Catamount Health.
(d) If Medicare does not pay for a
service covered by a Catamount Health carrier, the carrier and health care
professional shall negotiate a payment rate, subject to the approval or order
of the Commissioner at his or her discretion.
(e) Health care professional payment shall be
consistent with chronic care management principles, including, but not limited
to, those developed under
18 V.S.A. §
702 and 33 V.S.A. § 1903a.
(f) A health care professional participating
in a carrier's Catamount Health network that treats a Catamount Health insured
shall not balance bill the insured.
(i)
"Balance bill" as used above means to charge to or collect from a Catamount
Health insured any amount in excess of the charge agreed to for services
provided to Catamount Health insureds by the Catamount Health carrier and the
health care professional providing the service.
Section 9 Wellness Programs
A Catamount Health carrier may use financial or other
incentives to encourage healthy lifestyles and patient self-management, in
accordance with programs of health promotion and disease prevention established
under rules adopted by the Commissioner pursuant to
8 V.S.A. §§
4080a(h)(2)(B) and
4080b(h)(2)(B).
Section 10 Eligibility Determination
(a) Catamount Health insurance shall be
offered, issued and renewed to all eligible individuals as defined by
applicable law, including the Act and
8 V.S.A. §
4080f.
After consultation with the Agency of Human Services with respect to an
eligibility screening mechanism, carriers shall file a plan for determining
eligibility consistent with the provisions of the this section, and subject to
approval of the Commissioner under Section
5. Catamount
Health carriers shall process Catamount Health applications within 30 business
days from the date the application is completed.
(i) A carrier shall guarantee acceptance of
any uninsured individual for any Catamount Health plan offered by the carrier.
A carrier shall guarantee acceptance of each dependent of an uninsured
individual in Catamount Health.
(A) A carrier
shall not provide Catamount Health coverage for an individual of the age of
majority who is claimed on a tax return as a dependent of a resident of another
state.
(ii) Subject to
subdivision (A) below, a carrier shall not sell Catamount Health to an
individual who has access to employer-sponsored insurance through his or her
employer.
(A) A carrier shall guarantee
acceptance to an uninsured individual who has access to employer-sponsored
insurance if the individual has an income under 300% of the federal poverty
level and:
(1) the individual's
employer-sponsored health insurance plan is not an approved plan under
33 V.S.A. §
1974;
(2) pursuant to
33 V.S.A. §
1974, the Agency of Human Services has
determined that enrolling the individual in Catamount Health with premium
assistance is more cost effective for the State of Vermont than enrolling the
individual in employer-sponsored insurance; or
(3) the individual is eligible for
employer-sponsored insurance premium assistance under
33 V.S.A. §
1974, but is unable to enroll in the
employer's insurance plan until the next enrollment period.
(iii) An individual who
loses eligibility for the employer-sponsored premium assistance under
33 V.S.A. §
1974 shall be allowed to purchase Catamount
Health without being uninsured for 12 months.
(iv) For the purposes of this subsection,
Catamount Health carriers shall accept proof of agency determinations when made
under Title 33 relevant to eligibility as prescribed by the agency responsible
for making such decisions.
(v)
Catamount Health carriers and their producers shall inform each potentially
eligible individual inquiring about purchasing health insurance in the nongroup
market about the availability of Catamount Health and the existence of premium
assistance programs.
(b)
Catamount Health carriers shall follow those procedures in
8 V.S.A.
§
4089h (including any subsequent
amendments) for nonpayment of premium. However, to the extent an insured is
receiving premium assistance for Catamount Health through a state or federal
agency, the carrier shall follow any guidance, bulletins or rules provided by
the agency providing premium assistance, to the extent any such guidance,
bulletins or rules exist. As directed by the Commissioner, carriers shall give
notice of nonpayment of premium and premium increases to the appropriate
governmental agency.
(c) To the
extent an individual is receiving or applying for Catamount Health premium
assistance, carriers shall comply with, as determined by the Commissioner, any
guidance, bulletins or rules issued by the governmental entity responsible for,
or providing, premium assistance. In addition, Catamount Health carriers shall
provide, to the extent allowed by law and as determined by the Commissioner,
any information needed by the governmental entity to administer such premium
assistance programs.
(d)
Individuals who believe they are eligible for Catamount Health, but have been
denied coverage, may file a complaint with the Department of Banking,
Insurance, Securities and Health Care Administration. The carrier shall notify
the applicant at the time of the denial of his or her rights to file a written
complaint with the Department. The carrier's appeal notice shall be on a form
acceptable to the Commissioner. The Department shall provide written notice of
the complaint to the carrier. If an informal resolution between the Department
and the carrier cannot be reached within five business days of notice to the
carrier, the carrier shall have ten days from the date the notice of the
complaint was sent to file a written response. The Commissioner shall rule on
the eligibility issue after receipt of the carrier's response, provided a
response is timely filed. If the Commissioner rules the individual and
dependents are eligible for coverage, such coverage shall become effective
retroactive to the date the carrier received the completed application. The
carrier or the applicant may appeal an adverse decision by the Commissioner
under this subsection pursuant to Rule 82-1 (Revised). Coverage shall remain in
effect while an appeal is pending.
Section 11 Pay-for-Performance Demonstration
Project
Upon petition by a carrier, or as required by the
Commissioner, the Commissioner may establish a pay-for-performance
demonstration project for Catamount Health insurance.
Section 12 Premium Rates
(a) Catamount Health premium rates shall be
approved by the Commissioner prior to implementation. No rate shall be approved
if it is unjust, unfair, inequitable, misleading or contrary to the law of this
state. A rate shall be approved if it is sufficient not to threaten the
financial safety and soundness of the insurer, reflects efficient and
economical management, provides Catamount Health at the most reasonable price
consistent with actuarial review, is not unfairly discriminatory, and complies
with the other requirements of
8
V.S.A. §
4089f and the Act.
(b) Initial proposed Catamount Health rates
shall be filed no later than five months after the carrier files its letter of
intent to sell.
(c) Catamount
Health premium rates shall be actuarially determined considering differences in
the demographics of the populations and the different levels and methods of
payment for health care professionals.
(d) After the initial rate filing referenced
in subsection (b) above, Catamount Health carriers shall file for rate approval
at least 100 days prior to the proposed implementation of the rates being filed
for approval. The Commissioner shall rule on a rate filing within 45 days of
receipt. If a rate filing is denied, written request for a hearing may be filed
within 30 days of the notice of disapproval.
(i) Rate filings shall include a
certification by a member of the American Academy of Actuaries which certifies
a carrier's compliance with this section and the Act. Such certification shall
include sufficient detail for the Commissioner to verify that such
certification is appropriate. Carriers shall provide additional information as
requested by the Commissioner in order to verify representations in the rate
filing.
(ii) The following
statements by a member of the American Academy of Actuaries shall be included
with each filing:
(A) the rates and proposed
rating methodology meet the requirements of this Rule and
8 V.S.A. §
4080f;
and
(B) the rates are reasonable in
relation to the benefits provided, and they are neither excessive, deficient,
nor unfairly discriminatory.
(iii) Rate filings shall include, at a
minimum, the following:
(A) a description of
the base claims experience data;
(B) actuarial support for the health
insurance trend factor used to project the base claims experience data forward
to the rating period and a copy of the data used to calculate the trend
factors;
(C) a description of each
element of retention;
(D) a
description of all other adjustments or elements included in or used to
calculate the rates;
(E) an
identification of the effective date that the rates were designed for and the
effective period of the rates. For example: "These rates have been designed to
apply to [the carrier's Catamount Health plan], renewing on or after xx/xx/xx
and will remain in effect for twelve months following renewal";
(F) an explanation of adverse selection
factors considered by the carrier.
(e) Notice of a premium rate increase shall
be provided to insureds at least 45 days prior to implementation, subject to
waiver as approved by the Commissioner. In no event shall rate increases be
implemented without at least 30 days written notice to the insured.
(i) In the event rate increase notices cannot
be provided in a timely manner as defined by this section, the carrier shall
extend existing rates at least until applicable notice periods have been
satisfied. Existing rates extended under this subsection shall continue in one
month intervals until new rates are approved.
(f) To be considered acceptable to the
Commissioner, the rates submitted by a Catamount Health carrier shall be
effective for at least a twelvemonth policy period.
(i) Subject to approval by the Commissioner,
premium rates shall be submitted at least for "single", "two-person" and
"family" (more than two persons) classifications.
(g) Catamount Health products shall be
community rated. All of a carrier's Catamount Health products shall have the
same premium rate, subject to the classifications referred to in Section
12(f)(i) above, differing benefit levels and to the wellness or healthy
discounts authorized by the Act, this Rule and any subsequent applicable law.
(i) Medical underwriting and screening to
exclude or individually rate a Catamount insured is not allowed. Catamount
Health shall be rated as a single group. Catamount Health carriers shall not
use rating plans which contain any provisions for adjustments that are based
upon medical underwriting or medical screening.
(ii) Proposed community rates should be based
upon reasonable projections of Catamount Health experience that has been
incurred or is anticipated to be incurred. To the extent that the carrier's
Catamount Health claims experience is not deemed to be fully credible, it can
be combined with the carrier's other Vermont experience as deemed appropriate
by the Commissioner.
Projections of the base claims experience forward to the
period for which the proposed community rates are designed to be effective
should be accomplished with the use of an appropriate health insurance trend
factor.
(iii) In addition to
the expected claims cost, the carrier's community rates may contain appropriate
allowances for administrative expenses, taxes, profit (in the case of
for-profit carriers) or contribution to reserves (in the case of a nonprofit
entity) and the cost of reinsurance, if any, and other elements used by the
carrier as approved by the Commissioner.
(iv) The approved premium rates for the
Catamount Health product shall not be adjusted for demographics (including age
or gender), geographic area, industry, medical underwriting or screening,
experience rating, tier rating or durational rating. Credit for healthy
lifestyle or wellness program discounts are allowed and shall be shown in the
rate filing.
(h) If a
carrier discontinues sales of the Catamount Health product pursuant to
8 V.S.A. §
4080f(n), the carrier shall
continue to file for rate approval subject to this Rule for those lives that
continue to be covered under existing policies. However, if a carrier does not
file for rate approval, the Commissioner shall establish the appropriate
premium rates in accordance with the statute.
8 V.S.A.
§§
4062,
4080