VT| The Vermont Department of Financial Regulation’s Bulletin 237 clarifies the implementation of Act 55 of 2025, specifically addressing limits on hospital reimbursement claims for prescription drugs administered in outpatient or office settings. The bulletin emphasizes how Act 55’s reference to “average sales price” (ASP) is strictly linked to the calculation method codified under federal law, and outlines explicit exemptions for certain independent critical access hospitals.
Key guidance points:
- Hospitals are prohibited from billing health insurers more than 120% of the ASP, as calculated exclusively by the method in 42 U.S.C. 1395w-3ac, for prescription drugs administered outside of inpatient settings.
- Independent hospitals designated as critical access and unaffiliated with larger networks in or outside Vermont are exempt from these billing restrictions.
- Hospitals in the Rural Community Hospital Demonstration Program are not considered critical access hospitals and therefore remain subject to Act 55’s reimbursement limits based on statutory language.