VT| The Vermont Insurance Bulletin No. 234 outlines the implementation of Vermont’s Act 111 of 2024, which introduces significant changes to health insurance regulations, focusing on prior authorization, payment policies, claims editing, and step therapy protocols.
Key Points:
- Prior Authorization Changes (Effective January 1, 2025): Act 111 prohibits prior authorization for services ordered by primary care providers, except for prescription drugs and out-of-network services. Providers must use specific claim lines to indicate exemptions, and health plans must notify providers of compliance requirements.
- Payment Policy Updates: Health plans must provide at least 60 days’ advance notice for changes to payment policies or manuals that impact provider contracts. Providers can object in writing, and disputes require a “reasonable resolution.”
- Claims Editing Standards (Effective January 1, 2026): Claims editing must adhere to nationally recognized standards such as the CMS National Correct Coding Initiative. Health plans may not require prepayment documentation unless targeting specific circumstances like fraud investigations or high-dollar claims.
- Step Therapy Protocol Overrides: Health plans must grant exceptions to step therapy protocols under specific conditions, such as adverse reactions or lack of efficacy. Overrides must be processed within the same timeframe as prior authorization requests.
- Applicability and Oversight: Act 111 applies to non-ERISA health plans but excludes Medicare and Medicaid. The Department of Financial Regulation will oversee compliance and provide guidance on implementation.