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The Vermont Statutes Online
Title
08
:
Banking and Insurance
Chapter
112
:
LIFE AND HEALTH INSURANCE GUARANTY ASSOCIATION
Subchapter
002
:
HEALTH MAINTENANCE ORGANIZATION GUARANTY ASSOCIATION
§
4185. Application of subchapter 1 to the Vermont Health Maintenance
Organization Guaranty Association; maximum benefits
(a) Sections
4157, 4158, 4159, 4160, 4161, 4162, 4163, 4164, 4165, 4168, and 4169 of this
title shall govern and apply to the Association established under this
subchapter except as otherwise provided in this subchapter.
(b) Sections
4166 and 4167 of this title shall not apply to the Association established
under this subchapter.
(c)(1) Benefits
for which the Association may become liable shall in no event exceed the lesser
of:
(A) the
contractual obligations for which the Health Maintenance Organization is liable
or would have been liable if it were not impaired or insolvent; or
(B) $300,000.00
with respect to any one natural person.
(2) In no event
shall the Association be required to pay any provider participating in the
insolvent organization any amount for in-plan services rendered by such
provider prior to the insolvency of the organization in excess of:
(A) the amount
provided by a contract between a physician provider and the insolvent
organization for such services; or
(B) the amounts
provided by contract between a hospital provider and the Department of Vermont
Health Access for similar services to recipients of Medicaid; or
(C) in the event
neither subdivision (A) nor (B) of this subdivision (2) is applicable, then the
amounts paid under the Medicare area prevailing rate for the area where the
services were provided, or if no such rate exists with respect to such
services, then 80 percent of the usual and customary rates established by the
Health Insurance Association of America or any successor organization that
calculates the usual and customary rates for medical services and procedures.
The payments required to be made by the Association under this subsection shall
constitute full and complete payment of such provider services for the member.
(Added 1993, No. 30, § 15, eff. May 21, 1993; amended 1999, No. 147 (Adj.
Sess.), § 4; 2005, No. 174 (Adj. Sess.), § 11; 2009, No. 156 (Adj. Sess.), §
I.14.)
