§4185. Application of subchapter 1 to the Vermont Health Maintenance Organization

Link to law: http://legislature.vermont.gov/statutes/section/08/112/04185
Published: 2015

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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.)
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