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Title

08

:
Banking and Insurance






Chapter

107

:
HEALTH INSURANCE






Subchapter

001
:
GENERALLY










 

§

4062. Filing and approval of policy forms and premiums

(a)(1) No policy

of health insurance or certificate under a policy filed by an insurer offering

health insurance as defined in subdivision 3301(a)(2) of this title, a

nonprofit hospital or medical service corporation, health maintenance

organization, or a managed care organization and not exempted by subdivision

3368(a)(4) of this title shall be delivered or issued for delivery in this

State, nor shall any endorsement, rider, or application which becomes a part of

any such policy be used, until a copy of the form and of the rules for the

classification of risks has been filed with the Department of Financial

Regulation and a copy of the premium rates has been filed with the Green

Mountain Care Board; and the Green Mountain Care Board has issued a decision

approving, modifying, or disapproving the proposed rate.

(2)(A) The Green

Mountain Care Board shall review rate requests and shall approve, modify, or

disapprove a rate request within 90 calendar days after receipt of an initial

rate filing from an insurer. If an insurer fails to provide necessary materials

or other information to the Board in a timely manner, the Board may extend its

review for a reasonable additional period of time, not to exceed 30 calendar

days.

(B) Prior to the

Board's decision on a rate request, the Department of Financial Regulation

shall provide the Board with an analysis and opinion on the impact of the

proposed rate on the insurer's solvency and reserves.

(3) The Board

shall determine whether a rate is affordable, promotes quality care, promotes

access to health care, protects insurer solvency, and is not unjust, unfair,

inequitable, misleading, or contrary to the laws of this State. In making this

determination, the Board shall consider the analysis and opinion provided by

the Department of Financial Regulation pursuant to subdivision (2)(B) of this

subsection.

(b) In

conjunction with a rate filing required by subsection (a) of this section, an

insurer shall file a plain language summary of the proposed rate. All summaries

shall include a brief justification of any rate increase requested, the

information that the Secretary of the U.S. Department of Health and Human

Services (HHS) requires for rate increases over 10 percent, and any other

information required by the Board. The plain language summary shall be in the

format required by the Secretary of HHS pursuant to the Patient Protection and

Affordable Care Act of 2010, Public Law 111-148, as amended by the Health Care

and Education Reconciliation Act of 2010, Public Law 111-152, and shall include

notification of the public comment period established in subsection (c) of this

section. In addition, the insurer shall post the summaries on its website.

(c)(1) The Board

shall provide information to the public on the Board's website about the public

availability of the filings and summaries required under this section.

(2)(A) Beginning

no later than January 1, 2014, the Board shall post the rate filings pursuant

to subsection (a) of this section and summaries pursuant to subsection (b) of

this section on the Board's website within five calendar days of filing. The

Board shall also establish a mechanism by which members of the public may

request to be notified automatically each time a proposed rate is filed with

the Board.

(B) The Board

shall provide an electronic mechanism for the public to comment on all rate

filings. The Board shall accept public comment on each rate filing from the

date on which the Board posts the rate filing on its website pursuant to

subdivision (A) of this subdivision (2) until 15 calendar days after the Board

posts on its website the analyses and opinions of the Department of Financial

Regulation and of the Board's consulting actuary, if any, as required by subsection

(d) of this section. The Board shall review and consider the public comments

prior to issuing its decision.

(3)(A) In

addition to the public comment provisions set forth in this subsection, the

Office of the Health Care Advocate established in 18 V.S.A. chapter 229, acting

on behalf of health insurance consumers in this State, may, within 30 calendar

days after the Board receives an insurer's rate request pursuant to this

section, submit to the Board, in writing, suggested questions regarding the filing

for the Board to provide to its contracting actuary, if any.

(B) The Office

of the Health Care Advocate may also submit to the Board written comments on an

insurer's rate request. The Board shall post the comments on its website and

shall consider the comments prior to issuing its decision.

(d)(1) No later

than 60 calendar days after receiving an insurer's rate request pursuant to

this section, the Green Mountain Care Board shall make available to the public

the insurer's rate filing, the Department's analysis and opinion of the effect

of the proposed rate on the insurer's solvency, and the analysis and opinion of

the rate filing by the Board's contracting actuary, if any.

(2) The Board

shall post on its website, after redacting any confidential or proprietary

information relating to the insurer or to the insurer's rate filing:

(A) all

questions the Board poses to its contracting actuary, if any, and the actuary's

responses to the Board's questions; and

(B) all

questions the Board, the Board's contracting actuary, if any, or the Department

poses to the insurer and the insurer's responses to those questions.

(e) Within the

time period set forth in subdivision (a)(2)(A) of this section, the Board

shall:

(1) conduct a

public hearing, at which the Board shall:

(A) call as

witnesses the Commissioner of Financial Regulation or designee and the Board's

contracting actuary, if any, unless all parties agree to waive such testimony;

and

(B) provide an

opportunity for testimony from the insurer; the Office of the Health Care

Advocate; and members of the public;

(2) at a public

hearing, announce the Board's decision of whether to approve, modify, or

disapprove the proposed rate; and

(3) issue its

decision in writing.

(f)(1) The

insurer shall notify its policyholders of the Board's decision in a timely

manner, as defined by the Board by rule.

(2) Rates shall

take effect on the date specified in the insurer's rate filing.

(3) If the Board

has not issued its decision by the effective date specified in the insurer's

rate filing, the insurer shall notify its policyholders of its pending rate

request and of the effective date proposed by the insurer in its rate filing.

(g) An insurer,

the Office of the Health Care Advocate, and any member of the public with party

status, as defined by the Board by rule, may appeal a decision of the Board

approving, modifying, or disapproving the insurer's proposed rate to the

Vermont Supreme Court.

(h)(1) The

authority of the Board under this section shall apply only to the rate review

process for policies for major medical insurance coverage and shall not apply

to the policy forms for major medical insurance coverage or to the rate and

policy form review process for policies for specific disease, accident, injury,

hospital indemnity, dental care, vision care, disability income, long-term

care, student health insurance coverage, Medicare supplemental coverage, or

other limited benefit coverage, or to benefit plans that are paid directly to

an individual insured or to his or her assigns and for which the amount of the

benefit is not based on potential medical costs or actual costs incurred.

Premium rates and rules for the classification of risk for Medicare

supplemental insurance policies shall be governed by sections 4062b and 4080e

of this title.

(2) The policy

forms for major medical insurance coverage, as well as the policy forms,

premium rates, and rules for the classification of risk for the other lines of

insurance described in subdivision (1) of this subsection shall be reviewed and

approved or disapproved by the Commissioner. In making his or her

determination, the Commissioner shall consider whether a policy form, premium

rate, or rule is affordable and is not unjust, unfair, inequitable, misleading,

or contrary to the laws of this State. The Commissioner shall make his or her

determination within 30 days after the date the insurer filed the policy form,

premium rate, or rule with the Department. At the expiration of the 30-day

period, the form, premium rate, or rule shall be deemed approved unless prior

to then it has been affirmatively approved or disapproved by the Commissioner

or found to be incomplete. The Commissioner shall notify an insurer in writing

if the insurer files any form, premium rate, or rule containing a provision

that does not meet the standards expressed in this subsection. In such notice,

the Commissioner shall state that a hearing will be granted within 20 days upon

the insurer's written request.

(3) Repealed.]

(i)

Notwithstanding the procedures and timelines set forth in subsections (a)

through (e) of this section, the Board may establish, by rule, a streamlined

rate review process for certain rate decisions, including proposed rates

affecting fewer than a minimum number of covered lives and proposed rates for

which a de minimis increase, as defined by the Board by rule, is sought. (Added

1983, No. 238 (Adj. Sess.), § 4; amended 1989, No. 106, § 3; 1989, No. 225

(Adj. Sess.), § 25; 1995, No. 180 (Adj. Sess.), § 38; 2011, No. 48, § 15, eff.

Jan. 1, 2012; 2011, No. 78 (Adj. Sess.), § 2, eff. April 2, 2012; 2011, No. 171

(Adj. Sess.), § 25, eff. May 16, 2012; 2013, No. 79, § 5c, eff. Jan. 1, 2014;

2013, No. 144 (Adj. Sess.), § 5, eff. May 27, 2014; 2013, No. 179 (Adj. Sess.),

§ E.345.1; 2015, No. 54, § 31.)