Vermont Statutes

This law requires at least one formulation of each MAT drug to be on the lowest tier of the drug formulary. The law eliminates prior authorization for MAT drugs and associated counseling and therapy for commercial plans and mandates report about the impact of prior authorization in Medicaid.

Enacted through SB 43

This was an appropriations bill that has one section on mental health parity. It requires the Department of Vermont Health to ensure its clinical utilization review practices with respect to mental health services are consistent with the Federal Parity Law and state parity laws.

Among many other things, this bill repealed a subsection within a section of the insurance law relevant to parity. That section had required some insurance plans to file an annual report that included the following information:

• Behavioral health patient discharge rates from inpatient care, the average length of stay, and the percentage of those patients who were readmitted
• Percentage of enrollees receiving behavioral health treatment and number of people denied behavioral health services
• Number of denials appealed by patients and number of denials appealed by providers
• Level of patient satisfaction with their behavioral health coverage

Vt. Stat. Ann. tit. 8, § 4089b mandates that health insurance plans provide coverage for treatment of a mental condition and:
(1) not establish any rate, term, or condition that places a greater burden on an insured for access to treatment for a mental condition than for access to treatment for other health conditions, including no greater co-payment for primary or specialty mental health care or services than the co-payment applicable to care or services provided by a primary care provider or specialty provider under an insured’s;
(2) not exclude from its network or list of authorized providers any licensed mental health or substance abuse provider located within the geographic coverage area of the health benefit plan if the provider is willing to meet the terms and conditions for participation established by the health insurer; and
(3) make any deductible or out-of-pocket limits required under a health insurance plan comprehensive for coverage of both mental and physical health conditions.
Vt. Stat. Ann. tit. 8, § 4089b also allows health insurance plans to contract with managed care organizations for the provision of mental health services.
Vt. Stat. Ann. tit. 8, § 4089b also provides definitions, discusses eligibility requirements, and requirements for relevant rule adoption.

This bill created the Vermont All-Payer Model. The bill requires that the All-Payer Model be in compliance with the Federal Parity Law and state parity laws.

Among many other things, this bill changed the sections of the state law relevant to parity by changing wording in the section about utilization review so that it applies to any plan under the jurisdiction of the Department of Financial Regulations. It also eliminated some obsolete wording in the sections about behavioral health coverage and autism coverage.

Among many other things, this bill changed the state insurance law relative to parity in a number of ways:

• Requires the Department of Financial Regulation to develop “performance quality indicators” to evaluate how plans and managed care organizations are complying with one of the parity sections of the state insurance law
• Requires the Commissioner of the Department of Financial Regulation to submit recommendations to the General Assembly about how to distinguish behavioral health primary care services from behavioral health specialty services and issue regulations regarding this as well (which the Department did do)
• Requires plans to have copayments for behavioral health services that are “no greater” than copayments for other medical services

This bill changed the state insurance law about autism coverage to what it is currently (except for a few minor technical changes that were made in 2013). This section is summarized at the bottom of the page under “Vermont Parity Law,” “Autism Coverage.” This bill also required the Department of Human Services in consultation with Autism Speaks to submit a report to the General Assembly about implementation of this section of the insurance law.

Vt. Stat. Ann. tit. 8, § 4088i mandates that health insurance plans provide coverage for the diagnosis and treatment of early childhood developmental disorders, including applied behavior analysis, for children beginning at birth and continuing until the child reaches age 21. A health insurance plan shall not impose greater coinsurance, co-payment, deductible, or other cost-sharing requirements for coverage of the diagnosis or treatment of early childhood developmental disorders than apply to the diagnosis and treatment of any other physical or mental condition under the plan.
Vt. Stat. Ann. tit. 8, § 4088i continues on to discuss the requirements of coverage, such as services must be provided by a licensed provider, the services must be medically necessary, and treatment plan reviews may be implemented.

Among many other things, this bill changed a section of the state insurance law relevant to parity by removing the language that allowed plans to only cover behavioral health services that were provided in-network.

This bill added the section of the state insurance law about autism coverage. It has since been amended significantly. Here is how this bill is different than what is currently in the law:

• Only required coverage through age 6 or when a child enters first grade
• Had no specific language requiring coverage for applied behavior analysis
• Did not require coverage by Medicaid plans and other public plans
• Did not have specific language allowing plans to use prior authorization
• Did not require coverage for appropriate services provided in a child’s home
• Did not have any language about how often plans were allowed to review a child’s treatment plan
• Did not require coverage for services provided by someone under the supervision of a licensed professional
• Did not list pervasive developmental disorder not otherwise specified as a covered condition
• Included habilitative and rehabilitative care as a treatment for autism instead of behavioral health treatment
• Listed and defined autism spectrum disorder instead of “early childhood developmental disorder”
• Had a different definition of medically necessary that specifically mentioned that it should be based on recommendations or reports from the American Academy of Pediatrics and the American Academy of Child and Adolescent Psychiatry
• Did not define pharmacy care, psychiatric care, or psychological care