The bill amends sections 9418a and 9418b of Title 18 of the Vermont Statutes Annotated, focusing on the processing of claims and prior authorization requirements for health care services. In section 9418a, the bill clarifies that adherence to certain edit standards is not required when adjudicating claims for health care services delivered outside Vermont, unless agreed upon by the payer and the out-of-state provider. Additionally, it specifies that edit standards must be developed with input from the Vermont provider community and be supported by recognized guidelines. The language regarding exemptions for favorable edits and new codes has been updated to include these provisions.

In section 9418b, the bill establishes that health plans cannot impose prior authorization requirements for services ordered by primary care providers, with exceptions for out-of-network services and prescription drugs. The definition of a primary care provider has been revised to specify that it refers to a provider contracted and enrolled with the health plan. The effective dates for these changes are set for January 1, 2026, for section 9418a, while section 9418b will take effect upon passage and must be implemented by health plans as soon as practicable, but no later than January 1, 2026.

Statutes affected:
As Introduced: 18-9418a, 18-9418b
As Passed By the House -- Official: 18-9418a, 18-9418b
As Passed By the House -- Unofficial: 18-9418a, 18-9418b
As Passed by Both House and Senate -- Official: 18-9418a, 18-9418b
As Passed by Both House and Senate -- Unofficial: 18-9418a, 18-9418b
As Enacted: 18-9418a, 18-9418b