The bill H.31, introduced by Representative Black, aims to amend existing health insurance regulations in Vermont regarding claim edit standards and prior authorization requirements. Specifically, it stipulates that health insurance claim edit standards will not apply to services delivered outside of Vermont unless there is an agreement between the health insurer and the out-of-state provider. Additionally, the bill modifies the definition of a primary care provider to clarify that it refers to a health care provider who is contracted and enrolled with the health plan as a primary care provider, rather than adhering to the previous definition used by the Vermont Blueprint for Health.

The bill includes specific amendments to the Vermont Statutes Annotated, including the addition of a new provision that exempts claims for services delivered outside Vermont from standard edit requirements unless agreed upon by the involved parties. It also establishes that the prohibition on prior authorization for services ordered by primary care providers does not apply to out-of-network services or prescription drugs. The effective dates for these changes are set for January 1, 2026, for the claim edit standards, while the prior authorization provisions 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