Bill > H0031

This bill modifies Vermont's healthcare claims processing and prior authorization regulations. The first section amends existing law to provide additional exceptions to claim edit standards, specifically allowing health insurers (payers) to deviate from standard edit criteria when dealing with out-of-state healthcare services, unless the payer and provider mutually agree to apply Vermont's standards. The second section focuses on prior authorization requirements, prohibiting health plans from mandating prior authorization for services ordered by primary care providers, with exceptions for prescription drugs and out-of-network services. The bill also redefines "primary care provider" to mean a healthcare provider who is contracted and enrolled with a health plan, replacing the previous definition tied to the Vermont Blueprint for Health. The effective dates are staggered: the claim edit standards changes will take effect on January 1, 2026, while the prior authorization restrictions should be implemented as soon as practicable after the bill's passage, but no later than January 1, 2026. These changes aim to streamline healthcare claims processing and reduce administrative burdens for providers by limiting unnecessary prior authorization requirements.

Health and Social Services

https://legislature.vermont.gov/bill/status/2026/H.31