(a)As used in this section:
(1)“Adverse benefit determination” means a denial, reduction, modification, or termination of, or a failure to provide or make payment in whole or in part for, a benefit, including:
(A)a denial, reduction, modification, termination, or failure to provide or make payment that is based on a determination of the member’s eligibility to participate in a health benefit plan;
(B)a denial, reduction, modification, or termination of, or failure to make payment in whole or in part for, a benefit resulting from the application of any utilization review; and
(C)a failure to provide coverage for an item or service for which benefits are otherwise provided because the item or service is determined to be experimental, investigational, or not medically necessary or approp
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(a) As used in this section:
(1) “Adverse benefit determination” means a denial, reduction, modification, or termination of, or a failure to provide or make payment in whole or in part for, a benefit, including:
(A) a denial, reduction, modification, termination, or failure to provide or make payment that is based on a determination of the member’s eligibility to participate in a health benefit plan;
(B) a denial, reduction, modification, or termination of, or failure to make payment in whole or in part for, a benefit resulting from the application of any utilization review; and
(C) a failure to provide coverage for an item or service for which benefits are otherwise provided because the item or service is determined to be experimental, investigational, or not medically necessary or appropriate.
(2) “Claim” means a preservice review or a request for payment for a covered service that a member or the member’s health care provider submits to the insurer at or after the time that health care services have been provided.
(3) “Concurrent review” means utilization review conducted during a member’s stay in a hospital or other facility, or during another ongoing course of treatment.
(4) “Grievance” means a complaint submitted by or on behalf of a member regarding:
(A) an adverse benefit determination;
(B) the availability, delivery, or quality of health care services;
(C) claims payment, handling, or reimbursement for health care services; or
(D) matters relating to the contractual relationship between a member and the managed care organization or health insurer offering the health benefit plan.
(5) “Independent external review” means a review of a health care decision by an independent review organization pursuant to 8 V.S.A. § 4063.
(6) “Postservice review” means the review of any claim for a benefit that is not a preservice or concurrent review.
(7) “Preservice review” means the review of any claim for a benefit with respect to which the terms of coverage condition receipt of the benefit in whole or in part on approval of the benefit in advance of obtaining health care.
(8) “Utilization review” means a set of formal techniques designed to monitor the use, or evaluate the clinical necessity, appropriateness, efficacy, or efficiency, of health care services, procedures, or settings, including prescription drugs.
(b) Health insurers with a minimum of 2,000 Vermont lives covered at the end of the preceding year or who offer insurance through the Vermont Health Benefit Exchange pursuant to 33 V.S.A. chapter 18, subchapter 1 shall annually report the following information to the Commissioner of Financial Regulation, in plain language, as an addendum to the health insurer’s annual statement:
(1) the health insurer’s state of domicile and the total number of states in which the insurer operates;
(2) the total number of Vermont lives covered by the health insurer;
(3) the total number of claims submitted to the health insurer;
(4) the total number of claims denied by the health insurer, including the total number of denied claims for mental health services, treatment for substance use disorder, and prescription drugs;
(5) data regarding the number and percentage of denials of service by the health insurer based on utilization review, including utilization review at the preservice review, concurrent review, and postservice review levels and including denials of mental health services, services for substance use disorder, and prescription drugs broken out separately, including:
(A) denials of service by the health insurer;
(B) denials of service appealed to the health insurer at the first-level grievance and, of those, the total number overturned;
(C) denials of service appealed to the health insurer at any second-level grievance and, of those, the total number overturned;
(D) denials of service at the preservice level for which external review was sought and, of those, the total number overturned;
(6) the total number of adverse benefit determinations made by the health insurer, including:
(A) the total number of adverse benefit determinations appealed to the health insurer at the first-level grievance and, of those, the total number overturned;
(B) the total number of adverse benefit determinations appealed to the health insurer at any second-level grievance and, of those, the total number overturned;
(C) the total number of adverse benefit determinations for which external review was sought and, of those, the total number overturned;
(7) [Repealed.]
(8) the total number of claims denied by the health insurer as duplicate claims, as coding errors, or for services or providers not covered;
(9) the percentage of claims processed in a timely manner;
(10) the percentage of claims processed accurately, both financially and administratively;
(11) the number and percentage of utilization review decisions meeting the timelines described in subdivisions (A)-(D) of this subdivision (11), including timeliness data for all utilization review decisions and timeliness data for physical health, mental health, substance use disorder, and prescription drug utilization review decisions broken out separately:
(A) concurrent reviews within 24 hours;
(B) urgent preservice reviews within 48 hours of receipt of the request;
(C) nonurgent preservice reviews within two business days after receipt of request; and
(D) postservice reviews within 30 days after receipt of request;
(12) data regarding the number of grievances related to availability, delivery, or quality of health care services or matters relating to the contractual relationship between a member and the health insurer, including:
(A) health care provider performance and office management issues;
(B) plan administration;
(C) access to health care providers and services;
(D) access to mental health providers and services; and
(E) access to substance use disorder providers and services;
(13) the total number of claims, including separate numbers for claims related to mental health services, services for substance use disorder, and prescription drugs, denied by the health insurer on the grounds that the service was experimental, investigational, or an off-label use of a drug; was not medically necessary; or involved access to a provider that is inconsistent with the limitations imposed by the plan;
(14) results of surveys evaluating health care provider satisfaction with the health insurer;
(15) the health insurer’s actions taken in response to the prior year’s health care provider survey results;
(16)(A) the titles and salaries of all corporate officers and board members during the preceding year; and
(B) the bonuses and compensatory benefits of all corporate officers and board members during the preceding year;
(17) the health insurer’s marketing and advertising expenses during the preceding year;
(18) the health insurer’s federal and Vermont-specific lobbying expenses during the preceding year;
(19) the amount and recipient of each political contribution made by the health insurer during the preceding year;
(20) the amount and recipient of dues paid during the preceding year by the health insurer to trade groups that engage in lobbying efforts or that make political contributions;
(21) the health insurer’s legal expenses related to claims or service denials during the preceding year; and
(22) the amount and recipient of charitable contributions made by the health insurer during the preceding year.
(c) Health insurers may indicate the extent of overlap or duplication in reporting the information described in subsection (b) of this section.
(d) The Department of Financial Regulation shall create a standardized form using terms with uniform, industry-standard meanings for the purpose of collecting the information described in subsection (b) of this section, and each health insurer shall use the standardized form for reporting the required information as an addendum to its annual statement. To the extent possible, health insurers shall report information specific to Vermont on the standardized form and shall indicate on the form where the reported information is not specific to Vermont.
(e)(1) The Department of Financial Regulation and the Office of the Health Care Advocate shall post on their websites links to the standardized form completed by each health insurer pursuant to this section. Each health insurer shall post its form on its own website.
(2) The Department of Vermont Health Access shall post on the Vermont Health Benefit Exchange established pursuant to 33 V.S.A. chapter 18, subchapter 1 an electronic link to the standardized forms posted by the Department of Financial Regulation pursuant to subdivision (1) of this subsection.
(f) The Commissioner of Financial Regulation may adopt rules pursuant to 3 V.S.A. chapter 25 to carry out the purposes of this section. (Added 2011, No. 150 (Adj. Sess.), § 1; amended 2013, No. 79, § 40b; 2015, No. 152 (Adj. Sess.), § 8; 2023, No. 6, § 230, eff. July 1, 2023; 2025, No. 11, § 23, eff. September 1, 2025.)