Key Takeaways
- Vermont Health Connect is the state's own health insurance marketplace
- Vermont has a merged individual and small group market
- Pre-existing condition exclusions are prohibited
- Vermont requires community rating with no health-based pricing
- Essential health benefits are required in all qualified plans
Vermont Health Insurance Policy Requirements
Vermont has comprehensive health insurance regulations under Title 8 of the Vermont Statutes Annotated.
Regulatory Structure
Vermont health coverage is regulated by:
| Agency | Responsibility |
|---|---|
| Department of Financial Regulation (DFR) | Regulates all insurance |
| Green Mountain Care Board | Health care cost containment |
| Vermont Health Connect | State-based health marketplace |
Department of Financial Regulation
The DFR:
- Reviews and approves policy forms and rates
- Licenses insurance producers and companies
- Handles consumer complaints
- Enforces insurance laws and regulations
Vermont Health Connect
Vermont Health Connect is the state's official health insurance marketplace:
Key Features
- State-based marketplace (not HealthCare.gov)
- Premium tax credits available
- Qualified Health Plans (QHPs) certified by state
- Both individual and small group markets available
Enrollment Periods
- Annual open enrollment each fall
- Special enrollment for qualifying life events
- Financial assistance based on income
Unique Vermont Features
Merged Market
Vermont has merged its individual and small group markets:
- Same plans available to both markets
- Same rates for individuals and small groups
- Simplified shopping experience
Community Rating
Vermont uses modified community rating:
- No health-based pricing
- Limited variation by age and tobacco use
- Geographic area may affect rates
Required Coverage
Vermont ACA-compliant plans must cover Essential Health Benefits:
Essential Health Benefits
- Ambulatory patient services
- Emergency services
- Hospitalization
- Maternity and newborn care
- Mental health and substance use disorders
- Prescription drugs
- Rehabilitative services
- Laboratory services
- Preventive and wellness services
- Pediatric services (including dental and vision)
Pre-Existing Condition Protections
Vermont prohibits pre-existing condition exclusions:
| Market Segment | Pre-Existing Condition Exclusions |
|---|---|
| Individual | Prohibited |
| Small Group | Prohibited |
| Large Group | Prohibited |
Exam Tip: Vermont prohibits pre-existing condition exclusions in ALL markets, not just individual and small group.
Guaranteed Issue and Renewal
Vermont requires:
Guaranteed Issue
- Insurers must accept all applicants during open enrollment
- Cannot deny coverage based on health status
Guaranteed Renewal
- Cannot cancel coverage except for non-payment or fraud
- Plan discontinuation requires advance notice
Mental Health Parity
Vermont has strong mental health parity laws:
- Mental health benefits must equal medical benefits
- Same copays, deductibles, and limits
- Coverage for substance use disorders required
What is the name of Vermont's state-based health insurance marketplace?
What is unique about Vermont's individual and small group health markets?