Senate orders third reading of bill clarifying prior-authorization and claims-edit rules

The Vermont Senate on the floor ordered a third reading of House Bill H.31 after a floor report from Senator Lyons, a bill that clarifies claims-edit and prior-authorization language enacted last year in Act 111.

Senator Lyons told the chamber the bill addresses points of confusion that emerged after implementation of last session’s prior-authorization law and reflects negotiation with payers and providers. "There’s been a great deal of work that has happened during the summer and the fall with interested parties, including the Vermont Medical Society, Blue Cross and Blue Shield, and the Hospital Association, and the MVP, as well as DFR, Department of Financial Regulation," Lyons said on the floor.

The bill makes three main clarifications. First, it specifies that claims-edit requirements do not apply to services delivered out of state; Lyons said lawmakers cannot regulate how out-of-state payers process claims. Second, it revises the definition of “primary care provider.” The original law referenced the Vermont Blueprint for Health; H.31 replaces that cross-reference with language to mean "a health care provider who is contracted and enrolled with a health plan as a primary care provider," broadening coverage to all primary care clinicians who are contractually recognized by a plan rather than only Blueprint-designated practices. Third, Lyons said the bill adjusts implementation timing: a section tied to primary-care treatment that had been set to take effect in January 2025 is moved to January 26, 2026, to give payers and providers time to align operations.

Lyons said stakeholders who testified in committee supported the clarifications; she also reported the committee vote was 5-0-0. The Senate proceeded to a vote on whether to read the bill a third time; the presiding officer called for the question and "the ayes have it," ordering the third reading.

H.31 returns to the Senate floor for formal third-reading consideration and final passage procedures. If enacted, the changes will alter statutory definitions and effective dates but do not, on their face, change benefit coverage requirements contained in the original prior-authorization law.