Committee approves H.31 to clarify out-of-state claim edits and who qualifies as a primary care provider for prior-authorization exemptions

The Vermont House Committee on Health Care approved H.31 on Jan. 29 to clarify when health insurance claim edit standards apply and to revise the definition of “primary care provider” for prior-authorization exemptions.

Jen Carvey, Office of Legislative Counsel, told the committee the bill makes two main changes: it specifies that otherwise applicable claim edit standards do not apply when services are delivered outside Vermont unless the payer and the out-of-state provider agree otherwise, and it revises the prior-authorization exemption so that a “primary care provider” means a health care provider contracted and enrolled with the health plan as a primary care provider.

The clarification matters because, Carvey said, Vermont generally lacks authority to regulate activities that occur entirely outside the state: “We typically do not try to regulate what happens outside of the borders of Vermont. We generally don't have the authority to do that,” she said. The bill allows payers and out-of-state providers to contractually agree that some standards will apply.

On the prior-authorization definition, Carvey said the revised language aims to remove confusion about which providers plans must exempt: it makes implementation straightforward by tying the exemption to the plan’s own enrollment and contracting designation. “For our purposes of who is going to be exempt, who the health plan has to exempt has to not impose a prior authorization requirement, for anything ordered by a primary care provider. Who do we mean by primary care provider? … whoever you have contracted and enrolled in your plan as a primary care provider,” Carvey said.

Key provisions and limits

- Scope of claim edit rule: Section 1 of H.31 specifies that the claim edit standards adopted under prior legislation do not apply to services provided outside Vermont unless the payer and out-of-state provider agree otherwise. The committee record frames this as an extraterritorial jurisdiction clarification rather than a change to how Vermont regulates in-state providers.

- Primary care provider definition: Section 2 replaces a prior definition tied to the Vermont Blueprint for Health with one based on the plan’s enrollment/contracting designation. The change applies only to who is exempt from prior-authorization requirements; it does not remove prior-authorization rules for orders that are out-of-network or for prescription drugs.

- Effective dates: Carvey said the claim edit provision takes effect Jan. 1, 2026, to match the timing for the claim edit standard requirements. The revised primary-care-provider definition takes effect on passage and must be implemented by health plans as soon as reasonably practicable but no later than Jan. 1, 2026.

Stakeholder positions and implementation concerns

Carvey said the Department of Financial Regulation issued guidance and that commercial plans the committee regulates — including Blue Cross Blue Shield of Vermont, MVP, and Cigna — participated in stakeholder discussions. She reported that Vermont Medical Society and the Vermont Association of Hospital and Health Systems testified in favor of the bill. The presentation noted differing implementation perspectives: providers urged quicker implementation after passage, while payers asked for time to update plan systems and processes.

Committee members asked whether the bill affects urgent care, emergency care, referrals or prescriptions. Carvey clarified that the bill does not treat urgent care clinics differently: the rules hinge on whether an individual provider is designated by the plan as a primary care provider. She also noted that prior-authorization exemptions do not automatically apply to prescription drugs or out-of-network services and that a primary care referral alone does not render later services exempt from prior authorization.

Vote and next steps

A motion to approve H.31 as introduced was moved (mover not specified in the transcript) and seconded by Representative Chinos. The committee approved the measure on a roll-call of members recorded in the transcript: Representative Cordes (yes), Representative Critchlow (yes), Representative DeMar (yes), Representative Goldman (yes), Representative Page (yes), Representative Powers (yes), Representative Verbecco (yes), Representative McFaun (yes), and Representative Black (yes). The motion passed on a vote of 11-0-0. Representative Black was designated as the reporter for the committee’s recommendation.

The bill will proceed with the committee’s approval and the implementation timetable described in the presentation.