Committee reviews H.31 to limit Vermont claim-edit rules for out-of-state care and tie prior-authorization exemption to insurer designation of primary care

A legislative committee on Jan. 24 reviewed H.31, a bill that would prevent Vermont insurers from applying Vermont claim‑edit standards when adjudicating claims for services delivered outside the state unless the payer and the out‑of‑state provider agree those edit standards should apply.

The bill also replaces a prior cross‑reference to the Blueprint for Health with a definition that ties the prior‑authorization exemption for services ordered by a primary care provider to the health plan’s own designation: "a health care provider who is contracted and enrolled with the health plan as a primary care provider," Jen Carvey of the Office of Legislative Counsel told the Committee.

Why it matters: the change would affect how insurers adjudicate out‑of‑state claims and who qualifies for automatic exemptions from prior authorization. Advocates and regulators said the bill clarifies implementation but will delay uniform application for some smaller providers until insurers update certificates and plan networks.

What the bill says

Section 1 would add an exception so that certain claim‑edit standards in state law do not apply when adjudicating claims for health care services delivered outside Vermont unless the payer and the out‑of‑state provider agree that one or more edit standards will apply. As legislative counsel explained, "we can regulate what's happening in our borders and we're not trying to regulate what's happening outside our borders, but certainly there can be an agreement, between the payer and its provider that some of those some or all edit standards would apply." The Committee was given the example of an in‑state insurer receiving a claim from an out‑of‑state hospital; under the bill the insurer would not be required to apply Vermont's edit standards to that claim absent agreement with the out‑of‑state provider.

Section 2 would change the definition of "primary care provider" for purposes of the prior‑authorization exemption. Carvey said the bill strikes last year’s link to the Blueprint for Health definition because "there wasn't necessarily consensus about what that meant" and substitutes a definition that relies on how each health plan contracts and enrolls providers.

Effective dates and implementation

Carvey told the Committee the first section (the claim‑edit standard change) would take effect Jan. 1, 2026, aligned with the underlying statute's effective date. The prior‑authorization definition change (Section 2) would "take effect on passage and shall be implemented by all health plans as soon as reasonably practicable after that date, but not later than Jan. 1, 2026," she said.

Emily Brown of the Department of Financial Regulation (DFR) said the department supports H.31 and the related changes to Act 111. Brown also cautioned that consumer certificates and insurer filings currently reference the Blueprint definition; DFR required insurers to include information about prior‑authorization requirements in certificates during recent review of major‑medical forms. The department "hasn't heard any feedback from the insurers about issues implementing it as per the guidance," she said, but noted insurers will need to align contracts and actuary work with the statutory changes.

Concerns raised

Several witnesses who support the bill urged prompt action for market certainty. Claire Buckley of Leonine Public Affairs, speaking on behalf of insurer MVP, said insurers need to know the law early for rate filings and actuarial work: "we absolutely would, like you to move this bill as quickly as possible." Buckley noted the first rate filing for the next plan year begins in early May.

At the same time, Jessa Barnard of the Vermont Medical Society warned the committee that the delayed effective date will extend prior‑authorization burdens for some smaller providers: some small nurse‑practitioner and naturopathic practices that do not participate in Blueprint programs will continue to face prior‑authorization requirements through the end of the year while insurers update networks and contracts.

Next steps

Committee members discussed timing and indicated they expect to schedule a final markup and a possible vote next week. The Committee chair said, "I anticipate we're going to find a very great time next week to, do final markup and possible vote." No formal vote on H.31 occurred during this session.

Ending note: testimony at the hearing came from state regulatory staff, primary care and hospital associations, the Vermont Medical Society, and insurers; the Committee left the record open and plans to take further action at an upcoming meeting.