Get Full Government Meeting Transcripts, Videos, & Alerts Forever!
Get email alerts on the Claims And Reporting topic
No spam. Unsubscribe anytime.
Senate Finance sets $25,000 threshold for high‑dollar prepayment reviews and orders reporting for health‑care‑sharing plans
Summary
H.585 defines 'high‑dollar claims' as claims exceeding $25,000 per episode for purposes of prepayment validation and adds an annual reporting regime for non‑insurer health‑care‑sharing arrangements with penalties and public reporting requirements.
The committee also reviewed narrower technical changes in H.585: a concrete threshold for high‑dollar prepayment reviews and a new annual reporting requirement for health‑care‑sharing plans.
Joe Valente (DFR) told the committee Section 6 replaces the previously undefined term "high dollar" with a clear threshold: claims exceeding $25,000 per episode may be subject to prepayment coding validation review. This change clarifies when insurers may, but are not required to, seek medical‑record documentation before adjudicating a claim; existing exceptions for fraud, waste and abuse remain.
Separately, the bill adds reporting requirements for entities that are not authorized insurers but offer arrangements to facilitate payment of health care costs for Vermont residents. Persons offering such a plan or arrangement must submit annual information to the commissioner of DFR (first submission on or before October 1 of this year), including total participants, employer‑group counts, provider contracts in state, total fees collected, percentages retained for administrative expenses, total requests for reimbursement and denial/appeal rates, and marketing/training materials. DFR must determine completeness within specified review windows, may impose administrative penalties up to $5,000 per day for noncompliance, and may issue cease‑and‑desist orders if deficiencies persist. DFR will publish a summary report (first posted April 1, 2027) and provide accurate, evidence‑based consumer information and complaint processes on its website.
DFR staff told the committee that because health‑care‑sharing arrangements are not insurance under current law, the reporting regime aims to increase transparency without creating the appearance of state insurance oversight.
What’s next: DFR will implement intake and reporting processes and publish the required summary reports by the statutory deadlines; the committee did not take any enforcement votes in the walkthrough.
