H 585

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1H.585
2 Introduced by Representatives McCoy of Poultney and McFaun of Barre
3Town
4 Referred to Committee on
5 Date:
6 Subject: Health; health care reform; health insurers; health insurance; prior
7authorization; site-neutral billing; reinsurance
8 Statement of purpose of bill as introduced: This bill proposes to modify the
9 governance and executive compensation requirements for certain health
10 insurance companies. It would allow limited age rating for health insurance
11 plans in the individual and small group markets and expand access to
12 association health plans and to short-term, limited duration health insurance.
13 The bill would define high-dollar claims for purposes of claims edits and
14 would limit the primary care provider exemption from prior authorization
15 requirements to apply to independent providers only. The bill would also
16 begin implementing site-neutral billing policies for certain health care services
17 and would authorize the State to pursue a federal waiver to establish a
18 reinsurance program.
19    An act relating to health insurance reforms
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1 It is hereby enacted by the General Assembly of the State of Vermont:
2* * * Health Insurer Governance and Executive Compensation * * *
3 Sec. 1. 8 V.S.A. chapter 123 is amended to read:
4   CHAPTER 123. NONPROFIT HOSPITAL SERVICE CORPORATIONS
5***
6 § 4512. POWERS
7    (a) Such A hospital service corporation shall be a nonprofit sharing
8 corporation without capital stock. It shall be maintained and operated solely
9 for the benefit of the its subscribers thereof and shall ensure that benefits and
10 services are balanced with the efficient and economical management of the
11 corporation. A hospital service corporation shall not be authorized to pay
12 money in lieu of hospital service. A person, partnership, association, or
13 corporation shall not contract to furnish hospital service unless authorized so
14 to do so pursuant to the provisions of this chapter. Corporations formed under
15 the provisions of this chapter shall have the privileges and be subject to the
16 provisions of Title 11B as well as the applicable provisions of this chapter. In
17 the event of a conflict between the provisions of Title 11B and the provisions
18 of this chapter, the latter shall control.
19***
20 § 4513. PERMIT TO ENGAGE IN BUSINESS; FOREIGN
21CORPORATIONS
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1    (a) At least three-fourths of the board of directors of a corporation
2 organized under this chapter shall be composed of subscribers and members of
3 the public. The remainder may be providers. The subscriber members of the
4 board shall comprise at least a majority of the board. A corporation organized
5 under this chapter shall provide for the election of its board of directors at a
6 publicly announced meeting. As used in this section, “provider” means any
7 person who is a provider of hospital or medical services, or who is an
8 employee, director, trustee, or representative of a provider of such services.
9 [Repealed.]
10***
11 § 4513a. BOARD OF DIRECTORS
12    (a) Definitions. As used in this section:
13(1) “Provider” means any person who is a provider of hospital or
14 medical services, or who is an employee, director, trustee, or representative of
15 a provider of such services.
16(2) “Representative of the public” means any member of the board of
17 directors appointed by the Governor. A representative of the public may be a
18 member of the public, a subscriber, or a provider.
19    (b) Composition. At least three-fourths of the board of directors of a
20 corporation organized under this chapter shall be composed of subscribers and
21 members of the public. The remainder may be providers. The subscriber
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1 members of the board shall comprise at least a majority of the board. A
2 corporation organized under this chapter shall provide for the election of its
3 board of directors at a publicly announced meeting.
4    (c) Representatives of the public.
5(1) Two voting members of the board, but in no event less than one-
6 sixth of the board of directors, shall be representatives of the public appointed
7 by the Governor. Unless otherwise specified in this chapter, a representative
8 of the public shall have the same rights and responsibilities as any other
9 member of the board of directors.
10(2) The initial term of one representative of the public shall be two
11 years and the initial term of the other representative of the public shall be three
12 years. If there are more than two representatives of the public, their initial
13 terms shall be divided as equally as possible between the two initial term
14 lengths. Thereafter, each representative of the public appointed by the
15 Governor to succeed a representative of the public shall serve a three-year term
16 and shall serve until a successor is appointed.
17(3) A representative of the public shall be terminated only by the
18 appointing authority, by conclusion of the appointed term, or by voluntary
19 resignation.
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1(4) If a vacancy occurs prior to the conclusion of the three-year term,
2 whether by termination, resignation, or otherwise, the Governor shall appoint a
3 new representative of the public to complete the term.
4    (d) Committees.
5(1) The board of directors may create one or more committees and may
6 appoint members of the board, including the representatives of the public, to
7 serve on them.
8(2) The board shall create a compensation committee to review and
9 recommend to the full board for approval all compensation packages offered to
10 the corporation’s officers and executives.
11(A) The compensation committee shall be composed of two or more
12 members, who shall serve at the pleasure of the board of directors.
13(B) At least two representatives of the public shall be voting
14 members of the compensation committee.
15    (e) Guiding principles for representatives of the public. In discharging the
16 duties of a director, including as a member of a committee, each representative
17 of the public:
18(1) shall, in determining what the representative of the public
19 reasonably believes to be in the best interests of the hospital service
20 corporation, consider the effects of any action or inaction on:
21(A) the subscribers of the hospital service corporation;
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1(B) the community and societal considerations of the State of
2 Vermont, including the principles for health care reform expressed in 18
3 V.S.A. § 9371; and
4(C) the goal that the hospital service corporation’s benefits and
5 services should be provided at minimum cost and under efficient and
6 economical management of the corporation;
7(2) may consider any other relevant factors and the interests of any
8 other group that the representative of the public determines are appropriate to
9 consider; and
10(3) shall not be required to give priority to the interests of any particular
11 person or group described in subdivision (1) or (2) of this subsection over the
12 interests of any other person or group.
13    (f) No violation of Title 11B. The consideration of interests and factors in
14 the manner described in subsection (e) of this section shall not constitute a
15 violation of Title 11B.
16    (g) Limitations on liability.
17(1) A representative of the public is not liable for the failure of the
18 hospital service corporation to create general or specific impacts on the
19 community or the health care system.
20(2) A representative of the public is not liable to the hospital service
21 corporation for any action or failure to take action in the representative’s
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1 official capacity if the representative of the public performed the duties of the
2 office in compliance with Title 11B and this section. In the event of a conflict
3 between Title 11B and this chapter, this chapter shall control.
4(3) A representative of the public shall have no duty to any person who
5 is a beneficiary of the general or specific public benefit purposes of a hospital
6 service corporation arising solely from the person’s status as a beneficiary of
7 the general or specific public benefit.
8    (h) Bylaws. Any new hospital benefit corporation shall adopt bylaws in
9 accordance with the requirements of this chapter and Title 11B. All bylaws
10 shall be filed with the Commissioner of Financial Regulation for review and
11 approval.
12***
13 § 4516a. EXECUTIVE COMPENSATION
14    (a) As used in this section:
15(1) “Compensation” means total cash compensation, including base
16 salary and annual incentive compensation.
17(2) “Executives” means the president, chief executive officer, chief
18 medical officer, chief administrative officer, chief fiscal officer, vice
19 presidents, and all functionally equivalent roles in a hospital service
20 corporation.
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1    (b) On or before July 1, 2026, and prior to approving any changes to the
2 compensation of any executive after that date, each hospital service
3 corporation shall file with the Commissioner of Financial Regulation a
4 statement sworn to by the chair of the corporation’s board of directors and the
5 president of the corporation that includes the following information regarding
6 compensation paid to executives of the corporation:
7(1) all compensation benchmarks utilized in connection with
8 establishing or awarding compensation for each of the corporation’s
9 executives, including information used by any consultant, vendor, or other
10 third party retained by the corporation;
11(2) a detailed compensation survey or peer group data used by the
12 corporation or by any consultant, vendor, or other third party retained by the
13 corporation to establish compensation benchmarks or otherwise to establish or
14 award compensation for each of the corporation’s executives; and
15(3) if any bonus or variable compensation was awarded or paid for the
16 prior fiscal year, the criteria used to evaluate whether that compensation
17 should be paid or awarded and the specific results that supported the payment.
18    (c) The Commissioner may require the corporation to modify a group
19 described in subdivision (b)(2) of this section if, in the Commissioner’s
20 discretion, the group contains entities that are not sufficiently similar to the
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1 corporation in terms of size, business, operations, nonprofit status, or other
2 factors.
3    (d) The Commissioner may retain at the corporation’s expense such outside
4 consultants and other experts as are reasonably necessary to assist the
5 Commissioner in evaluating the materials provided pursuant to this section.
6 Any persons so retained shall be under the direction and control of the
7 Commissioner and shall act in a purely advisory capacity.
8    (e) Nothing in this section shall be construed to preclude a corporation
9 from segregating and designating any materials provided to the Commissioner
10 under this section as confidential due to content that is proprietary, privileged,
11 or otherwise confidential under Vermont law, and the Commissioner shall
12 maintain the confidentiality of the information as appropriate under the Public
13 Records Act.
14***
15 Sec. 2. HOSPITAL SERVICE CORPORATIONS; IMPLEMENTATION OF
16AMENDMENTS TO 8 V.S.A. CHAPTER 123
17    Not later than September 1, 2026, each hospital service corporation
18 operating in this State on July 1, 2026, shall amend its bylaws to comply with
19 the amendments to 8 V.S.A. chapter 123 as set forth in Sec. 1 of this act. The
20 hospital service corporation shall file its amended bylaws with the
21 Commissioner of Financial Regulation for review and approval.
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1* * * Limited Age Rating * * *
2 Sec. 3. 8 V.S.A. § 4516 is amended to read:
3 § 4516. ANNUAL REPORT TO COMMISSIONER
4    Annually, on or before March 1, a hospital service corporation shall file
5 with the Commissioner of Financial Regulation a statement sworn to by the
6 president and treasurer of the corporation showing its condition on December
7 31. The statement shall be in such form and contain such matters as the
8 Commissioner shall prescribe. To qualify for the tax exemption set forth in
9 section 4518 of this title, the statement shall include a certification that the
10 hospital service corporation operates on a nonprofit basis for the purpose of
11 providing an adequate hospital service plan to individuals of the State, both
12 groups and nongroups, without discrimination based on age, gender,
13 geographic area, industry, and medical history, except as allowed by 33 V.S.A.
14 § 1811(f)(2)(B).
15 Sec. 4. 8 V.S.A. § 4588 is amended to read:
16 § 4588. ANNUAL REPORT TO COMMISSIONER
17    Annually, on or before March 1, a medical service corporation shall file
18 with the Commissioner of Financial Regulation a statement sworn to by the
19 president and treasurer of the corporation showing its condition on December
20 31, which shall be in such form and contain such matters as the Commissioner
21 shall prescribe. To qualify for the tax exemption set forth in section 4590 of
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1 this title, the statement shall include a certification that the medical service
2 corporation operates on a nonprofit basis for the purpose of providing an
3 adequate medical service plan to individuals of the State, both groups and
4 nongroups, without discrimination based on age, gender, geographic area,
5 industry, and medical history, except as allowed by 33 V.S.A. § 1811(f)(2)(B).
6 Sec. 5. 8 V.S.A. § 5115 is amended to read:
7 § 5115. DUTY OF NONPROFIT HEALTH MAINTENANCE
8ORGANIZATIONS
9    Any nonprofit health maintenance organization subject to this chapter shall
10 offer nongroup plans to individuals in accordance with 33 V.S.A. § 1811
11 without discrimination based on age, gender, industry, and medical history,
12 except as allowed by 33 V.S.A. § 1811(f)(2)(B).
13 Sec. 6. DEPARTMENT OF FINANCIAL REGULATION; HEALTH
14INSURANCE PLANS; LIMITED AGE RATING
15    The Department of Financial Regulation shall review and amend its rules
16 and guidance as needed to allow health insurers to use age classifications in the
17 premiums charged for their individual and small group plans starting in the
18 2028 plan year, provided that the premium charged to any cohort shall not
19 deviate by more than five percent above or below the community rate filed by
20 the health insurer pursuant to 8 V.S.A. § 4026.
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1* * * Expanding Access to Association Health Plans * * *
2 Sec. 7. 8 V.S.A. § 4041 is amended to read:
3 § 4041. GROUP HEALTH INSURANCE POLICIES; DEFINITIONS
4    (a) As used in this section:
5(1) “Employees” includes the officers, managers, and employees of the
6 employer; the partners, if the employer is a partnership; the officers, managers,
7 and employees of subsidiary or affiliated corporations of a corporation
8 employer; and the individual proprietors, partners, and employees of
9 individuals and firms, the business of which is controlled by the insured
10 employer through stock ownership, contract, or otherwise.
11(2) “Employer” may be deemed to include any municipal or
12 governmental entity or officer, or the appropriate officer for an unincorporated
13 town or gore or for the Unified Towns and Gores of Essex County, as well as
14 private individuals, partnerships, and corporations.
15    (b) Group health insurance is a form of health insurance that covers one or
16 more persons, with or without their dependents, that is issued upon the
17 following basis:
18(1)(A) Under a policy issued to an employer, who is deemed the
19 policyholder, insuring at least one employee of the employer, for the benefit of
20 persons other than the employer.
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1(B) In accordance with section 3368 of this title, an employer
2 domiciled in a jurisdiction other than Vermont that has more than 25
3 certificate-holder employees whose principal worksite and domicile is in
4 Vermont and that is defined as a large group in its own jurisdiction and under
5 the Patient Protection and Affordable Care Act, Pub. L. No. 111-148, § 1304,
6 as amended by the Health Care and Education Reconciliation Act of 2010,
7 Pub. L. No. 111-152, may purchase insurance in the large group health
8 insurance market for its Vermont-domiciled certificate-holder employees.
9(2)(A) Under a policy issued:
10(i) to an association, a trust, or one or more trustees of a fund
11 established by one or more associations otherwise eligible for the issuance of a
12 policy under this subdivision (2) and maintained, directly or indirectly, by one
13 or more associations for the benefit of its members or a contract or plan issued
14 by such an association or trust; or
15(ii) by a “multiple employer welfare arrangement” that constitutes
16 an “employer,” as those terms are defined in the Employee Retirement Income
17 Security Act of 1974, as amended, and accompanying U.S. Department of
18 Labor regulations and guidance.
19(B)(i) The association or associations shall have:
20(I) a minimum of 100 persons at the time of incorporation or
21 formation;
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1(II) been organized and maintained in good faith for purposes
2 other than that of obtaining insurance;
3(III) been in active existence for at least one year; and
4(IV) a constitution and bylaws that provide that:
5(aa) the association or associations hold regular meetings
6 not less than annually to further purposes of the members;
7(bb) except for credit unions, the association or associations
8 collect dues or solicit contributions from members; and
9(cc) the members constitute a majority of the voting power
10 of the association for all purposes and have representation on the governing
11 board and committees.
12(ii)(I) The association or associations shall not be controlled by a
13 health insurer, as evidenced by the operation of the association or associations.
14(II) The following factors may be used as evidence to
15 determine whether an association is a health insurer-operated association;
16 provided, however, that the presence or absence of one or more of these
17 factors shall not serve to limit or be dispositive of such a determination:
18(aa) common board members, officers, executives, or
19 employees;
20(bb) common ownership of the health insurer and the
21 association, or of the association and another eligible group; and
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1(cc) common use of office space or equipment used by the
2 health insurer to transact insurance. [Repealed.]
3(C) An association’s members shall have a shared or common
4 purpose that is not primarily a business or customer relationship. [Repealed.]
5(D)(i) A policy issued by an association shall not insure persons
6 other than the members or employees of the association or associations, or
7 employees of members, or all of any class or classes of employees of the
8 association, associations, or members, together, in each case, with the
9 employees’ or members’ dependents, as applicable, for the benefit of persons
10 other than the employee’s employer.
11(ii) A policy issued by an association shall insure all eligible
12 persons, except those who reject coverage in writing.
13(E) An association shall not use the solicitation of insurance as the
14 primary method of obtaining new members.
15(F) If a health insurer collects membership fees or dues on behalf of
16 an association, the health insurer shall disclose to the members of the
17 association that the health insurer is billing and collecting membership fees
18 and dues on behalf of the association.
19(3)(A) Under a policy issued to a trust, or to one or more trustees of a
20 fund established and maintained, directly or indirectly, by:
21(i) two or more employers;
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1(ii) one or more labor unions or similar employee organizations;
2 or
3(iii) one or more employers and one or more labor unions or
4 similar employee organizations.
5(B)(i) A policy under this subdivision (3) must be issued to the trust
6 or trustees for the purpose of insuring all of the employees of the employers or
7 all of the members of the unions or organizations, or all of any class or classes
8 of employees or members, together, in each case, with the employees’ or
9 members’ dependents, as applicable, for the benefit of persons other than the
10 employers or the unions or organizations.
11(ii) A policy issued to a trust shall insure all eligible persons,
12 except those who reject coverage in writing.
13(4) Under a policy issued to any other substantially similar group that,
14 in the discretion of the Commissioner, may be subject to the issuance of a
15 group accident and sickness policy or contract.
16 Sec. 8. 8 V.S.A. § 4043 is amended to read:
17 § 4043. ASSOCIATION HEALTH PLANS
18      (a)(1) As used in this section, “association health plan” means a policy
19 issued to an association; to a trust; or to one or more trustees of a fund
20 established, created, or maintained for the benefit of the members of one or
21 more associations or a contract or plan issued by an association or trust or by a
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1 multiple employer welfare arrangement as defined in the Employee Retirement
2 Income Security Act of 1974, 29 U.S.C. § 1001 et seq.
3(2) No association health plan shall be issued, offered, or renewed in
4 this State to any person other than an association that was formed or could
5 have been formed under the Employee Retirement Income Security Act of
6 1974, 29 U.S.C. § 1001 et seq., and accompanying U.S. Department of Labor
7 regulations and guidance, in each case, as in effect as of January 19, 2017 a
8 group described in subdivision 4041(b)(2), (3), or (4) of this chapter.
9    (b) The Commissioner shall adopt rules pursuant to 3 V.S.A. chapter 25
10 regulating association health plans in order to protect Vermont consumers and
11 promote the stability of Vermont’s health insurance markets, to the extent
12 permitted under federal law, including rules regarding licensure, solvency and
13 reserve requirements, and rating requirements.
14    (c) The Notwithstanding any statute or rule to the contrary, the provisions
15 of section sections 3661 and 4042 of this title shall apply to fully insured
16 association health plans.
17      * * * Expanding Access to Short-Term, Limited-Duration Plans * * *
18 Sec. 9. 8 V.S.A. § 4053 is amended to read:
19 § 4053. SHORT-TERM, LIMITED-DURATION HEALTH INSURANCE
20    (a) As used in this section, “short-term, limited-duration health insurance”
21 means health insurance that provides medical, hospital, or major medical
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1 expense benefits coverage pursuant to a policy or contract with a health insurer
2 and that has an expiration date specified in the policy or contract that is three
3 months or less after the original effective date of the policy or contract has the
4 same meaning as “short-term, limited-duration insurance” in 45 C.F.R.
5 § 144.103.
6    (b) No person shall provide short-term, limited-duration health insurance
7 coverage without a certificate of authority from the Commissioner to offer
8 health insurance in this State unless the person is exempted by subdivision
9 3368(a)(4) of this title.
10    (c) A short-term, limited-duration health insurance policy or contract shall
11 be nonrenewable, and a health insurer shall not issue a short-term, limited-
12 duration health insurance policy or contract to any person if the issuance
13 would result in the person being covered by short-term, limited-duration health
14 insurance coverage for more than three months in any 12-month period not
15 have a duration of longer than 12 months in total, taking into account any
16 renewals or extensions.
17    (d) A policy or contract for short-term, limited-duration health insurance
18 coverage shall display prominently in the policy or contract and in any
19 application materials provided in connection with enrollment in that coverage,
20 in at least 14-point type, certain disclosures regarding the scope of short-term,
21 limited-duration health insurance coverage, including the types of benefits and
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1 consumer protections that are and are not included. The Commissioner shall
2 determine the specific disclosure language that shall be used in all short-term,
3 limited-duration health insurance policies, contracts, and application materials
4 and shall provide the language to the health insurers offering that coverage.
5    (e) The Commissioner shall adopt rules pursuant to 3 V.S.A. chapter 25:
6(1) establishing the minimum financial, marketing, service, and other
7 requirements for registration of a health insurer to provide short-term, limited-
8 duration health insurance coverage to individuals in this State;
9(2) requiring a health insurer seeking to provide short-term, limited-
10 duration health insurance coverage to individuals in this State to file its rates
11 and forms with the Commissioner for the Commissioner’s approval;
12(3) requiring a health insurer seeking to provide short-term, limited-
13 duration health insurance coverage to individuals in this State to file its
14 advertising materials with the Commissioner for the Commissioner’s approval;
15 and
16(4) establishing such other requirements as the Commissioner deems
17 necessary to protect Vermont consumers and promote the stability of
18 Vermont’s health insurance markets.
19    (f) The provisions of section 4063 of this title, and any rules adopted under
20 that section, shall apply to short-term, limited-duration health insurance
21 coverage.
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1      * * * Defining “High-Dollar Claims” for Claims Edit Purposes * * *
2 Sec. 10. 18 V.S.A. § 9418a is amended to read:
3 § 9418a. PROCESSING CLAIMS, DOWNCODING, AND ADHERENCE
4TO CODING RULES
5***
6    (e)(1) Except as otherwise provided in subdivision (2) of this subsection,
7 no health plan, contracting entity, covered entity, or payer shall subject any
8 health care provider to prepayment coding validation edit review. As used in
9 this subsection, “prepayment coding validation edit review” means any action
10 by the health plan, contracting entity, covered entity, or payer, or by a
11 contractor, assignee, agent, or other entity acting on its behalf, requiring a
12 health care provider to provide medical record documentation in conjunction
13 with or after submission of a claim for payment for health care services
14 delivered, but before the claim has been adjudicated.
15(2) Nothing in this subsection shall be construed to prohibit targeted
16 prepayment coding validation edit review of a specific provider, provider
17 group, or facility under certain circumstances, including evaluating high-dollar
18 claims exceeding $25,000.00 per episode of care; verifying complex financial
19 arrangements; investigating member questions; conducting post-audit
20 monitoring; addressing a reasonable belief of fraud, waste, or abuse; or other
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1 circumstances determined by the Commissioner through a bulletin or
2 guidance.
3***
4     * * * Limiting Prior Authorization Exemptions for Primary Care * * *
5 Sec. 11. 18 V.S.A. § 9418b is amended to read:
6 § 9418b. PRIOR AUTHORIZATION
7***
8    (c)(1)(A) Except as provided in subdivision (B) of this subdivision (1), a
9 health plan shall not impose any prior authorization requirement for any
10 admission, item, service, treatment, or procedure ordered by a primary care
11 provider who practices at an independent physician practice that is not owned
12 or affiliated with a hospital or hospital network and who is not employed by or
13 otherwise under the control of a hospital or hospital network.
14(B) The prohibition set forth in subdivision (A) of this subdivision
15 (1) shall not be construed to prohibit prior authorization requirements for
16 prescription drugs or for an admission, item, service, treatment, or procedure
17 that is provided out-of-network.
18(2) As used in this subsection, “primary care provider” means a health
19 care provider who is contracted and enrolled with the health plan as a primary
20 care provider.
21***
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1* * * Site-Neutral Billing * * *
2 Sec. 12. 18 V.S.A. § 9376 is amended to read:
3 § 9376. PAYMENT AMOUNTS; METHODS
4    (a) Intent. It is the intent of the General Assembly:
5(1) to ensure payments to health care professionals that are consistent
6 with efficiency, economy, and quality of care and will permit them to provide,
7 on a solvent basis, effective and efficient health care services that are in the
8 public interest. It is also the intent of the General Assembly;
9(2) to eliminate the shift of costs between the payers of health care
10 services to ensure that the amount paid to health care professionals is sufficient
11 to enlist enough providers to ensure that health care services are available to
12 all Vermonters and are distributed equitably; and
13(3) that payments for health care services that can be delivered safely
14 and affordably outside a hospital setting should be standardized regardless of
15 the health care setting in which they are delivered.
16***
17    (f) Site-neutral billing.
18(1) The Board, in coordination with the Department of Financial
19 Regulation, shall identify outpatient or ambulatory items and services that are
20 safe and appropriate to be delivered in lower-cost, nonhospital settings. For
21 each of these items and services, the Board shall establish a single reference-
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1 based price that shall be applied in all hospital and nonhospital service
2 locations across Vermont, based on a percentage of the Medicare
3 reimbursement rate for the same or a similar item or service or on another
4 benchmark, as appropriate, using the same parameters as set forth in
5 subdivision (e)(2)(A) of this section.
6(2)(A) In developing site-neutral, reference-based prices for site-neutral
7 billing pursuant to this subsection (f), the Board and the Department shall
8 consult with health insurers, hospitals, other health care professionals as
9 applicable; the Office of the Health Care Advocate; and the Agency of Human
10 Services.
11(B) The Board shall implement site-neutral billing in a manner that
12 does not allow health care professionals to charge or collect from patients or
13 health insurers, and does not allow health insurers to pay, any amount for the
14 outpatient or ambulatory item or service in excess of the site-neutral,
15 reference-based amount established by the Board.
16(3) The Board shall identify factors that would necessitate terminating
17 or modifying the use of site-neutral billing, such as a measurable reduction in
18 access to or quality of care.
19(4) The Board’s authority to implement site-neutral billing pursuant to
20 this subsection shall not include the authority to set amounts applicable to
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1 outpatient or ambulatory items provided or services delivered to patients who
2 are enrolled in Medicare or Medicaid.
3* * * Section 1332 Reinsurance Waiver * * *
4 Sec. 13. REINSURANCE; AUTHORIZATION TO PURSUE SECTION
51332 WAIVER
6   The Department of Vermont Health Access, in consultation with the
7 Department of Financial Regulation, is authorized to submit a State Innovation
8 Waiver pursuant to Section 1332 of the Patient Protection and Affordable Care
9 Act of 2010, Pub. L. No. 111-148, as amended by the Health Care and
10 Education Reconciliation Act of 2010, Pub. L. No. 111-152, to establish a
11 program for reinsurance and seek federal pass-through funding of amounts
12 attributable to premium tax credits under 26 U.S.C. § 36B and cost-sharing
13 reductions under 42 U.S.C. § 18071.
14* * * Effective Date * * *
15 Sec. 14. EFFECTIVE DATE
16   This act shall take effect on July 1, 2026.
      * * * Health Insurer Governance and Executive Compensation * * *
 Sec. 1. 8 V.S.A. chapter 123 is amended to read:
    CHAPTER 123. NONPROFIT HOSPITAL SERVICE CORPORATIONS
                                       ***
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§ 4512. POWERS
   (a)   Such A hospital service corporation shall be a nonprofit sharing
corporation without capital stock. It shall be maintained and operated solely
for the benefit of the its subscribers thereof and shall ensure that benefits and
services are balanced with the efficient and economical management of the
corporation. A hospital service corporation shall not be authorized to pay
money in lieu of hospital service.  A person, partnership, association, or
corporation shall not contract to furnish hospital service unless authorized so
to do so pursuant to the provisions of this chapter. Corporations formed under
the provisions of this chapter shall have the privileges and be subject to the
provisions of Title 11B as well as the applicable provisions of this chapter. In
the event of a conflict between the provisions of Title 11B and the provisions of
this chapter, the latter shall control.
                                      ***
§ 4513. PERMIT TO ENGAGE IN BUSINESS; FOREIGN
     CORPORATIONS
   (a)   At least three-fourths of the board of directors of a corporation
organized under this chapter shall be composed of subscribers and members of
the public. The remainder may be providers. The subscriber members of the
board shall comprise at least a majority of the board. A corporation organized
under this chapter shall provide for the election of its board of directors at a
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publicly announced meeting. As used in this section, “provider” means any
person who is a provider of hospital or medical services, or who is an
employee, director, trustee, or representative of a provider of such services.
[Repealed.]
                                 ***
§ 4513a. BOARD OF DIRECTORS
   (a) Definitions. As used in this section:
  (1) “Provider” means any person who is a provider of hospital or
medical services, or who is an employee, director, trustee, or representative of
a provider of such services.
  (2) “Representative of the public” means any member of the board of
directors appointed by the Governor. A representative of the public may be a
member of the public, a subscriber, or a provider.
   (b) Composition. At least three-fourths of the board of directors of a
corporation organized under this chapter shall be composed of subscribers and
members of the public. The remainder may be providers. The subscriber
members of the board shall comprise at least a majority of the board. A
corporation organized under this chapter shall provide for the election of its
board of directors at a publicly announced meeting.
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   (c) Representatives of the public.
  (1) Two voting members of the board, but in no event less than one-sixth
of the board of directors, shall be representatives of the public appointed by
the Governor. Unless otherwise specified in this chapter, a representative of
the public shall have the same rights and responsibilities as any other member
of the board of directors.
  (2) The initial term of one representative of the public shall be two years
and the initial term of the other representative of the public shall be three
years. If there are more than two representatives of the public, their initial
terms shall be divided as equally as possible between the two initial term
lengths.    Thereafter, each representative of the public appointed by the
Governor to succeed a representative of the public shall serve a three-year
term and shall serve until a successor is appointed.
  (3)   A representative of the public shall be terminated only by the
appointing authority, by conclusion of the appointed term, or by voluntary
resignation.
  (4) If a vacancy occurs prior to the conclusion of the three-year term,
whether by termination, resignation, or otherwise, the Governor shall appoint
a new representative of the public to complete the term.
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   (d) Committees.
  (1) The board of directors may create one or more committees and may
appoint members of the board, including the representatives of the public, to
serve on them.
  (2) The board shall create a compensation committee to review and
recommend to the full board for approval all compensation packages offered to
the corporation’s officers and executives.
        (A) The compensation committee shall be composed of two or more
members, who shall serve at the pleasure of the board of directors.
        (B) At least two representatives of the public shall be voting members
of the compensation committee.
   (e) Guiding principles for representatives of the public. In discharging the
duties of a director, including as a member of a committee, each representative
of the public:
  (1)  shall, in determining what the representative of the public
reasonably believes to be in the best interests of the hospital service
corporation, consider the effects of any action or inaction on:
        (A) the subscribers of the hospital service corporation;
        (B)     the community and societal considerations of the State of
Vermont, including the principles for health care reform expressed in 18 V.S.A.
§ 9371; and
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     (C) the goal that the hospital service corporation’s benefits and
services should be provided at minimum cost and under efficient and
economical management of the corporation;
  (2) may consider any other relevant factors and the interests of any
other group that the representative of the public determines are appropriate to
consider; and
  (3) shall not be required to give priority to the interests of any particular
person or group described in subdivision (1) or (2) of this subsection over the
interests of any other person or group.
   (f) No violation of Title 11B. The consideration of interests and factors in
the manner described in subsection (e) of this section shall not constitute a
violation of Title 11B.
   (g) Limitations on liability.
  (1) A representative of the public is not liable for the failure of the
hospital service corporation to create general or specific impacts on the
community or the health care system.
  (2) A representative of the public is not liable to the hospital service
corporation for any action or failure to take action in the representative’s
official capacity if the representative of the public performed the duties of the
office in compliance with Title 11B and this section. In the event of a conflict
between Title 11B and this chapter, this chapter shall control.
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  (3) A representative of the public shall have no duty to any person who
is a beneficiary of the general or specific public benefit purposes of a hospital
service corporation arising solely from the person’s status as a beneficiary of
the general or specific public benefit.
   (h) Bylaws. Any new hospital benefit corporation shall adopt bylaws in
accordance with the requirements of this chapter and Title 11B. All bylaws
shall be filed with the Commissioner of Financial Regulation for review and
approval.
                                   ***
§ 4516a. EXECUTIVE COMPENSATION
   (a) As used in this section:
  (1) “Compensation” means total cash compensation, including base
salary and annual incentive compensation.
  (2)   “Executives” means the president, chief executive officer, chief
medical officer, chief administrative officer, chief fiscal officer, vice presidents,
and all functionally equivalent roles in a hospital service corporation.
   (b)(1) On or before July 1, 2026, and prior to approving any changes to
the compensation of any executive after that date, each hospital service
corporation shall file with the Commissioner of Financial Regulation a
statement sworn to by the chair of the corporation’s board of directors and the
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president of the corporation that includes the following information regarding
compensation paid to executives of the corporation:
        (A)   all compensation benchmarks utilized in connection with
establishing or awarding compensation for each of the corporation’s
executives, including information used by any consultant, vendor, or other
third party retained by the corporation;
        (B) a detailed compensation survey or peer group data used by the
corporation or by any consultant, vendor, or other third party retained by the
corporation to establish compensation benchmarks or otherwise to establish or
award compensation for each of the corporation’s executives; and
        (C) if any bonus or variable compensation was awarded or paid for
the prior fiscal year, the criteria used to evaluate whether that compensation
should be paid or awarded and the specific results that supported the payment.
  (2)     All information provided pursuant to this subsection shall be
sufficiently detailed to allow for a comprehensive examination of the
benchmarks and to enable the Commissioner or designee to perform
independent computations to evaluate the benchmarks provided.
   (c) The Commissioner may require the corporation to modify a group
described in subdivision (b)(2) of this section if, in the Commissioner’s
discretion, the group contains entities that are not sufficiently similar to the
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corporation in terms of size, business, operations, nonprofit status, or other
factors.
   (d) The Commissioner may retain at the corporation’s expense such outside
consultants and other experts as are reasonably necessary to assist the
Commissioner in evaluating the materials provided pursuant to this section.
Any persons so retained shall be under the direction and control of the
Commissioner and shall act in a purely advisory capacity.
   (e) Nothing in this section shall be construed to preclude a corporation
from segregating and designating any materials provided to the Commissioner
under this section as confidential due to content that is proprietary, privileged,
or otherwise confidential under Vermont law, and the Commissioner shall
maintain the confidentiality of the information as appropriate under the Public
Records Act.
                                  ***
Sec. 2. HOSPITAL SERVICE CORPORATIONS; IMPLEMENTATION OF
       AMENDMENTS TO 8 V.S.A. CHAPTER 123
   Not later than September 1, 2026, each hospital service corporation
operating in this State on July 1, 2026, shall amend its bylaws to comply with
the amendments to 8 V.S.A. chapter 123 as set forth in Sec. 1 of this act. The
hospital service corporation shall file its amended bylaws with the
Commissioner of Financial Regulation for review and approval.
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        * * * Expanding Access to Association Health Plans * * *
Sec. 3. 8 V.S.A. § 4041 is amended to read:
§ 4041. GROUP HEALTH INSURANCE POLICIES; DEFINITIONS
   (a) As used in this section:
  (1) “Employees” includes the officers, managers, and employees of the
employer; the partners, if the employer is a partnership; the officers,
managers, and employees of subsidiary or affiliated corporations of a
corporation employer; and the individual proprietors, partners, and employees
of individuals and firms, the business of which is controlled by the insured
employer through stock ownership, contract, or otherwise.
  (2)      “Employer” may be deemed to include any municipal or
governmental entity or officer, or the appropriate officer for an unincorporated
town or gore or for the Unified Towns and Gores of Essex County, as well as
private individuals, partnerships, and corporations.
   (b) Group health insurance is a form of health insurance that covers one or
more persons, with or without their dependents, that is issued upon the
following basis:
  (1)(A)    Under a policy issued to an employer, who is deemed the
policyholder, insuring at least one employee of the employer, for the benefit of
persons other than the employer.
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     (B)    In accordance with section 3368 of this title, an employer
domiciled in a jurisdiction other than Vermont that has more than 25
certificate-holder employees whose principal worksite and domicile is in
Vermont and that is defined as a large group in its own jurisdiction and under
the Patient Protection and Affordable Care Act, Pub. L. No. 111-148, § 1304,
as amended by the Health Care and Education Reconciliation Act of 2010,
Pub. L. No. 111-152, may purchase insurance in the large group health
insurance market for its Vermont-domiciled certificate-holder employees.
  (2)(A) Under a policy issued:
         (i) to an association, a trust, or one or more trustees of a fund
established by one or more associations otherwise eligible for the issuance of a
policy under this subdivision (2) and maintained, directly or indirectly, by one
or more associations for the benefit of its members or a contract or plan issued
by such an association or trust; or
         (ii)   by a “multiple employer welfare arrangement” that
constitutes an “employer,” as those terms are defined in the Employee
Retirement Income Security Act of 1974, as amended, and accompanying U.S.
Department of Labor regulations and guidance.
     (B)(i) The association or associations shall have:
            (I) a minimum of 100 persons at the time of incorporation or
formation;
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            (II) been organized and maintained in good faith for purposes
other than that of obtaining insurance;
            (III) been in active existence for at least one year; and
            (IV) a constitution and bylaws that provide that:
               (aa) the association or associations hold regular meetings
not less than annually to further purposes of the members;
               (bb) except for credit unions, the association or associations
collect dues or solicit contributions from members; and
               (cc) the members constitute a majority of the voting power
of the association for all purposes and have representation on the governing
board and committees.
         (ii)(I) The association or associations shall not be controlled by a
health insurer, as evidenced by the operation of the association or
associations.
            (II) The following factors may be used as evidence to determine
whether an association is a health insurer-operated association; provided,
however, that the presence or absence of one or more of these factors shall not
serve to limit or be dispositive of such a determination:
               (aa)    common board members, officers, executives, or
employees;
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              (bb)   common ownership of the health insurer and the
association, or of the association and another eligible group; and
              (cc) common use of office space or equipment used by the
health insurer to transact insurance. [Repealed.]
     (C)   An association’s members shall have a shared or common
purpose that is not primarily a business or customer relationship. [Repealed.]
     (D)(i) A policy issued by an association shall not insure persons
other than the members or employees of the association or associations, or
employees of members, or all of any class or classes of employees of the
association, associations, or members, together, in each case, with the
employees’ or members’ dependents, as applicable, for the benefit of persons
other than the employee’s employer.
        (ii) A policy issued by an association shall insure all eligible
persons, except those who reject coverage in writing.
     (E) An association shall not use the solicitation of insurance as the
primary method of obtaining new members.
     (F) If a health insurer collects membership fees or dues on behalf of
an association, the health insurer shall disclose to the members of the
association that the health insurer is billing and collecting membership fees
and dues on behalf of the association.
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  (3)(A) Under a policy issued to a trust, or to one or more trustees of a
fund established and maintained, directly or indirectly, by:
        (i) two or more employers;
        (ii) one or more labor unions or similar employee organizations;
or
        (iii) one or more employers and one or more labor unions or
similar employee organizations.
     (B)(i) A policy under this subdivision (3) must be issued to the trust
or trustees for the purpose of insuring all of the employees of the employers or
all of the members of the unions or organizations, or all of any class or classes
of employees or members, together, in each case, with the employees’ or
members’ dependents, as applicable, for the benefit of persons other than the
employers or the unions or organizations.
        (ii) A policy issued to a trust shall insure all eligible persons,
except those who reject coverage in writing.
  (4) Under a policy issued to any other substantially similar group that,
in the discretion of the Commissioner, may be subject to the issuance of a
group accident and sickness policy or contract.
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Sec. 4. 8 V.S.A. § 4043 is amended to read:
§ 4043. ASSOCIATION HEALTH PLANS
   (a)(1) As used in this section, “association health plan” means a policy
issued to an association; to a trust; or to one or more trustees of a fund
established, created, or maintained for the benefit of the members of one or
more associations or a contract or plan issued by an association or trust or by
a multiple employer welfare arrangement as defined in the Employee
Retirement Income Security Act of 1974, 29 U.S.C. § 1001 et seq.
  (2) No association health plan shall be issued, offered, or renewed in
this State to any person other than an association that was formed or could
have been formed under the Employee Retirement Income Security Act of
1974, 29 U.S.C. § 1001 et seq., and accompanying U.S. Department of Labor
regulations and guidance, in each case, as in effect as of January 19, 2017 a
group described in subdivision 4041(b)(2), (3), or (4) of this chapter.
   (b) The Commissioner shall adopt rules pursuant to 3 V.S.A. chapter 25
regulating association health plans in order to protect Vermont consumers and
promote the stability of Vermont’s health insurance markets, to the extent
permitted under federal law, including rules regarding licensure, solvency and
reserve requirements, and rating requirements.
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   (c) The Notwithstanding any statute or rule to the contrary, the provisions
of section sections 3661 and 4042 of this title shall apply to fully insured
association health plans.
Sec. 5. ASSOCIATION HEALTH PLANS; FEDERAL LANDSCAPE;
    MARKET IMPACTS; RATE REVIEW; REPORT
   On or before January 15, 2027, the Department of Financial Regulation
shall report to the House Committee on Health Care and the Senate
Committees on Health and Welfare and on Finance the following information
related to expanding access to association health plans beginning on January
1, 2028, as permitted by 8 V.S.A. §§ 4041 and 4043, as amended by Secs. 3
and 4 of this act:
  (1)   the status of federal law regarding association health plans,
including the extent to which federal law would allow for the expanded access
to association health plans in Vermont beginning on January 1, 2028;
  (2) an analysis of the projected impacts on Vermont’s health insurance
markets of expanding access to association health plans beginning on January
1, 2028, including the likely effects on enrollment in and premiums for
qualified health benefit plans in the individual and small group markets, using
scenarios that show potential impacts over consecutive years if various
percentages of healthier lives were to leave the individual and the small group
markets to enroll in association health plans; and
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  (3) in consultation with the Green Mountain Care Board, the potential
impact of expanding access to association health plans beginning on January
1, 2028, on the Green Mountain Care Board’s health insurance rate review
responsibilities pursuant to 8 V.S.A. § 4026.
 * * * Defining “High-Dollar Claims” for Claims Edit Purposes * * *
Sec. 6. 18 V.S.A. § 9418a is amended to read:
§ 9418a. PROCESSING CLAIMS, DOWNCODING, AND ADHERENCE
      TO CODING RULES
                                  ***
   (e)(1) Except as otherwise provided in subdivision (2) of this subsection, no
health plan, contracting entity, covered entity, or payer shall subject any health
care provider to prepayment coding validation edit review. As used in this
subsection, “prepayment coding validation edit review” means any action by
the health plan, contracting entity, covered entity, or payer, or by a contractor,
assignee, agent, or other entity acting on its behalf, requiring a health care
provider to provide medical record documentation in conjunction with or after
submission of a claim for payment for health care services delivered, but
before the claim has been adjudicated.
  (2) Nothing in this subsection shall be construed to prohibit targeted
prepayment coding validation edit review of a specific provider, provider
group, or facility under certain circumstances, including evaluating high-
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dollar claims exceeding $25,000.00 per episode of care; verifying complex
financial arrangements; investigating member questions; conducting post-
audit monitoring; addressing a reasonable belief of fraud, waste, or abuse; or
other circumstances determined by the Commissioner through a bulletin or
guidance.
                                 ***
         * * * Site-Neutral Billing for Certain Services * * *
Sec. 7. 18 V.S.A. § 9423 is added to read:
§ 9423. SITE-NEUTRAL REIMBURSEMENT FOR PHYSICAL
     THERAPY, OCCUPATIONAL THERAPY, AND ATHLETIC
     TRAINING
  Each health plan shall establish and pay for all physical therapy,
occupational therapy, and athletic training items and services provided to its
insureds in reimbursement amounts that are uniform and consistent across all
of the health plan’s contracts and fee schedules, except that a plan may
reimburse different amounts for items and services that are delivered in an
inpatient setting. Health plans shall express each reimbursement amount as a
percentage of the Medicare rate for the same item or service.
Sec. 8. SITE-NEUTRAL REIMBURSEMENT FOR PHYSICAL
    THERAPY, OCCUPATIONAL THERAPY, AND ATHLETIC
     TRAINING; IMPLEMENTATION REPORT
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   On or before March 1, 2027, each health insurer that is required to make
site-neutral reimbursements for physical therapy, occupational therapy, and
athletic training items and services pursuant to 18 V.S.A. § 9423, as added by
Sec. 7 of this act, shall provide an update to the House Committee on Health
Care and the Senate Committees on Health and Welfare and on Finance
regarding its implementation of the site-neutral reimbursements, any trends or
other financial impacts it has identified so far as a result of implementation,
and any recommendations regarding the enactment of additional site-neutral
reimbursement requirements.
  * * * Increasing Flexibility in Health Insurance Plan Design * * *
Sec. 9. INCREASING FLEXIBILITY IN HEALTH INSURANCE PLAN
    DESIGN; REPORT
   The Department of Vermont Health Access, in consultation with the
Department of Financial Regulation, shall consider the feasibility and
potential impacts on premiums and on plan design of allowing health insurers
to offer health insurance plans in the large group market and at each metal
level in the individual and small group markets that do not include the out-of-
pocket limits for prescription drugs established in 8 V.S.A. § 4092, provided
the health insurers also offer plans in the same markets that do include the out-
of-pocket limits for prescription drugs established in 8 V.S.A. § 4092. On or
before January 15, 2027, the Department of Vermont Health Access shall
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provide its findings and recommendations for increasing flexibility in health
insurance plans’ out-of-pocket prescription drug limits to the House
Committee on Health Care and the Senate Committees on Health and Welfare
and on Finance.
* * * Annual Reporting on Health Care Sharing Plans and Arrangements * * *
Sec. 10. 8 V.S.A. chapter 115 is added to read:
           CHAPTER 115. HEALTH CARE SHARING PLANS
§ 4271. HEALTH CARE SHARING PLAN OR ARRANGEMENT;
       REPORTING AND CERTIFICATION
   (a) A person that is not authorized by the Commissioner under chapter
101, 123, 125, or 139 of this title to offer insurance in this State and that offers
or intends to offer a plan or arrangement to facilitate payment or
reimbursement of health care costs or services for residents of this State,
regardless of whether the person is domiciled in this State or another state,
shall submit to the Commissioner on or after October 1, 2026, and on or after
March 1 each year thereafter:
    (1) the following information:
      (A) the total number of individuals and households that participated
in the plan or arrangement in this State in the immediately preceding calendar
year;
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    (B) the total number of employer groups that participated in the plan
or arrangement in this State in the immediately preceding calendar year,
specifying the total number of participating individuals in each participating
employer group;
    (C) if the person offers a plan or arrangement in other states, the
total number of participants in the plan or arrangement nationally;
    (D) any contracts the person has entered into with providers in this
State who provide health care services to plan or arrangement participants;
    (E) the total amount of fees, dues, or other payments collected by the
person in the immediately preceding calendar year from individuals, employer
groups, or others that participated in the plan or arrangement, specifying the
percentage of fees, dues, or other payments retained by the person for
administrative expenses;
    (F) the total dollar amount of requests for reimbursement of health
care costs or services that were submitted in this State in the immediately
preceding calendar year by plan or arrangement participants or providers who
provided health care services to plan or arrangement participants;
    (G) the total dollar amount of requests for reimbursement of health
care costs or services that were submitted in this State and were determined to
qualify for reimbursement under the plan or arrangement in the immediately
preceding calendar year;
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     (H) the total dollar amount of payments made to providers in this
State in the immediately preceding calendar year for health care services that
were provided to or received by plan or arrangement participants;
     (I)   the total dollar amount of reimbursements made to plan or
arrangement participants in this State in the immediately preceding calendar
year for health care services provided to or received by a plan or arrangement
participant;
     (J) the total number of requests for reimbursement of health care
costs or services submitted in this State in the immediately preceding calendar
year that were denied, expressed as a percentage of total reimbursement
requests submitted in that calendar year, and the total number of
reimbursement request denials that were appealed;
     (K) the total dollar amount of health care expenses submitted in this
State by plan or arrangement participants or providers in the immediately
preceding calendar year that qualify for reimbursement pursuant to the plan or
arrangement criteria but that, as of the end of that calendar year, have not
been reimbursed, excluding any amounts that the plan or arrangement
participants incurring the health care costs must pay before receiving
reimbursement under the plan or arrangement;
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     (L) the estimated number of plan or arrangement participants the
person anticipates in this State in the next calendar year, specifying the
number of individuals, households, employer groups, and employees;
     (M)    a list of other states in which the person offers a plan or
arrangement;
     (N)   a list of any third parties, other than a licensed insurance
producer, that are associated with or assist the person in offering or enrolling
participants in this State in the plan or arrangement, copies of any training
materials provided to a third party, and a detailed accounting of any
commissions or other fees or remuneration paid to a third party in the
immediately preceding calendar year for:
        (i) marketing, promoting, or enrolling participants in a plan or
arrangement offered by the person in this State; or
        (ii) operating, managing, or administering a plan or arrangement
offered by the person in this State;
     (O)    the total number of licensed insurance producers that are
associated with or assist the person in offering or enrolling participants in this
State in the plan or arrangement, the total number of participants enrolled in
the plan or arrangement through a licensed insurance producer, copies of any
training materials provided to a producer, and a detailed accounting of any
commissions or other fees or remuneration paid to a producer in the
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immediately preceding calendar year for marketing, promoting, or enrolling
participants in a plan or arrangement offered by the person in this State;
     (P) copies of any consumer-facing and marketing materials used in
this State in promoting the person’s plan or arrangement, including plan or
arrangement descriptions, benefit descriptions, and other materials that
explain the plan or arrangement;
     (Q) the name, mailing address, email address, and telephone number
of an individual serving as a contact for the person in this State;
     (R) a list of any parent companies, subsidiaries, and other names that
the person has operated under at any time within the immediately preceding
five calendar years; and
     (S) an organizational chart of the person and a list of the officers and
directors of the person; and
  (2) a certification by an officer of the person that, to the best of the
person’s good-faith knowledge and belief, the information submitted is
accurate and satisfies the requirements of this subsection.
   (b)(1) If a person subject to the requirements of subsection (a) of this
section fails to submit the information required by that subsection, the
submission is incomplete. The Commissioner shall make a determination of
completeness not later than 45 days after the submission is received. If the
Commissioner has not informed the person of any deficiencies in the
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submission within 45 days after receiving the submission, the submission is
considered complete.
   (2)(A)  If the Commissioner determines that a person has failed to
comply with the requirements of subsection (a) of this section, the
Commissioner shall:
            (i)     notify the person that the submission is incomplete and
enumerate in the notification each deficiency found in the person’s submission;
and
            (ii)    allow the person 30 days after notice of the incomplete
submission to remedy the deficiency found in the submission.
          (B) If the person does not remedy the deficiency within the 30-day
period, the Commissioner may impose an administrative penalty not to exceed
$5,000.00 per day.
          (C)     If the person does not remedy the deficiency or deficiencies
within 30 days after the initial administrative penalty is imposed, the
Commissioner may issue a cease and desist order pursuant to section 2110 of
this title.
   (c) On or before April 1, 2027, and on or before each October 1 thereafter,
the Commissioner shall:
   (1) prepare a written report summarizing the information submitted by
persons pursuant to subsection (a) of this section; and
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  (2) post the report on the Department’s website, along with accurate
and evidence-based information about the persons that submitted information
pursuant to subsection (a) of this section, including how consumers may file
complaints.
   (d) The Commissioner may adopt rules as necessary to implement this
section.
                       * * * Effective Dates * * *
Sec. 11. EFFECTIVE DATES
   This act shall take effect on July 1, 2026, except that:
  (1) Secs. 3 and 4 (association health plans; 8 V.S.A. §§ 4041 and 4043)
shall take effect on January 1, 2028; and
  (2) Sec. 7 (18 V.S.A. § 9423; site-neutral reimbursements for physical
therapy, occupational therapy, and athletic training) shall take effect on
October 1, 2026, and shall apply to provider contracts that are entered into,
amended, renewed, or otherwise take effect on and after that date.