VT H0031

Health plans are prohibited from requiring prior authorization for admissions, items, services, treatments, or procedures ordered by a primary care provider, except for prescription drugs and out-of-network services.

"Primary care provider" is redefined as a health care provider who is contracted and enrolled with the health plan as a primary care provider, replacing the previous reference to the Vermont Blueprint for Health definition.

Claim edit standards do not apply to health care services delivered outside Vermont, unless the payer and out-of-state provider agree to apply them.

Payers may use alternative edit standards if they are more favorable to providers, developed with input from Vermont and national provider organizations, approved by the Commissioner of Financial Regulation, and made available to providers.

Claim edit provisions take effect January 1, 2026; prior authorization changes take effect upon passage and must be implemented by all health plans no later than January 1, 2026. Governor signed March 5, 2025.