With the passage of the 2010 Patient Protection and Affordable Care Act, each of the states is faced with reviewing its insurance regulations for compliance with federal law. Major changes are already in place nationally regarding the handling of pre-existing conditions. Children may no longer be excluded from insurance coverage based on such conditions, and they are allowed to remain on their parents’ health policies up to age 26. (This is true regardless of educational or marital status.)
Adults who suffer from pre-existing conditions may seek insurance via high-risk pools, a temporary arrangement until January 1, 2014 when health care exchanges will begin to operate in each state.
General Insurance Regulations
Insurers in Vermont must offer guaranteed renewability and may currently exclude for a pre-existing condition for 12 months with a 12-month look-back period. Coverage may not be denied for reasons of age or health status, and rates can only be raised once a year according to set limits. Companies must offer applicants three options: family coverage, two-person coverage and individual coverage.
Health Care Exchange
On May 26, 2011, Vermont established a far-reaching health reform law placing the state on a trajectory for a single-payer health care system. As a transitional step, the law created the Vermont Health Benefit Exchange. By 2017, Vermont plans to apply for a federal Waiver for State Innovation to transition to Green Mountain Care, a public-private, single-payer system that will provide coverage for all state residents.
Pre-Existing Condition Insurance
The U.S. Department of Health and Human Services administers the Pre-Existing Condition Insurance Plan, which covers primary and specialty care, hospital stays, and medications. Monthly premiums range from $148 to $635 with deductibles of $1000 to $3000 (with the potential for a separate drug deductible.) Out-of-pocket expenses are capped annually at $7000.
Eligibility for Medicaid benefits is determined by income as a percentage of the Federal Poverty Level. All children from birth to age 19 are entitled to Medicaid at 225% FPL. Pregnant women qualify at 200%, parents at 185%, childless adults at 150%, and disabled Social Security recipients at 100%.
Approximately 17 percent of the population of Vermont receives Medicare benefits, with more than 105,000 drawing on prescription drug coverage.
Low-income residents on Medicare can get additional help with drug and medical expenses via Green Mountain Care. The Choices for Care program offers long-term assistance, while the State Health Insurance Program (SHIP), provides counseling and informational services.