Marketplace in Vermont
If you live in Vermont, Vermont Health Connect is the Health Insurance Marketplace to serve you. Instead of HealthCare.gov, you’ll use the Vermont Health Connect website to apply for coverage, compare plans, and enroll. Visit Vermont Health Connect now to apply. Spanish language speakers can contact cuidadodesalud.gov.
Choosing the Right Health Insurance Plan
There are 5 categories of Marketplace insurance plans: Bronze, Silver, Gold, Platinum, and Catastrophic. Plans range from bare bones “bronze” plans which cover 60% of pocket medical costs to “platinum” plans which have greater coverage but come with higher premiums. In general higher premiums mean lower out-of-pocket costs and a wider insurer network of doctors and hospitals.The plans are as listed below: NOTE: All cost sharing is of out of pocket costs. Please see ObamaCare health benefits for services that are covered at no out of pocket charge on all plans. The maximum out-of-pocket costs for any Marketplace plan for 2014 are $6,350 for an individual plan and $12,700 for a family plan. Bronze Plan: The bronze plan is the lowest cost plan available. It has the lowest premiums and in exchange has the lowest actuarial value. The actuarial value of a bronze plan is 60%. This means that 60% of medical costs are paid for by the insurance company, leaving the other 40% to be paid by you. Silver Plan: The Silver plan is the second lowest cost plan, it has an actuarial value of 70%. This means that 70% of medical costs are paid for by the insurance company, leaving the other 30% to be paid by you. The Silver plan is the standard choice for most reasonably healthy families who historically use medical services. Gold Plan: The Gold plan is the second most expensive plan, it has an actuarial value of 80%. This means that 80% of medical costs are paid for by the insurance company, leaving the other 20% to be paid by you. Platinum Plan: The Platinum plan is the plan with the highest premiums offered on the insurance exchange. The Platinum plan as an actuarial value of 90%. This means that 90% of medical costs are paid for by the insurance company, leaving the other 10% to be paid by you. This plan is suggested to those with high incomes and those in poor health. Although coverage is more expensive up front the 90% coverage of costs will help those who use medical services frequently. Catastrophic plans – which have very high deductibles and essentially provide protection from worst-case scenarios, like a serious accident or extended illness — are available to people under 30 years old and to people who have hardship exemptions from the fee that most people without health coverage must pay.
Vermont will expand its Medicaid program in 2014 to cover households with incomes up to 133% of the federal poverty level. That works out to about $15,800 a year for 1 person or $32,500 for a family of 4. You can find out whether you qualify for Medicaid in Vermont 2 ways: Contact your state Medicaid agency right now or fill out an application for coverage in the Health Insurance Marketplace.
If you need more detailed analysis, identification of issues, solutions, and implementation of your health insurance plan please let us know with the form below and we’ll get right back to you.
Accountable Care Organizations in Vermont
ACOs are profit-driven health innovators primarily serving Medicare patients who are financially rewarded by the government and private insurance companies for delivering medical services that lead to better health outcomes for less money.
- Trustees Of Dartmouth College VT – Health Care Innovation Award
- Health Resources In Action VT- Health Care Innovation Award
- State of Vermont VT- Multi-payer Advanced Primary Care Program
- State of Vermont VT – State Innovation Models Initiative: Model Testing Awards
Health care facilities where Innovation Models are being tested
- The Rutland Hospital Rutland, VT – BPCI Initiative: Model 2
The Insurance Exchange/Marketplace
What has been done, not been done, or left up to the federal government to do.
Establishing the Exchange in Vermont
On May 26, 2011, Governor Peter Shumlin (D) signed into law HB 202, a far-reaching health reform law that puts the state on a path toward establishing a single-payer health care system.1 As an interim step, the law created the Vermont Health Benefit Exchange to meet the requirements of federal health reform. The state plans to put into place the components of federal health reform, including the exchange, and in 2017 apply for a federal Waiver for State Innovation to transition to Green Mountain Care, the new public-private single-payer system that will provide coverage for all state residents. In May 2012, the Governor signed additional health system reform legislation further defining the role and duties of the Green Mountain Care Board and the Exchange (HB 559).2 The Vermont Health Insurance Exchange was branded as Vermont Health Connect. Structure: HB 202 defines Vermont’s Exchange as a state-operated division within the Department of Vermont Health Access and headed by a Deputy Commissioner. Governance: The Exchange will be administered by the Department of Vermont Health Access in consultation with a 22-member Medicaid and Exchange Advisory Committee. The Commissioner of Vermont Health Access will serve on the Advisory Committee and appoint members including, a representative of health insurers; five beneficiaries of Medicaid or Medicaid-funded programs; five individuals or representatives of small businesses eligible for or enrolled in the Exchange; five advocates for consumer organizations; and five health care professionals. The Vermont Exchange will be overseen by the Green Mountain Care Board, which is charged with moving the state through several stages of health care system change, ultimately leading to the establishment of a single-payer system. The Green Mountain Care Board consists of a chair and four members appointed by the Governor. Members cannot be affiliated with entities supervised or regulated by the Board, except for health care practitioners; participate in issues in which there is a financial interest; discuss future employment or appear before the Board of other state agencies on behalf of a person subject to supervision or regulation by the Board for a year after leaving the Board. The Chair and all members of the Board are state employees. Current appointed Board members are:
- Anya Rader Wallack (Chair)
- Al Gobeille
- Karen Hein, M.D.
- Con Hogan
- Allan Ramsay, M.D.
The Green Mountain Care Board began work on October 1, 2011 and in December, a Deputy Commissioner of the Exchange was hired. As required by the Vermont Health Reform Law of 2011, the Board and Governor Shumlin’s administration submitted reports to the House Committee on Health Care and the Senate Committee on Health and Welfare in January 2012.3 In July 2012, the Department of Vermont Health Access merged the existing Exchange Advisory Group with the Medicaid Advisory Board so as to create the Medicaid and Exchange Advisory Committee and maintain compliance with HB 202. The new Advisory Group includes representatives from consumer advocacy organizations, legislators, providers, brokers, and insurance associations. Contracting with Plans: Vermont Health Connect will selectively contract with carriers according to criteria developed by the Commissioner of the Department of Vermont Health Access and will offer qualified health plans (QHPs) from at least two private carriers, plus two multi-state plans. There are few carriers in Vermont’s non-group and small group markets; therefore, the state is working to ensure adequate participation. Carriers will be required to offer at least silver and gold level plans and bronze plans will be allowed to be sold in the Exchange.4 Carriers will also be required to offer six standard plans designs and will have the option of offering non-standard “choice” plans within set parameters. The state released a Request for Proposals in November 2012 for qualified health plans and stand-alone dental plans to be sold in the Exchange; the state selected QHPs and premium rates will be available to the public in July 2013.5 In July 2013, the Green Mountain Care Board announced the approved rates for the two insurers, BlueCross BlueShield of Vermont and MVP Health Care, that will participate in Vermont Health Connect, which were 4-5% lower than the initial rate filings.6 Earlier in May 2013, the Commissioner of the Vermont Department of Financial Regulation announced that the Vermont Health CO-OP had failed to meet the state’s insurance standards and had been denied a license to sell insurance in the state. Recommendations for quality requirements were developed for the state in August 2012 by subcontractors, including that the state continue using a higher standard to evaluate quality and wellness data for QHPs using Utilization Review Accreditation Commission (URAC) and National Committee for Quality Assurance (NCQA) standards as well as additional state requirements for consumer protections.7 This would be a higher standard than required by the Affordable Care Act. Dental and Vision Benefits: The Green Mountain Care Board considered dental options assessed by the Department of Vermont Health Access and voted not to mandate the inclusion of adult dental coverage through the Exchange for 2014. Consumer Assistance and Outreach: Vermont Health Connect contracted for the development of a comprehensive outreach and education plan.8 As of July 2013, Vermont Health Connect had launched its outreach campaign with a YouTube channel, Facebook page, Twitter account, new printed educational materials, as well as radio and television ads. It had also scheduled a number of forums and is developing partnerships with community organizations, providers, and businesses.9 On April 10, 2013, Vermont Health Connect released a Notice of Application for Navigator Organizations that will manage individual Navigators.10 To ensure sufficient distribution of Navigator Organizations throughout the state, grants are divided into three tiers: Tier 1 organizations will receive up to $40,000 and will target a specific geographic area or population; Tier 2 organizations will received grants of $40,000-$100,000 and will target a specific geographic are or population; Tier 3 organizations will receive grants up to $200,000, will have statewide reach, and will coordinate with other Navigator Organizations as well as state and local partners. On May 21, 2013, Vermont Health Connect announced it had awarded $2 million to 18 Navigator Organizations throughout the state. Four organizations receiving grant awards will serve as statewide coordinating Navigator Organization with two focusing on individuals and families and two serving small businesses.11 Navigators must complete 24 hours of training and pass a certification exam. The In-person training for Navigators was offered in early July. Vermont Health Connect contracted with the vendor supporting the existing Medicaid Support Center to expand the call center to include Exchange customers and to improve the quality of the service. The Support Center staff will be increased to 70 and the hours will be extended to include weekend hours. The Support Center will include dedicated lines for enrollment assisters and carriers and will be able to accept credit/debit payments. Training of Support Center staff will begin in July and the call center will go live in September.12 Small Business Health Options Program (SHOP) Exchange: HB 559 opens Vermont’s SHOP Exchange to small businesses with 50 or fewer employees in 2014, 100 or fewer employees by 2016, and to all employers by 2017. The state is working with subcontractors to finalize various aspects of the SHOP Exchange including, administrative requirements for the small businesses, broker management, premium billing and collection, and eligibility verification. In January 2012, the Green Mountain Care Board concluded that the individual and small group markets should be merged in 2014. Additionally, the Board recommended that insurance plans for small groups and individuals should only be sold through the Exchange so as to increase Exchange sustainability and promote payment reforms. Based on these recommendations, HB 559 merges the individual and small group health insurance markets into one market and requires plans to be sold only through the Exchange. The law allows for brokers to assist with enrollment through the Exchange. Small business employers will have the option of choosing between two different models for their employees. One option is to give the full choice of insurers and plans to their employees; the other is to give employees the choice of metal level from one insurer’s offerings.13 Information Technology (IT): Vermont intends to use a single, streamlined process for determining eligibility for the Exchange, Medicaid, CHIP, and other public programs. The state’s new system, Vermont Integrated Eligibility and Workflow Solution (VIEWS ), will integrate required components first and then incorporate other benefit programs in the future. The Department of Vermont Health Access has solicited various subcontractors to develop and implement the proposed system.14 The state plans to begin system testing July 1, 2013 and intends to be ready for open enrollment in October 2013. Vermont is also participating as part of a consortium of New England states in the “Enroll UX 2014” project, which is a public-private partnership creating design standards for exchanges that all states can use. The state is actively exploring opportunities to leverage Oregon’s Oracle-based Exchange architecture. Financing: The Board has solicited a subcontractor to develop a plan for financial sustainability. The Exchange Board must recommend two financing plans to the Legislature by January 15, 2013. One plan will recommend financing amounts and mechanisms that must be in place by January 1, 2014 and the second will address the financing of Green Mountain Care. On January 24, 2013, Governor Shumlin submitted the financing plan to the state legislature.15 The plan proposes to fund Vermont Health Connect operations for fiscal years 2014-2016 through reinvestment of ACA savings and increasing the health care claims assessment by one percent. In 2017, the state will move to a single payer system with a separate financing mechanism. Essential Health Benefits (EHB): The Affordable Care Act requires that all individual and small-group plans sold in a state, including those offered through the Exchange, cover certain defined health benefits. States must decide whether to benchmark their EHB plan to one of ten plans operating in the state or default to the largest small-group plan in the state. The Green Mountain Care Board held two public hearings on essential health benefits, the benchmark plan, and plan design and is considering potential market disruptions and how plan design could cause selection problems. The state solicited subcontractors to examine plan designs in the state’s individual and small group markets. The state recommended the Vermont Health Plan- BlueCare, HMO to serve as the benchmark plan. In addition, the Children’s Health Insurance Program (CHIP) will serve as the pediatric dental supplement and the Federal Employee Vision Plan (FEDVIP) will be the pediatric vision supplement.
In September 2010, the Vermont Agency of Human Services received the federal Exchange Planning grant of $1 million. In addition, Vermont is a member of the consortium of New England states that received a federal Early Innovator Grant of $44 million to develop, share, and leverage insurance exchange technology. The multi-state consortium also includes Connecticut, Rhode Island, Maine, and Massachusetts with the University of Massachusetts Medical School as the grant holder. The state has received three Level One Establishment grants: $18 million in November 2011 to further plan and develop the Exchange; $2.2 million in January 2013 to implement and operate an In-person Assister program; and $42.7 million in July 2013 to support the implementation of an integrated eligibility system, consumer support center functionality, and individual and SHOP premium processing. In August 2012, Vermont received a $104.2 million Level Two Establishment grant to fund Exchange development and operations through December 2014.16
Expansion of Medicaid
From 2014 to 2017, the federal government will pay for 100% of the difference between a state’s current Medicaid eligibility level and the ACA minimum. Federal contributions to the expansion will drop to 95% in 2017 and remain at 90% after 2020, according to the ACA. As the ACA was originally written, states would lose all Medicaid funding if they refused to expand their program to the ACA minimum. However, the Supreme Court in June 2012 ruled that the federal government could not withhold Medicaid funding for states that chose not to expand their programs. The decision effectively allowed state officials to opt out of the expansion, and some have said they will do just that. Vermont is participating in Medicaid expansion.
On January 3, 2013, Vermont received conditional approval from the U.S. Department of Health and Human Services (HHS) to establish a state-based exchange.17 Final approval is contingent upon the state demonstrating its ability to perform all required Exchange activities on time, complying with future guidance and regulations, and receiving legislative approval for a self-sustainability financing plan. The state must also develop a contingency plan by February 1, 2013 if the state is unable to meet timelines and milestones, particularly relating to implementation of the IT infrastructure. For more information on Vermont’s Health Benefit Exchange planning, visit: http://healthconnect.vermont.gov/
- Act 48 (HB 202). An Act Related to Universal and Unified Health System in Vermont. Signed May 26, 2011. ← Return to text
- House Bill 559. Introduced 2012 session. ← Return to text
- Act 48 Integration Report: The Exchange. Submitted by the Agency of Administration, January 17, 2012← Return to text
- Vermont Exchange Advisory Group Meeting minutes. May 14, 2012. http://dvha.vermont.gov/administration/hbe-advisory-group-minutes-05-14-12.pdf and Overview H.559. Exchange Advisory Meeting. May 14, 2012. http://dvha.vermont.gov/administration/hbe-h559-overview.pdf← Return to text
- Department of Vermont Health Access. RFP Selection of Qualified Health Plans. November 1, 2012. http://www.vermontbusinessregistry.com/bidAttachments/9464/Vermont%20QHP%20RFP%200341011313.pdf← Return to text
- Green Mountain Care Board press release, July 8, 2013. http://gmcboard.vermont.gov/sites/gmcboard/files/Exchange_rate_decision%20release_revised.pdf← Return to text
- Roadmap for Implementing Quality Requirements: Recommendations for Vermont’s Health Benefit Exchange. August 3, 2012. http://dvha.vermont.gov/administration/qualityimplereportfinal.pdf← Return to text
- Vermont Health Benefit Exchange Outreach and Education Plan, prepared by GMMB http://healthconnect.vermont.gov/sites/hcexchange/files/For%20Websitevermont-health-connect-outreach-and-education-plan.pdf← Return to text
- Medicaid and Exchange Advisory Board presentation, Outreach and Education Update http://healthconnect.vermont.gov/sites/hcexchange/files/MEAB%20O%20and%20E%2003July2013%20%282%29.pdf← Return to text
- Customer Support Update, presentation to Medicaid and Exchange Advisory Board, May 6, 2013 http://healthconnect.vermont.gov/sites/hcexchange/files/CSC%20Slides%20for%20MEAB_02May2013v3.pdf← Return to text
- The Vermont Health Benefit Exchange: An Update for Small Business Owners. November 28, 2012. http://dvha.vermont.gov/administration/exchange-update-small-biz-11.28.12-final.pdf← Return to text
- Planning Review: Vermont Health Benefit Exchange. May 10-11, 2012. http://dvha.vermont.gov/administration/hbe-powerpoint-presentation-for-vermonts-planning-review-with-hhs-05-2012.pdf← Return to text
- Health Care Reform Financing Plan, January 24, 2013 http://hcr.vermont.gov/sites/hcr/files/2013/Health%20Care%20Reform%20Financing%20Plan%202014%20and%202017_FINAL.pdf← Return to text
- Vermont Affordable Insurance Exchange Grants Awards List. http://www.cms.gov/cciio/Resources/Marketplace-Grants/vt.html← Return to text
- Letter from HHS to Governor Shumlin, January 3, 2013. http://www.cciio.cms.gov/resources/files/vt-blueprint-exchange-letter-01-03-2013.pdf← Return to text