Service Delivery and Treatment Modalities

V.S.A. tit. 8, ch. 107, subch. 12

in effect

8 V.S.A. § 4098a Coverage of health care services delivered through telemedicine and by store-and-forward means

4098a. Coverage of health care services delivered through telemedicine and by store-and-forward means (a) As used in this section: (1) “Distant site” means the location of the health care provider delivering services through telemedicine at the time the services are provided. (2) “Health insurance plan” has the same meaning as in section 4011 of this title and also includes a stand-alone dental plan or policy or other dental insurance plan offered by a dental insurer. (3) “Health care facility” has the same meaning as in 18 V.S.A. § 9402. (4) “Health care provider” means a person, partnership, or corporation, other than a facility or institution, that is licensed, certified, or otherwise authorized by law to provide professional health care services, including dental services, in this State to an individual during that individual’s medical care, treatment, or confinement. (5) “Originating site” means the location of the patient, whether or not accompanied by a health care provider, at the time services are provided by a health care provider through telemedicine, including a health care provider’s office, a hospital, or a health care facility, or the patient’s home or another nonmedical environment such as a school-based health center, a university-based health center, or the patient’s workplace. (6) “Store-and-forward” means an asynchronous transmission of medical information, such as one or more video clips, audio clips, still images, x-rays, magnetic resonance imaging scans, electrocardiograms, electroencephalograms, or laboratory results, sent over a secure connection that complies with the requirements of the Health Insurance Portability and Accountability Act of 1996, Pub. L. No. 104-191, to be reviewed at a later date by a health care provider at a distant site who is trained in the relevant specialty. In store-and-forward, the health care provider at the distant site reviews the medical information without the patient present in real time and communicates a care plan or treatment recommendation back to the patient or referring provider, or both. (7) “Telemedicine” means the delivery of health care services, including dental services, such as diagnosis, consultation, or treatment, through the use of live interactive audio and video over a secure connection that complies with the requirements of the Health Insurance Portability and Accountability Act of 1996, Pub. L. No. 104-191. (b)(1) A health insurance plan shall provide coverage for health care services and dental services delivered through telemedicine by a health care provider at a distant site to a covered individual at an originating site to the same extent that the plan would cover the services if they were provided through in-person consultation. (2)(A) A health insurance plan shall provide the same reimbursement rate for services billed using equivalent procedure codes and modifiers, subject to the terms of the health insurance plan and provider contract, regardless of whether the service was provided through an in-person visit with the health care provider or through telemedicine. (B) The provisions of subdivision (A) of this subdivision (2) shall not apply: (i) to services provided pursuant to the health insurance plan’s contract with a third-party telemedicine vendor to provide health care or dental services; or (ii) in the event that a health insurer and health care provider enter into a value-based contract for health care services that include care delivered through telemedicine or by store-and-forward means. (c) A health insurance plan may charge a deductible, co-payment, or coinsurance for a health care service or dental service provided through telemedicine as long as it does not exceed the deductible, co-payment, or coinsurance applicable to an in-person consultation. (d) A health insurance plan may limit coverage to health care providers in the plan’s network. A health insurance plan shall not impose limitations on the number of telemedicine consultations a covered individual may receive that exceed limitations otherwise placed on in-person covered services. (e) Nothing in this section shall be construed to prohibit a health insurance plan from providing coverage for only those services that are medically necessary and are clinically appropriate for delivery through telemedicine, subject to the terms and conditions of the covered individual’s policy. (f)(1) A health insurance plan shall reimburse for health care services and dental services delivered by store-and-forward means. (2) A health insurance plan shall not impose more than one cost-sharing requirement on a covered individual for receipt of health care services or dental services delivered by store-and-forward means. If the services would require cost sharing under the terms of the covered individual’s health insurance plan, the plan may impose the cost sharing requirement on the services of the originating site health care provider or of the distant site health care provider, but not both. (g) A health insurance plan shall not construe a covered individual’s receipt of services delivered through telemedicine or by store-and-forward means as limiting in any way the covered individual’s ability to receive additional covered in-person services from the same or a different health care provider for diagnosis or treatment of the same condition. (h) Nothing in this section shall be construed to require a health insurance plan to reimburse the distant site health care provider if the distant site health care provider has insufficient information to render an opinion. (i) In order to facilitate the use of telemedicine in treating substance use disorder, when the originating site is a health care facility, health insurers and the Department of Vermont Health Access shall ensure that the health care provider at the distant site and the health care facility at the originating site are both reimbursed for the services rendered, unless the health care providers at both the distant and originating sites are employed by the same entity. (j) This section shall apply to Medicaid and any other public health care assistance program offered or administered by the State or by any subdivision or instrumentality of the State. Recodified and amended 2025, No. 11, § 2, eff. September 1, 2025.

8 V.S.A. § 4098b Coverage of health care services delivered by audio-only telephone

4098b. Coverage of health care services delivered by audio-only telephone (a) As used in this section, “health care provider” means a person, partnership, or corporation, other than a facility or institution, that is licensed, certified, or otherwise authorized by law to provide professional health care services in this State to an individual during that individual’s medical care, treatment, or confinement. (b)(1) A health insurance plan shall provide coverage for all medically necessary, clinically appropriate health care services delivered remotely by audio-only telephone to the same extent that the plan would cover the services if they were provided through in-person consultation. Services covered under this subdivision shall include services that are covered when provided in the home by home health agencies. (2)(A) A health insurance plan shall provide the same reimbursement rate for services billed using equivalent procedure codes and modifiers, subject to the terms of the health insurance plan and provider contract, regardless of whether the service was provided through an in-person visit with the health care provider or by audio-only telephone. (B) The provisions of subdivision (A) of this subdivision (2) shall not apply in the event that a health insurer and health care provider enter into a value-based contract for health care services that include care delivered by audio-only telephone. (c) A health insurance plan may charge an otherwise permissible deductible, co-payment, or coinsurance for a health care service delivered by audio-only telephone, provided that it does not exceed the deductible, co-payment, or coinsurance applicable to an in-person consultation. (d) A health insurance plan shall not require a health care provider to have an existing relationship with a covered individual in order to be reimbursed for health care services delivered by audio-only telephone. (e) This section shall apply to Medicaid, to the extent permitted by the Centers for Medicare and Medicaid Services, and any other public health care assistance program offered or administered by the State or by any subdivision or instrumentality of the State. Recodified and amended 2025, No. 11, § 2, eff. September 1, 2025.

8 V.S.A. § 4098c Covered services provided by naturopathic physicians

4098c. Covered services provided by naturopathic physicians (a) A health insurance plan shall provide coverage for medically necessary health care services covered by the plan when provided by a naturopathic physician licensed in this State for treatment within the scope of practice described in 26 V.S.A. chapter 81 and shall recognize naturopathic physicians who practice primary care to be primary care physicians. (b) Health care services provided by naturopathic physicians may be subject to reasonable deductibles, co-payment and coinsurance amounts, and fee or benefit limits consistent with those applicable to other primary care physicians under the plan, as well as practice parameters, cost-effectiveness and clinical efficacy standards, and utilization review consistent with any applicable rules published by the Department of Financial Regulation. Any amounts, limits, standards, and review shall not function to direct treatment in a manner unfairly discriminative against naturopathic care, and collectively shall be not more restrictive than those applicable under the same plan to care or services provided by other primary care physicians, but may allow for the management of the benefit consistent with variations in practice patterns and treatment modalities among different types of health care professionals. (c) A health insurance plan may require that the naturopathic physician’s services be provided by a licensed naturopathic physician under contract with the insurer or shall be covered in a manner consistent with out-of-network provider reimbursement practices for primary care physicians; however, this shall not relieve a health insurance plan from compliance with the applicable network adequacy requirements adopted by the Commissioner by rule. (d) Nothing contained in this section shall be construed as impeding or preventing either the provision or the coverage of health care services by licensed naturopathic physicians, within the lawful scope of naturopathic practice, in hospital facilities on a staff or employee basis. (e) This section shall apply to Medicaid and any other public health care assistance program offered or administered by the State or by any subdivision or instrumentality of the State. Recodified and amended 2025, No. 11, § 2, eff. September 1, 2025.

8 V.S.A. § 4098d Covered services provided by athletic trainers

4098d. Covered services provided by athletic trainers (a) To the extent a health insurance plan provides coverage for a particular type of health care service or for any particular medical condition that is within the scope of practice of athletic trainers, a licensed athletic trainer who acts within the scope of practice authorized by 26 V.S.A. chapter 83 shall not be denied reimbursement by the health insurance plan for those covered services if the health insurance plan would reimburse another health care professional for those services. (b) Health care services provided by athletic trainers may be subject to reasonable deductibles, co-payment and coinsurance amounts, fee or benefit limits, practice parameters, and utilization review consistent with applicable rules adopted by the Department of Financial Regulation, provided that the amounts, limits, and review shall not function to direct treatment in a manner unfairly discriminative against athletic trainer care, and collectively shall be not more restrictive than those applicable under the same policy for care or services provided by other health care professionals but allowing for the management of the benefit consistent with variations in practice patterns and treatment modalities among different types of health care professionals. (c) A health insurer may require that the athletic trainer services be provided by a licensed athletic trainer under contract with the insurer. (d) Nothing in this section shall be construed as impeding or preventing either the provision or coverage of health care services by licensed athletic trainers within the lawful scope of athletic trainer practice. Recodified and amended 2025, No. 11, § 2, eff. September 1, 2025.

8 V.S.A. § 4098e Choice of providers for vision care and medical eye care services

4098e. Choice of providers for vision care and medical eye care services (a) As used in this section: (1) “Covered services” means services and materials for which reimbursement from a vision care plan or other health insurance plan is provided by a member’s or subscriber’s plan contract, or for which a reimbursement would be available but for application of the deductible, co-payment, or coinsurance requirements under the member’s or subscriber’s health insurance plan. (2) “Health insurance plan” has the same meaning as in section 4011 of this chapter and also includes vision care plans. (3) “Materials” includes lenses, devices containing lenses, prisms, lens treatments and coatings, contact lenses, and prosthetic devices to correct, relieve, or treat defects or abnormal conditions of the human eye or its adnexa. (4) “Ophthalmologist” means a physician licensed pursuant to 26 V.S.A. chapter 23 or an osteopathic physician licensed pursuant to 26 V.S.A. chapter 33 who has had special training in the field of ophthalmology. (5) “Optician” means a person licensed pursuant to 26 V.S.A. chapter 47. (6) “Optometrist” means a person licensed pursuant to 26 V.S.A. chapter 30. (7) “Vision care plan” means an integrated or stand-alone plan, policy, or contract providing vision benefits to enrollees with respect to covered services or covered materials, or both. (b) To the extent a health insurance plan provides coverage for vision care or medical eye care services, it shall cover those services whether provided by a licensed optometrist or by a licensed ophthalmologist, provided the health care professional is acting within the health care professional’s authorized scope of practice and participates in the plan’s network. (c) A health insurance plan shall impose no greater co-payment, coinsurance, or other cost-sharing amount for services when provided by an optometrist than for the same service when provided by an ophthalmologist. (d) A health insurance plan shall provide to a licensed health care professional acting within the health care professional’s scope of practice the same level of reimbursement or other compensation for providing vision care and medical eye care services that are within the lawful scope of practice of the professions of medicine, optometry, and osteopathy, regardless of whether the health care professional is an optometrist or an ophthalmologist. (e)(1) A health insurer shall permit a licensed optometrist to participate in plans or contracts providing for vision care or medical eye care to the same extent as it does an ophthalmologist. (2) A health insurer shall not require a licensed optometrist or ophthalmologist to provide discounted materials benefits or to participate as a provider in another health insurance or vision care plan or contract as a condition or requirement for the optometrist’s or ophthalmologist’s participation as a provider in any health insurance or vision care plan or contract. (f)(1) An agreement between a health insurer and an optometrist or ophthalmologist for the provision of vision services to plan members or subscribers in connection with coverage under a stand-alone vision care plan or other health insurance plan shall not require that an optometrist or ophthalmologist provide services or materials at a fee limited or set by the plan or insurer unless the services or materials are reimbursed as covered services under the contract. (2) An optometrist or ophthalmologist shall not charge more for services and materials that are noncovered services under a vision care plan or other health insurance plan than the optometrist’s or ophthalmologist’s usual and customary rate for those services and materials. (3) Reimbursement paid by a vision care plan or other health insurance plan for covered services and materials shall be reasonable and shall not provide nominal reimbursement in order to claim that services and materials are covered services. (4)(A) A vision care plan or other health insurance plan shall not restrict or otherwise limit, directly or indirectly, an optometrist’s, ophthalmologist’s, or independent optician’s choice of or relationship with sources and suppliers of products, services, or materials or use of optical laboratories if the optometrist, ophthalmologist, or optician determines that the source, supplier, or laboratory that the optometrist, ophthalmologist, or optician has selected offers the products, services, or materials in a manner that is more beneficial to the consumer, including with respect to cost, quality, timing, or selection, than the source, supplier, or laboratory selected by the vision care plan or other health insurance plan. The plan shall not impose any penalty or fee on an optometrist, ophthalmologist, or independent optician for using any supplier, optical laboratory, product, service, or material. (B) The optometrist, ophthalmologist, or optician shall notify the consumer of any additional costs the consumer may incur as the result of procuring the products, services, or materials from the source, supplier, or laboratory selected by the optometrist, ophthalmologist, or optician instead of from the source, supplier, or laboratory selected by the vision care plan or other health insurance plan. (C) Nothing in this subdivision (4) shall be construed to prevent a vision care plan or other health insurance plan from informing its policyholders of the benefits available under the plan or from conducting an audit of an optometrist’s, ophthalmologist’s, or optician’s use of alternative sources, suppliers, or laboratories. (D) The provisions of this subdivision (4) shall not apply to Medicaid. (g)(1) Except as otherwise specified in subdivision (f)(4), this section shall apply to Medicaid and any other public health care assistance program offered or administered by the State or by any subdivision or instrumentality of the State. (2) The Department of Financial Regulation shall enforce the provisions of this section as they relate to health insurance plans and vision care plans other than Medicaid. Recodified and amended 2025, No. 11, § 2, eff. September 1, 2025.

Source: Vermont General Assembly (legislature.vermont.gov)URL: https://legislature.vermont.gov/statutes/chapter/08/107Fetched: 10/21/2026