Qualified Health Plans (QHPs)
- 2021 QHP Certification Timeline
- Process for Non-Standard QHP Proposal Review
- GMCB Order Approving Modification to the 2021 Standard QHP and Reflective Silver Plans (March 4, 2020)
- Non-Standard QHP Approval Process & 2021 Evaluation Criteria (January 29, 2020 Presentation)
Actuary: A specialist in analyzing risk who studies health trends, predicts changes that influence the costs of medical care, and analyzes the factors that impact insurance rates. The GMCB contracts with actuarial firms to analyze insurance rate filings and offer an official opinion that becomes an important part of the GMCB’s decision-making process.
Appeal: A request by a party or interested party to the Vermont Supreme Court to review a GMCB decision. Any appeal must be made within 30 days of the GMCB decision.
Comprehensive major medical health insurance plan: The type of health insurance most people receive through an employer or purchase as individuals. This type of insurance offers both basic coverage for routine services and coverage for major medical needs such as extensive surgery.
Decision: A formal, written disposition by the GMCB on a rate filing. The GMCB must issue a decision approving, modifying, or disapproving a rate request through a process that must be completed in most instances within 90 days. What determines the GMCB decision? The Board’s analysis answers these questions:
- Is the rate affordable?
- Does the rate promote quality care?
- Does the rate promote access to care?
- Is the rate adequate to cover the insurer’s costs?
- Is the rate unjust, unfair, inequitable, misleading, or contrary to law?
- Is the rate excessive, inadequate or unfairly discriminatory?
Filing: A formal request to maintain or change the rates charged for a particular health insurance plan offered to Vermonters. An insurer does not have to file its request with the GMCB if the health plan is part of state or federal programs such as Medicaid and Medicare, or if the plan is purchased from a company that is not licensed in Vermont (which can occur when a Vermonter is employed by a company that is headquartered out of state).
The Office of Health Care Advocate (HCA): A project of Vermont Legal Aid that offers Vermonters advice, information, referrals and direct assistance with their health care and health insurance questions and problems. In addition, the HCA represents the interests of Vermont consumers of health care in the legislature and before state agencies. You can reach the HCA's hotline at (800) 917-7787, and get more information by visiting its website.
Opinions: The two formal analyses and recommendations provided to the GMCB that are posted to the website within 60 days of a filing: the actuarial opinion, and the Vermont Department of Financial Regulation's (DFR) solvency opinion. The actuarial opinion looks at the reasonableness of a proposed rate change taking into account factors such as the adequacy of the proposed rate, the validity of the insurer's rate calculation methodology, and whether the insurer has included state and federal taxes, fees and mandates in its computation. DFR's solvency opinion assesses the financial impact of the proposed rate on the insurance company's overall financial health. The analysis includes an assessment of whether the company has adequate financial reserves - funds set aside to ensure the company can pay future claims, losses or benefits.
Party/Interested Party: An organization or person officially recognized as having a close interest in a rate filing. A party can present evidence at hearing, make arguments, and provide responses to all issues introduced to the GMCB regarding the filing in question. The insurer submitting the filing is a party. Vermont’s Office of Health Care Advocate may choose to become a party to a rate filing as a consumer representative upon notice to the GMCB.
Interested party status may be granted to certain people or organizations that can show, through written application to the GMCB, that they have a substantial and direct interest in the filing. An interested party has the right to be copied on filing materials submitted to the GMCB, to participate as a party in the review and hearing process, and to appeal the GMCB’s decision to the Vermont Supreme Court. Being covered by the insurance policy and subject to the proposed rate increase, without more, is not sufficient to obtain interested party status.
Public Comment: Opinions, observations or questions regarding a specific rate filing, or the rate review process generally, submitted to the GMCB by individuals or organizations. The GMCB invites comment via this website and by email, telephone, and U.S. mail. In addition, the Board will accept comments from the public at rate review hearings concerning the filing then under review. Written comments are accepted from the first day the filing is posted on the GMCB website until midnight on the 15th day after the actuarial and solvency opinions have been posted.
Public Hearing: An official public meeting at which the parties to a specific rate filing - including the insurer, the Health Care Advocate, and any person or entity that has been granted interested party status - present evidence through sworn witness testimony and documentary exhibits. The public may also provide comment at the hearing. A hearing may be waived (1) if all parties agree to the waiver; (2) if the proposed rate increase applies to fewer than 100 people and is less than 10%; or (3) if the requested rate increase is less than 3%, regardless of how many people are affected.
Rate: The average an insurance company charges for a defined package of insurance plans. Since the rate is an average, Vermonters’ premiums—the amount we actually pay for insurance every month—may be higher or lower than the rate due to a group’s specific claims experience.
Solvency: The insurer’s financial ability to meet its short and long-term financial obligations, including projected medical claims of its covered population. The Department of Financial Regulation (DFR) provides the GMCB with an opinion assessing each insurer’s solvency in light of the specific filing at hand.