Vermont Statutes
Chapter 112 - Life and Health Insurance Guaranty Association
§ 4185. Application of subchapter 1 to the Vermont Health Maintenance Organization Guaranty Association; maximum benefits

§ 4185. Application of subchapter 1 to the Vermont Health Maintenance Organization Guaranty Association; maximum benefits
(a) Sections 4157, 4158, 4159, 4160, 4161, 4162, 4163, 4164, 4165, 4168, and 4169 of this title shall govern and apply to the Association established under this subchapter except as otherwise provided in this subchapter.
(b) Sections 4166 and 4167 of this title shall not apply to the Association established under this subchapter.
(c)(1) Benefits for which the Association may become liable shall in no event exceed the lesser of:
(A) the contractual obligations for which the Health Maintenance Organization is liable or would have been liable if it were not impaired or insolvent; or
(B) $300,000.00 with respect to any one natural person.
(2) In no event shall the Association be required to pay any provider participating in the insolvent organization any amount for in-plan services rendered by such provider prior to the insolvency of the organization in excess of:
(A) the amount provided by a contract between a physician provider and the insolvent organization for such services; or
(B) the amounts provided by contract between a hospital provider and the Department of Vermont Health Access for similar services to recipients of Medicaid; or
(C) in the event neither subdivision (A) nor (B) of this subdivision (2) is applicable, then the amounts paid under the Medicare area prevailing rate for the area where the services were provided, or if no such rate exists with respect to such services, then 80 percent of the usual and customary rates established by the Health Insurance Association of America or any successor organization that calculates the usual and customary rates for medical services and procedures. The payments required to be made by the Association under this subsection shall constitute full and complete payment of such provider services for the member. (Added 1993, No. 30, § 15, eff. May 21, 1993; amended 1999, No. 147 (Adj. Sess.), § 4; 2005, No. 174 (Adj. Sess.), § 11; 2009, No. 156 (Adj. Sess.), § I.14.)

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