§ 4100b. Coverage of children

(a) As used in this subchapter:

(1) "Health plan" shall include a group health plan as defined under Section 607(1) of the Employee Retirement Income Security Act of 1974 and a nongroup plan as defined in section 4080b of this title.

(2) "Insurer" shall include any entity providing health insurance or a health plan, a health maintenance organization as defined in subdivision 5101(2) of this title, or a hospital or medical service corporation as defined in chapters 123 and 125 of this title.

(3) "Dependent coverage" means family coverage, or coverage for one or more persons as long as the coverage for one or more persons is greater than or equal to the coverage available under family coverage.

(b) An insurer shall not deny enrollment of a child under the health plan of the child's parent ordered to provide medical support on the grounds that:

(1) the child was born out of wedlock;

(2) the child is not claimed as a dependent on the parent's federal tax return; or

(3) the child does not reside with the parent or in the insurer's service area.

(c) Where a child has health coverage through an insurer of a parent, the insurer shall:

(1) provide such information to either parent as may be necessary for the child to obtain benefits through that coverage;

(2) permit either parent, a provider with parental authorization, the State Medicaid agency as assignee, or any State agency administering health benefits or a health benefit plan for which Medicaid is a source of funding to submit claims for covered services, and to appeal the denial of any benefit, without the approval of the other parent; and

(3) make payments on claims submitted in accordance with subdivision (2) of this subsection directly to the parent who paid the provider, the provider as assignee, the State Medicaid agency, or any State agency administering health benefits or a health benefit plan for which Medicaid is a source of funding.

(d) Where a parent is required by a court or administrative order to provide health coverage for a child, and the parent is eligible for dependent health coverage, the insurer shall be required:

(1) To enroll, under the dependent coverage, a child who is otherwise eligible for the coverage without regard to any enrollment season restrictions or any seasonal restrictions on switching from one plan to another, upon application of either parent, the employer, the State agency administering the Medicaid program, any State agency administering health benefits or a health benefit plan for which Medicaid is a source of funding, or the child support enforcement program.

(2) Not to disenroll or eliminate coverage of the child unless the insurer is provided satisfactory written evidence that:

(A) the court or administrative order is no longer in effect;

(B) the child is or will be enrolled in comparable health coverage through another insurer which will take effect not later than the effective date of disenrollment; or

(C) the employer has eliminated dependent health coverage for all of its employees if allowed by law.

(3) To provide enrollment under subdivision (1) of this subsection with coverage effective three days after the mailing of notice of the court or administrative order to the insurer or upon actual receipt of notice by the insurer, whichever is sooner. The insurer shall have 10 days from notice to process the enrollment and shall be entitled to premiums from the effective date of enrollment.

(e) An insurer may not impose requirements on a State agency, which has been assigned the rights of an individual eligible for medical assistance under Medicaid and covered for health benefits from the insurer, that are different from requirements applicable to an agent or assignee of any other individual so covered.

(f) Any insurer that fails to enroll a child after notice under 15 V.S.A. § 663(d) or 33 V.S.A. § 4110(a)(4), shall be directly liable for any medical expenses of the child that would have been covered under the plan had the insurer enrolled the child upon receiving notice.

(g) Notice by first class mail, postage prepaid, or by any other method showing actual receipt, shall be presumptive evidence of its receipt by the insurer to whom it is addressed. Any period of time which is determined under this subchapter by the giving of notice shall commence to run from the date of mailing, if the notice is mailed, or the date of actual receipt if another method of transmitting the notice is used.

(h) An insurer may cancel any health plan which is the subject of a medical support order for nonpayment of premium only if the insurer mails or delivers notice of cancellation to both parents and all other persons or agencies identified in the medical support order. Any insurer cancelling a health plan for nonpayment of premium shall reinstate the health plan effective from the date of cancellation if the nonpayment of premium is cured within 45 days of the cancellation. (Added 1993, No. 231 (Adj. Sess.), § 2; amended 1995, No. 43, §§ 1, 2, eff. April 17, 1995; 2005, No. 191 (Adj. Sess.), § 18; 2013, No. 79, § 12, eff. Jan. 1, 2014.)