Under Vermont laws and regulations, a Third-Party Administrator (TPA) is defined as any person who, on behalf of a health insurer or purchaser of health benefits, receives or collects charges, contributions or premiums for, or adjusts or settles claims on or for residents of this State or Vermont health care providers and facilities. This includes an entity conducting administrative services for business or possessing claims data, eligibility data, provider files, and other information relating to health care provided to Vermont residents or by Vermont health care providers or facilities.
TPAs are required to register on an annual basis—by December 31st—with the State of Vermont. This requirement pertains to comprehensive major medical health benefit plans that may be insured or self-insured, Medicare Supplement, and Medicare Parts C and D. Agencies serving 200 or more Vermont resident members must also report claims in Vermont’s All-Payer Claims Database (APCD), called Vermont Health Care Uniform Reporting and Evaluation system, or VHCURES.
Agencies serving fewer than 200 Vermont residents must register annually but are not required to report to VHCURES.
Currently both annual registration and VHCURES reporting occurs via Onpoint Health Data, GMCB’s contractor for VHCURES data collection, consolidation, and user support. Click the link below to access the State of Vermont Registration Forms in the Onpoint Claims Data Manager.
If you are experiencing problems with the registration or need further information about the process, please contact Onpoint Health Data Systems at email@example.com or by phone at 207-623-2555.
UPDATE: The March 1, 2016, U.S. Supreme Court decision Gobeille v. Liberty Mut. Ins. Co., 136 S. Ct. 936 (2016), affects the Green Mountain Care Board’s authority to mandate certain data reporting for the claims databases. The decision does not affect state TPA registration or licensing laws, including the Vermont TPA registration requirement. TPA licensing and registration laws long precede the development of APCDs and the registration requirements were not examined by the Court in Gobeille; the Gobeille decision does not pertain to the licensing or registration requirements imposed by more than 40 states. In Vermont, “[a]ny person or entity that provides third party administration services, a third party administrator or ‘TPA’ . . . , shall register . . ., both before doing business in Vermont and on an annual basis prior to December 31 thereafter.” Regulation H-2008-01, § 3(B). All TPAs conducting business in Vermont must continue to register with the GMCB and must renew that registration on an annual basis.
General questions or inquiries related to VHCURES stewardship and governance can be sent to GMCB at firstname.lastname@example.org.