New to helping someone in Vermont?
You do not need a law degree to help someone fight a health insurance denial. Start by gathering three basic documents:
- Insurance card — shows which company administers the plan (often BCBSVT or MVP on Vermont Health Connect).
- Denial letter or explanation of benefits (EOB) — the notice that says a service was denied, not paid, or needs approval first. Look for appeal instructions and a deadline.
- Summary of Benefits and Coverage (SBC) — helps you tell whether the fight is about medical necessity or whether the benefit exists at all.
Your first tasks: identify what type of plan this is (Vermont Health Connect, job-based, Medicaid, Medicare) and write down the appeal deadline from the letter.
For many Vermont-regulated plans, you have a first-level internal grievance with the insurer, then a right to independent external review through a DFR-assigned IRO under 8 V.S.A. § 4089f and Rule H-2011-02.
For steps that work in every state, read these general guides first, then return here for Vermont rules:
What is different in Vermont?
- Vermont Health Connect: State-based Marketplace at healthconnect.vermont.gov. 2026 qualified health plan carriers: Blue Cross Blue Shield of Vermont and MVP Health Care.
- Prior authorization: Act 111 (2024, effective January 1, 2025) — 18 V.S.A. § 9418b: 24-hour acknowledgment; 2 business days non-urgent / 24-hour urgent decisions; deemed granted if deadlines missed; no PA for primary care orders; step therapy overrides.
- Internal appeals: First-level insurer grievance required; federal standards often apply — 180 days to file; 30/60-day decisions; 72-hour urgent.
- External review: File with DFR within 120 days or 4 months (whichever is longer); IRO decision within 30 days standard / 3 days expedited; binding on insurer; $25 fee (may be waived).
- Medicaid: Internal appeal 60 days, then fair hearing 120 days from appeal resolution—not commercial IRO review.
Who is in charge of your plan?
- DFR (Department of Financial Regulation): External review, regulated commercial plans — dfr.vermont.gov. Consumer Services: 800-964-1784 · 802-828-3302
- U.S. Department of Labor / HHS: Many self-funded ERISA plans.
- DVHA / Green Mountain Care: Medicaid appeals — Appeals and fair hearings · 800-250-8427
- CMS: Medicare and Medicare Advantage.
After appeals are exhausted, see Regulator complaints.