13-001 Code Vt. R. 13-170-001-X
Part ONE GENERAL PROVISIONS AND DEFINITIONS
(01/15/2017, GCR 16-094)
The Agency of Human Services (AHS) was created in 1969 to serve as the umbrella organization for all human-service activities within state government. It is the Single State Agency for Medicaid purposes and the adopting authority for this rule.
(01/15/2017, GCR 16-094)
(01/15/2017, GCR 16-094)
The state offers several types of health benefits, including:
* Medicaid;
* Children's Health Insurance Program (CHIP);
* Enrollment in a Qualified Health Plan (QHP) with financial assistance.
The benefits for which a person is eligible is determined based on the individual's income, resources (in specified cases), and circumstances as covered in succeeding sections.
Except as may be otherwise restricted, an individual may select the particular health benefit or benefits that they wish to be considered for. In the absence of such a selection, AHS will determine an individual's eligibility for the most advantageous benefit that they qualify for.
If an individual becomes ineligible for one benefit, AHS will determine eligibility for the next most advantageous benefit that they then qualify for.
(01/15/2017, GCR 16-094)
The Medicaid program is authorized in Title XIX of the Social Security Act (the Act).
Vermont provides Medicaid to those who meet the requirements of one of three eligibility groups:
* Mandatory categorically needy;
* Optional categorically needy; and
* Medically needy.
To be eligible for federal funds, states are required to provide
Medicaid coverage for certain groups of individuals. These groups-the mandatory categorically needy-derive from the historic ties to programs that provided federally-assisted income-maintenance payments ( e.g., SSI and Aid to Families with Dependent Children).
States are also required to provide Medicaid to related groups not receiving cash payments.
States also have the option of providing Medicaid coverage for other "categorically related" groups. These optional groups share characteristics of the mandatory groups (that is, they fall within defined categories), but the eligibility criteria are somewhat more liberally defined.
The medically-needy option allows states to extend Medicaid eligibility to additional groups of people. These individuals would be eligible for Medicaid under one of the mandatory or optional groups, except that they do not meet the income or resource standards for those groups. Individuals may qualify immediately or may "spend down" by incurring medical expenses greater than the amount by which their income or resources exceed their state's medically-needy standards. [1]
The Vermont Medicaid program covers all mandatory categories of enrollees. It also offers all mandatory services-general hospital inpatient; outpatient hospital and rural health clinics; other laboratory and x-ray; nursing facility, Early Periodic Screening, Diagnosis and Treatment (EPSDT), and family planning services and supplies; physician's services and medical and surgical services of a dentist; home health services; and nurse-midwife and nurse practitioner services. Vermont includes certain, but not all, optional categories of enrollees. Vermont has also elected to cover certain, but not all, optional services for which federal financial participation is available. It also operates health care programs permitted by research demonstration waiver authority under § 1115 of the Social Security Act.
The scope of coverage for children under the EPSDT provisions of Title XIX is different and more extensive than coverage for adults. The EPSDT provisions of Medicaid law specify that services that are optional for adults are mandatory covered services for all Medicaid- eligible children under age 21 when such services are determined necessary as a result of an EPSDT screen. Specifically, Vermont is required to provide such other necessary health care, diagnostic services, treatment, and other measures described in subsection (a) of [1396d] to correct or ameliorate defects and physical and mental illnesses and conditions discovered by the screening services, whether or not such services are covered under the State [Medicaid] plan. [3]
A further definition of the scope of EPSDT services is found in 42 USC § 1396 d(a)(13) which requires states to provide other diagnostic, screening, preventive, and rehabilitative services, including any medical or remedial services (provided in a facility, home, or other setting) recommended by a physician or other licensed professional of the healing arts within the scope of their practice under State Law, for the maximum reduction of physical or mental disability and restoration of an individual to the best functional level.
Vermont is authorized to establish reasonable standards, consistent with the objectives of the Medicaid statute, for determining the extent of coverage in the optional categories [4] based on such criteria as medical necessity or utilization control. [5] In establishing such standards for coverage, Vermont ensures that the amount, duration, and scope of coverage are reasonably sufficient to achieve the purpose of the service. [6] Vermont may not limit services based upon diagnosis, type of illness, or condition. [7]
(01/15/2017, GCR 16-094)
CHIP (known from its inception until March 2009 as the State Children's Health Insurance Program, or SCHIP) is authorized by Title XXI of the Social Security Act.
Vermont utilizes CHIP to provide health coverage to uninsured children with household incomes between 237% and 312% of the federal poverty level (FPL). CHIP is part of the coverage array known as "Dr. Dynasaur." All of the provisions in this rule that apply to the "child" Medicaid coverage group ( § 7.03(a)(3)) apply with equal effect to an individual who is enrolled in CHIP.
(01/15/2017, GCR 16-094)
Vermont has elected to establish and operate its own Exchange. Vermont Act No. 48 of 2011, "An act relating to a universal and unified health system," established the Vermont health benefit exchange (Vermont Health Connect, VHC). The purpose of VHC is to facilitate the purchase of affordable, qualified health benefit plans by individuals, and small employers in the merged individual and small group markets; and later in the large group market in Vermont in order to reduce the number of uninsured and underinsured; to reduce disruption when individuals lose employer-based insurance; to reduce administrative costs in the insurance market; to contain costs; to promote health, prevention, and healthy lifestyles by individuals; and to improve quality of health care.
Qualified health plans (QHPs) must provide a comprehensive set of services (essential health benefits), meet specific standards for actuarial value and the limitation of cost-sharing.
Additionally, catastrophic plans are available to individuals up to age 30 or to individuals who are exempt from the federal penalty for not having coverage.
The state will certify health plans offered through VHC on an annual basis.
Eligible individuals who purchase insurance through VHC may receive federal premium tax credits and Vermont premium reductions. Some also qualify for federal and Vermont cost-sharing reductions (CSR).
Federal premium tax credits are available to eligible individuals and families with incomes up to 400 percent of the FPL to purchase insurance through VHC. [8]
The state will supplement the federal premium tax credits with premium reductions for individuals and families with income at or below 300% of the federal poverty level.
In addition to premium subsidies, eligible individuals receive federal and state CSRs for silver level plans (see level of coverage in § 3.00) and in other limited circumstances. These subsidies reduce the cost- sharing amounts and annual cost-sharing limits and have the effect of increasing the actuarial value of the plan.
Modified adjusted gross income (MAGI) is used to determine eligibility for federal and state premium subsidies and CSRs. In order to be eligible for federal CSR, state premium reductions and state CSR, the individual must be eligible for federal premium tax credits. [9]
Federal health-care regulations contain a number of provisions aimed at the administration of the health-benefits eligibility-determination process. These provisions are intended to promote administratively- efficient, streamlined, and coordinated eligibility business processes.
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As used in this rule, the following terms have the following meanings:
Adjusted monthly premium [11]
The premium an insurer charges for the applicable benchmark plan (ABP) to cover all members of the tax filer's coverage family.
Advance payment of the premium tax credit (APTC) [12 ]
The payment of premium tax credits specified in section 36B of the Internal Revenue Code that are provided on an advance basis on behalf of an eligible individual enrolled in a QHP through VHC and paid directly to the QHP issuer.
Affordable Care Act (ACA) [13]
The Patient Protection and Affordable Care Act of 2010 ( Pub. L. 111- 148), as amended by the Health Care and Education Reconciliation Act of 2010 ( Pub. L. 111-152), as amended by the Three Percent Withholding Repeal and Job Creation Act ( Pub. L. 112-56).
Aid to the Aged, Blind, or Disabled (AABD) [14]
Vermont's supplemental security income (SSI) state supplement program.
Alternate reporter
A person who is authorized to receive either original notifications or copies of such notifications on behalf of an individual. (See, § 5.02(b)(1)(iv)).
Annual open enrollment period (AOEP) [15]
The period each year during which a qualified individual may enroll or change coverage in a QHP.
Applicable benchmark plan (ABP) [16]
As defined in § 60.06, the second-lowest-cost silver plan offered through VHC.
Applicant [17]
Application [18]
A single, streamlined application for health benefits, submitted by or on behalf of an applicant. For determining eligibility on a basis other than the applicable MAGI standard, the single, streamlined application may be supplemented with form(s) to collect additional information needed, or an appropriate alternative application may be used.
Application date
If an application is supplemented with form(s) to collect additional information, including the use of an alternative application, the application date is the date the initial application is received by AHS.
Application filer [19]
Approve
To determine that an individual is eligible for health benefits.
Approval month
The month in which the individual's eligibility is approved.
Authorized representative
A person or entity designated by an individual to act responsibly in assisting the individual with their application, renewal of eligibility and other ongoing communications. See, § 5.02
Benefit year (or taxable year) [20]
A calendar year for which a health plan provides coverage for health benefits.
Broker [21]
A person or entity licensed by the state as a broker or insurance producer
Business day
Any day during which state offices are open to serve the public.
Cancel
To determine that an applicant who was approved for health benefits but not yet enrolled is no longer eligible for health benefits.
Caretaker relative [22]
Case file
The permanent collection of documents and information required to determine eligibility and to provide benefits to individuals.
Categorically needy [23]
Families and children; aged, blind, or disabled individuals; and pregnant women, described under subparts B and C of 42 CFR part 435 who are eligible for Medicaid. Subpart B describes the mandatory eligibility groups who, generally, are receiving or are deemed to be receiving cash assistance under the Act. These mandatory groups are specified in §§ 1902(a)(10)(A)(i), 1902(e), 1902(f), and 1928 of the Act. Subpart C describes the optional eligibility groups of individuals who, generally, meet the categorical requirements or income or resource requirements that are the same as or less restrictive than those of the cash assistance programs and who are not receiving cash payments. These optional groups are specified in §§ 1902(a)(10)(A)(ii), 1902(e), and 1902(f) of the Act.
Catastrophic plan [24]
A health plan available to an individual up to age 30 or to an individual who is exempt from the mandate to purchase coverage that:
Certified application counselors
Staff and volunteers of organizations who are authorized and registered by AHS to provide assistance to individuals with the application process and during renewal of eligibility. See, § 5.05
Close
To determine that an enrollee is no longer eligible to receive health benefits.
Code
Internal Revenue Code.
Combined eligibility notice [25]
An eligibility notice that informs an individual, or multiple family members of a household when feasible, of eligibility for each of the health-benefits programs, and enrollment in a QHP, for which a determination or denial was made. A combined notice must meet the requirements of § 68.01.
Community spouse (CS)
For purposes of Medicaid, the spouse of an institutionalized individual who is not living in a medical institution or a nursing facility. An individual is considered a community spouse even when receiving Medicaid coverage of long-term care services and supports in a home and community-based setting if they are the spouse of an individual who is also receiving Medicaid coverage of long-term care services and supports.
Cost sharing [26]
Any expenditure required by or on behalf of an individual with respect to essential health benefits; such term includes deductibles, coinsurance, copayments, or similar charges, but excludes premiums, balance-billing amounts for non-network providers, and spending for non-covered services.
Cost-sharing reductions (CSR) [27]
Reductions in cost sharing for an individual who is enrolled in a silver- level QHP or for an individual who is an Indian enrolled in a QHP.
Couple
Two individuals who are married to each other or are parties to a civil union, according to the laws of the State of Vermont, except, for purposes of APTC/CSR, two individuals who are married to each other within the meaning of 26 CFR § 1.7703-1. IRS's regulations do not recognize parties to civil unions as married couples. Couples in civil unions are not permitted to file joint federal tax returns, but may qualify for APTC/CSR by filing separate tax returns.
Coverage
The scope of health benefits provided to an individual.
Coverage date
The date coverage begins.
Coverage family [28]
See, § 60.02(b)
Coverage group [29]
Category of Medicaid eligibility, defined by particular categorical, financial, and nonfinancial criteria.
Coverage island
A discrete period of Medicaid coverage that is available in certain defined circumstances. See, § 70.02(d)
Coverage month [30]
A month for which, as of the first day of the month:
Date of application
See, application date
Day
A calendar day unless a business day is specified.
Deny
To determine that an applicant is ineligible for health benefits.
Dependent child [31]
An individual who is:
Disability [32]
An individual age 18 and older is considered "disabled" if they are unable to engage in any substantial gainful activity because of any medically-determinable physical or mental impairment, or combination of impairments, that can be expected to result in death, or has lasted or can be expected to last for a continuous period of not fewer than 12 months. To meet this definition, an individual must have a severe impairment, which makes them unable to do their previous work or any other substantial gainful activity that exists in the national economy. To determine whether an individual is able to do any other work, AHS considers their residual functional capacity, age, education, and work experience.
An individual under age 18 is considered disabled if they have a medically-determinable physical or mental impairment, or combination of impairments, resulting in marked and severe functional limitations, that can be expected to result in death or that have lasted or can be expected to last for at least 12 consecutive months. An individual under age 18 who engages in substantial gainful activity may not be considered disabled.
Disenroll
To end coverage.
Dr. Dynasaur
The collection of programs that provide health benefits to children under age 19 in the group defined in § 7.03(a)(3) and pregnant women in the group defined in § 7.03(a)(2).
Electronic account [33]
An electronic file that includes all information collected and generated by the state regarding each individual's health-benefits eligibility and enrollment, including all documentation required under § 4.04 and including information collected or generated as part of a fair hearing process conducted with regard to health-benefits eligibility and enrollment.
Eligible
The status of an individual determined to meet all financial and nonfinancial qualifications for health benefits.
Eligible employer-sponsored plan [34]
Eligibility determination [36]
An approval or denial of eligibility as well as a renewal or termination of eligibility.
Eligibility process
Activities conducted for the purposes of determining, redetermining, and maintaining the eligibility of an individual.
Employer contributions [37]
Any financial contributions toward an employer-sponsored health plan, or other eligible employer-sponsored benefit made by the employer including those made by salary reduction agreement that is excluded from gross income.
Enroll
To initiate coverage for an approved individual.
Enrollee [38]
An individual who has been approved and is currently receiving health benefits. The term "enrollee" includes the term "beneficiary,' which is an individual who has been determined eligible for, and is currently receiving, Medicaid.
Exchange (Vermont Health Connect (VHC)) [39]
A state-managed entity through which individuals, qualified employees, and small businesses can compare, shop for, purchase, and enroll in QHPs; and individuals can apply for and enroll in health- benefits programs. In Vermont, the Exchange is known as Vermont Health Connect (VHC).
Exchange service area [40]
The area in which the Exchange (in Vermont, VHC) is certified to operate.
Family size
See, § 28.02(b)
Federal poverty level (FPL) [41]
The poverty guidelines most recently published in the Federal Register by the Secretary of HHS under the authority of 42 USC § 9902(2), as in effect for the applicable budget period used to determine an individual's income eligibility for means-tested health benefits.
Financial responsibility group
For purposes of MABD, the individuals whose income or resources are considered when determining eligibility for a Medicaid group (defined below). See § 29.03 for rules on the formation of the financial responsibility group for MABD eligibility purposes.
Grace period
The period of time during which an enrollee who has failed to pay all outstanding premiums remains enrolled in coverage, with or without pended claims.
Grandfathered health plan coverage [42]
Coverage provided by a group health plan, or a group or individual health insurance issuer, in which an individual was enrolled on March 23, 2010 (for as long as it maintains that status under federal criteria).
Group health plan [43]
An employee welfare benefit plan to the extent that the plan provides medical care (including items and services paid for as medical care) to employees (including both current and former employees) or their dependents (as defined under the terms of the plan) directly or through insurance, reimbursement, or otherwise.
Health-benefits program [44]
A program that is one of the following:
Health benefits
Any health-related program or benefit, administered or regulated by the state, including, but not limited to, QHPs, APTC, premium reductions, federal or state CSR, and Medicaid.
Health insurance coverage [45]
Benefits consisting of medical care (provided directly, through insurance or reimbursement, or otherwise) under any hospital or medical service policy or certificate, hospital or medical service plan contract, or HMO contract offered by a health insurance issuer. Health insurance coverage includes group health insurance coverage and individual health insurance coverage.
Health insurance issuer or issuer [46]
An insurance company, nonprofit hospital and medical service corporation, insurance service, or insurance organization (including an HMO) that is required to be licensed to engage in the business of insurance in a state and that is subject to state law that regulates insurance (within the meaning of section 514(b)(2) of ERISA).
Health plan [47]
This term has the meaning given in § 1301(b)(1) of the ACA. That section incorporates the definition found in § 2791(a) of the Public Health Service Act.
Human Services Board
AHS's fair hearings entity for eligibility issues. See, § 80.01
Indian [48]
A person who is a member of an Indian tribe.
Indian tribe [49]
Any Indian tribe, band, nation or other organized group, or community, including pueblos, rancherias, colonies and any Alaska Native Village, or regional or village corporation as defined in or established pursuant to the Alaska Native Claims Settlement Act, which is recognized as eligible for the special programs and services provided by the United States to Indians because of their status as Indians.
Individual
An applicant or enrollee for health benefits.
Institution [50]
An establishment that furnishes (in single or multiple facilities) food, shelter, and some treatment or services to four or more individuals unrelated to the proprietor.
Institutionalized individual
A person requesting Medicaid coverage of long-term care services and supports, whether the care is received in a home and community- based setting or in an institution licensed by AHS.
Institutionalized spouse (IS)
For purposes of Medicaid, an institutionalized individual whose spouse qualifies as a community spouse.
Interpreter
A person who orally translates for an individual who has limited English proficiency or an impairment.
Lawfully present
See, § 17.01(g)
Level of coverage [51]
One of four standardized actuarial values for plan coverage as defined by § 1302(d)(1) of the ACA: bronze, silver, gold or platinum.
Limited English proficiency
An ineffective ability to communicate in the English language for individuals who do not speak English as their primary language and may be entitled to language assistance with respect to a particular type of service, benefit or encounter.
Long-term care
Highest-need and high-need care, as determined by AHS, received by an individual living in a nursing facility, rehabilitation center, intermediate-care facility for the developmentally disabled (ICF-DD), and other medical facility for at least 30 consecutive days. It also includes care received by an individual in a home and community- based setting as specified in relevant waiver authorizations and any related program regulations.
For more information on Vermont's waiver governing terms and conditions, see: http://dvha.vermont.gov/administration.
Long-term care services and supports [52]
A range of medical, personal, and social services that can help an individual with functional limitations live their life more independently. Supports range from daily living (e.g. grocery shopping and food preparation) to 24-hour medical care provided in nursing facilities. Examples of long-term care services and supports include nursing facility services; a level of care in any institution equivalent to nursing facility services; home and community-based services to qualifying individuals as specified in relevant waiver authorizations or in any related program regulations, to include:
For more information on Vermont's waiver governing terms and conditions, see: http://dvha.vermont.gov/administration. See, also, DVHA's Medicaid Covered Services Rule 7601.
MAGI-based income [53]
See, § 28.03(c)
Medicaid for Children and Adults (MCA)
The health-benefits program available to a member of a Medicaid coverage group for parents and other caretaker relatives, children, pregnant women, or adults under 65 years of age.
Medicaid for the Aged, Blind, and Disabled (MABD)
The health-benefits program available to a member of a Medicaid coverage group for people who are aged, blind, or disabled. MABD is based on the requirements for two financial assistance programs federally administered by the Social Security Administration: the supplemental security income program (SSI) and aid to the aged, blind, and disabled program (AABD).
Medicaid group
Individuals who are considered in the financial-eligibility determination for MABD. The countable income and resources of the financial responsibility group are compared against the income and resource standards applicable to the Medicaid group's size. See § 29.04 for rules on the formation of the Medicaid group.
Medicaid services [54]
Medical benefits funded through Medicaid. They include Medicaid services (Medicaid Covered Services Rules 7201 - 7508. 7), long-term care services and supports (Medicaid Covered Services Rules 7601 - 7608), services defined in regulations for Choices for Care, Developmental Disabilities, and the waiver for Traumatic Brain Injury supports, as specified in relevant waiver authorizations.
Medical incapacity
See, § 64.09.
Medical institution [55]
An institution that:
Medically needy [56]
Families; children; individuals who are aged, blind, or disabled; and pregnant women who are not categorically needy but who may be eligible for Medicaid because their income and, for individuals who are aged, blind or disabled, their resources are within limits set by the state under its Medicaid plan (including persons whose income and, if applicable, resources fall within these limits after their incurred expenses for medical or remedial care are deducted).
Minimum essential coverage (MEC) [57]
Health coverage under government-sponsored programs, employer- sponsored plans that meet specific criteria, grandfathered health plans, individual health plans, and certain other health-benefits coverage. See, § 23.00.
Minimum value [58]
When used to describe coverage in an eligible employer-sponsored plan, minimum value means that the percentage of the total allowed costs of benefits provided under the plan is greater than or equal to 60 percent, and the benefits under the plan include substantial coverage of inpatient hospital services and physician services.
Modified adjusted gross income (MAGI)
See, § 28.00
Navigator [59]
An entity or individual selected by AHS and awarded a grant to provide assistance to individuals and employers with enrollment in Medicaid programs and qualified health plans, and to engage in the activities and meet the standards described in § 5.03.
Non-applicant [60]
A person who is not seeking an eligibility determination for himself or herself and is included in an applicant's or enrollee's household to determine eligibility for such applicant or enrollee.
Nonpayment
Failure to pay any or all of a premium due.
OASDI [61]
Old age, survivors, and disability insurance under Title II of the Act.
Optional state supplement [62]
A cash payment made by a state, under § 1616 of the Act, to an aged, blind, or disabled individual. See, AABD.
Patient share
See, § 24.00.
Physician's certificate
See, § 64.09.
Plan year [63]
A consecutive 12-month period during which a health plan provides coverage. For plan years beginning on January 1, 2015, a plan year must be a calendar year.
Plain language [64]
Language that the intended audience, including individuals with limited English proficiency, can readily understand and use because that language is concise, well-organized, and follows other best practices of plain language writing.
Pregnant woman [65]
A woman during pregnancy and the post partum period, which begins on the date the pregnancy ends, extends 60 days, and then ends on the last day of the month in which the 60-day period ends.
Premium
A monthly charge that must be paid by an individual as a condition of initial and ongoing health-benefits eligibility and enrollment.
The premium for the first month of coverage.
The premium for successive months of coverage, which are billed and due on a monthly basis.
Premium due date
The day on which a health-benefits premium is due.
Premium Reduction
State subsidy paid directly to the QHP issuer to reduce monthly premiums for an eligible individual enrolled in a QHP through VHC.
Private facility [66]
Any home privately owned and operated, or any home or institution supported by private or charitable funds, over which neither the state nor any of its subdivisions has supervision or control even though individuals may be boarded or cared for therein at public expense. Vermont private institutions include boarding homes, fraternal homes, religious homes, community care homes, residential care facilities, medical facilities (i.e. general hospitals) and nursing facilities licensed by the State of Vermont.
Protected Income Level (PIL)
The income standard for the medically-needy Medicaid coverage groups.
Public Institution [67]
Any institution meeting all of the following conditions:
Qualified Health Plan (QHP)
A health plan certified by Vermont's Department of Financial Regulation (DFR) and offered by Vermont Health Connect.68
QHP issuer [69]
A health insurance issuer that offers a QHP in accordance with a certification from DFR.
Qualified individual [70]
For purposes of QHP, an individual who has been determined eligible by AHS to enroll in a QHP.
Qualifying coverage in an employer-sponsored plan [71 ]
Coverage in an eligible employer-sponsored plan that meets the affordability and minimum-value standards specified in 26 CFR § 1.36 B- 2(c)(3), and described in §§ 23.02 (affordable) and 23.03 (minimum value).
Quality control (QC)
A system of continuing review to measure the accuracy of eligibility decisions. Also, the name of the AHS unit that is responsible for administering quality-control functions.
Reasonable compatibility
See, § 57.00(a)
Reenroll
To restore coverage after closure.
Reinstate
To restore eligibility after cancellation or closure.
Renew
To redetermine eligibility at a specified periodic interval ( e.g., annual renewal of eligibility).
Secure electronic interface [72]
An interface that allows for the exchange of data between information technology systems and adheres to the requirements in subpart C of 42 CFR part 433.
Self-only coverage [73]
Health insurance that covers one individual.
Special enrollment period (SEP) [74]
A period during which a qualified individual or enrollee who experiences certain qualifying events may enroll in, or change enrollment in, a QHP outside of AOEPs.
Spouse
A husband, a wife or a party to a civil union according to the laws of the State of Vermont, except, for purposes of APTC/CSR, a husband or a wife if married within the meaning of 26 CFR § 1.7703-1. IRS's regulations do not recognize parties to civil unions as "spouses." Parties to civil unions are not permitted to file joint federal tax returns, but may qualify for APTC/CSR by filing separate tax returns.
SSI
Supplemental security income program under Title XVI of the Act.
Substantial gainful activity
Tax filer [75]
For purposes of eligibility for a QHP with financial assistance, an individual who indicates that they expect:
Tax dependent
Third party
Any person, entity, or program that is or may be responsible to pay all or part of the expenditures for another person's medical benefits.
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An individual who is receiving health benefits from another state is not eligible for health benefits in Vermont.
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Policies are administered in accordance with federal and state law. Individuals will be informed of their rights and responsibilities with respect to application for and receipt of health benefits.
AHS does not discriminate on the basis of race, color, sex, sexual orientation, religion, national origin, disability, or age in admission or access to, or treatment or employment in, its programs or activities.
The confidentiality of information obtained during the eligibility process is protected in accordance with federal and state laws and regulations. The use and disclosure of information concerning applicants, enrollees, and legally-liable third parties is restricted to purposes directly connected with the administration of health-benefits programs, with enrollment in a QHP or as otherwise required by law.
Eligible individuals have the right to the timely provision of benefits, as defined in § 61.00.
Individuals who inquire have the right to receive information about health benefits, coverage-type requirements, and their rights and responsibilities as enrollees of health-benefits programs or as enrollees in QHPs.
Any person, individually or through an authorized representative or legal representative has the right, and will be afforded the opportunity without delay, to apply for benefits.
An individual has the right to inspect information in their case file and contest the accuracy of the information.
An individual has the right to appeal, as provided in § 68.00.
Individuals will be informed of the availability of interpreter services. Unless the individual chooses to provide their own interpreter services, AHS will provide either telephonic or other interpreter services whenever:
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An individual must cooperate in providing information necessary to establish and maintain their eligibility, and must comply with all rules and regulations, including recovery and obtaining or maintaining available health insurance.
An individual enrolled in a health-benefits program must cooperate with any quality-control (QC) review of their case. ( § 4.05 )
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Case records include the following information:
Case information may contribute in statistical or other general terms to material needed for planning, research, and overall administration of human-services programs. Individual case information shall, however, be held in accordance with the confidentiality requirements set forth in § 4.08.
Case records are retained as required by federal and state requirements for audit and/or review.
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A person commits fraud in Vermont if he or she:
An individual who commits fraud may be prosecuted under Vermont law. If convicted, the individual may be fined or imprisoned or both. Action may also be taken to recover the value of benefits paid in error due to fraud.
An individual may report suspected fraud to AHS. When AHS suspects that fraud may have been committed, it will investigate the case. If appropriate, the case will be referred to the State's Attorney or Attorney General for a decision on whether or not to prosecute.
The following criteria will be used to evaluate cases of suspected fraud to determine whether they should be referred to a law enforcement agency:
Any investigation of a case of suspected fraud is pursued with the same regard for confidentiality and protection of the legal and other rights of the individual as with a determination of eligibility.
Procedures will be established for review and documentation of a fraud investigation.
The final decision regarding referral to a law enforcement agency shall be the responsibility of the appropriate department's commissioner.
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AHS must establish and implement privacy and security standards that are consistent with the following principles.
For the purposes of implementing the principle described in paragraph (a)(1)(vii) of this subsection, AHS must establish and implement operational, technical, administrative and physical safeguards that are consistent with any applicable laws (including this subsection) to ensure:
AHS must monitor, periodically assess, and update the security controls and related system risks to ensure the continued effectiveness of those controls.
AHS must develop and utilize secure electronic interfaces when sharing personally identifiable information electronically.
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To the extent that electronic transactions are performed with a covered entity, standards, implementation specifications, operating rules, and code sets adopted by the Secretary of HHS in 45 CFR parts 160 and 162 will be used.
Interoperable and secure standards and protocols developed by the Secretary of HHS in accordance with § 3021 of the PHS Act will be incorporated. Such standards and protocols will be incorporated within VHC information technology systems.
(01/15/2017, GCR 16-094)
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AHS will provide assistance to any individual seeking help with the application or renewal process in person, over the telephone, and online, and in a manner that is accessible to individuals with disabilities and those who are limited English proficient. Eligibility and enrollment assistance that meets the accessibility standards in paragraph (c) of this subsection is provided, and referrals are made to assistance programs in the state when available and appropriate. These functions include assistance provided directly to any individual seeking help with the application or renewal process.
A toll-free call center is provided to address the needs of individuals requesting assistance and meets the accessibility requirements outlined in paragraph (c) of this subsection.
An up-to-date internet website that meets the requirements outlined in paragraph (c) of this subsection is maintained. The website:
Outreach and education activities that meet the standards in paragraph (c) of this subsection to educate consumers about VHC and Vermont's health-benefits programs to encourage participation will be conducted.
As required by the Americans with Disabilities Act, reasonable accommodations and modifications will be made to policies, practices, or procedures when necessary, as determined by the appropriate commissioners or their designees, to provide equal access to programs, services and activities, or when necessary to avoid discrimination on the basis of disability. An individual may appeal the commissioner's determination regarding necessity to the appropriate fair hearings entity or appeals entity in accordance with departmental regulations governing appeals and fair hearings.
AHS assistance programs and activities will:
(01/15/2017, GCR 16-094)
The authorized representative:
For purposes of this subsection, electronic, including telephonically recorded, signatures and handwritten signatures transmitted by facsimile or other electronic transmission will be accepted. Designations of authorized representatives will be accepted through all of the modalities described in § 52.02(b).
The authorization form or the AHS call center representative (if the authorization is made over the telephone) shall advise that:
If the individual is a minor or an incapacitated adult, no authorization is required; someone acting responsibly for the individual may assist in the application process or during a redetermination of eligibility. Such person may also sign the initial application on the applicant's behalf.
Upon presentment of a valid document of appointment, a judicially- appointed legal guardian or representative may act on an individual's behalf.
(01/15/2017, GCR 16-094)
AHS conducts a Navigator program consistent with this subsection through which it awards grants to eligible entities to perform the functions of navigator organizations, and certifies individuals as Navigators. The functions of navigator organizations include providing assistance to individuals and employers with enrollment in Medicaid programs and qualified health plans.
AHS maintains and publicly disseminates:
To receive a Navigator grant, an entity must:
A Navigator must not:
In addition to prohibited conduct in (d) of this subsection, the following standards apply to Navigators:
An entity that serves as a Navigator must carry out at least the following duties:
Funding for navigator grants may not be from Federal funds received by the state to establish VHC.
(01/15/2017, GCR 16-094)
A broker may:
Prior to enrolling a qualified individual, employee, or employer in a QHP through VHC, or assisting an individual in applying for a QHP with financial assistance, a broker must have an executed agreement with AHS, and must comply with the terms of that agreement, which includes at least the following requirements:
A broker who facilitates enrollment of an individual, employer, or employee in any QHP must comply with procedures, including payment mechanisms and standard fee or compensation schedules, established by AHS, that allow brokers to be appropriately compensated for assisting with the enrollment of qualified individuals and qualified employers in any QHP offered through VHC for which the individual or employer is eligible; and assisting a qualified individual in applying for financial assistance for a QHP purchased through VHC.
(01/15/2017, GCR 16-094)
AHS certifies staff and volunteers of state-partner organizations to act as application counselors, authorized to provide assistance to individuals with the application process and during renewal of eligibility.
AHS will establish procedures to withdraw certification from individual application counselors, or from all application counselors associated with a particular organization, when it finds noncompliance with the terms and conditions of the application counselor agreement.
Certified application counselors are certified to:
AHS must establish procedures to ensure that:
Application counselors may not:
Notwithstanding the non-discrimination provisions of § 5.01(g), an organization that receives federal funds to provide services to a defined population under the terms of federal legal authorities that participates in the certified application counselor program may limit its provision of certified application counselor services to the same defined population, but must comply with § 5.01(g) with respect to the provision of certified application counselor services to that defined population, If the organization limits its provision of certified application counselor services pursuant to this exception, but is approached for certified application counselor services by an individual who is not included in the defined population that the organization serves, the organization must refer the individual to other AHS-approved resources that can provide assistance. If the organization does not limit its provision of certified application counselor services pursuant to this exception, the organization must comply with § 5.01(g).
Part TWO ELIGIBILITY STANDARDS
(01/15/2017, GCR 16-095)
To qualify for Medicaid, an individual must meet nonfinancial, categorical, and financial eligibility criteria.
The nonfinancial criteria include the following:
An individual must meet the categorical criteria ( e.g., age, disability, etc.) of at least one coverage group to be eligible for health benefits through the Medicaid program.
Although there are a few coverage groups with no financial requirements, financial eligibility generally requires that an individual have no more than a specified amount of income or, in some cases, resources. The Medicaid financial eligibility requirements are:
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An individual is eligible for MCA if they meet the nonfinancial, categorical, and financial criteria outlined in this section.
(01/15/2017, GCR 16-095)
The individual must meet all of the following nonfinancial eligibility criteria for Medicaid:
(01/15/2017, GCR 16-095)
The individual must meet the criteria for at least one of the following coverage groups:
A parent or caretaker relative of a dependent child (as defined in § 3.00) and their spouse, if living within the same household as the parent or caretaker relative, with a MAGI-based household income, as defined in § 28.03, that is at or below a specified dollar amount that is set based on the parent or caretaker relative's family size and whether they live in or outside of Chittenden County. A chart of these dollar amounts is made publicly available via website.
A woman may be retroactively granted Medicaid eligibility under this coverage group if she was pregnant and met all eligibility criteria. However, she would not be eligible for Medicaid under this coverage group for the 60-day post partum period if she applied for Medicaid after her pregnancy ended.
Medicaid cannot be provided under this sub clause to a parent or other caretaker relative living with a child who is under the age of 21 unless such child is receiving benefits under Medicaid or Dr. Dynasaur, or otherwise is enrolled in MEC.
Families who become ineligible for Medicaid because a parent, caretaker relative, or pregnant woman has new or increased earnings may be eligible for Transitional Medical Assistance (TMA) for up to 12 months, beginning with the month immediately following the month in which they become ineligible. TMA will be provided to:
For a parent or caretaker relative to remain eligible for the first six-month extension, they must continue to have a dependent child, as defined in § 3.00, living with them. Parents, caretaker relatives, pregnant women, and children eligible for TMA must continue to reside in Vermont.
To be eligible for TMA for the six-month period following the initial six-month extension, parents, caretaker relatives, and pregnant women must meet the criteria for the initial six-month extension in (C) above, and must also:
If TMA for a parent, caretaker relative, pregnant woman, or child is terminated due to failure to meet the criteria described above, Medicaid coverage will continue under another Medicaid category if the parent, caretaker relative, pregnant woman or child is eligible under that category.
If a parent, caretaker relative, or pregnant woman fails to meet the quarterly reporting requirement without good cause, as determined by AHS, AHS will terminate TMA. TMA will not be reinstated until the month after the quarterly report is received.
Extended Medicaid coverage will be provided to:
An individual under age 21, a pregnant woman, or a parent or other caretaker relative, as described above, may qualify for MCA as medically needy even if their income exceeds coverage group limits.
For purposes of determining medically-needy eligibility under this sub clause, AHS applies the MAGI-based methodologies defined in § 28.03 subject to the requirements of § 28.04.
If countable income determined under paragraph (a)(8)(ii) of this sub clause is equal to or less than the PIL for the individual's family size, the individual is eligible for Medicaid.
The provisions under § 30.00 specify how an individual may use non- covered medical expenses to "spend down" their income to the applicable limits.
For an individual eligible for MCA who seeks Medicaid coverage of long- term care services and supports under MCA, AHS will apply the following rules in determining the individual's eligibility for such coverage:
There are no resource tests for the coverage groups described under (a) of this subsection.
(01/15/2017, GCR 16- 095)
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An individual is eligible for MABD if they meet the nonfinancial, categorical, and financial criteria outlined in this section. [19]
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The individual must meet all of the following nonfinancial eligibility criteria for Medicaid:
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An individual applying for MABD must establish their categorical relationship to SSI by qualifying as one or more of the following:
An individual qualifying on the basis of age must be at least 65 years of age in or before the month in which eligibility begins.
An individual qualifying on the basis of blindness must be:
An individual qualifying on the basis of disability must be:
A blind or disabled individual who is either single or not the head of a household; and
See, also, § 29.02(a)(1).
(01/15/2017, GCR 16-095)
Disability and blindness determinations are made by AHS in accordance with the applicable requirements of the Social Security Administration based on information supplied by the individual and by reports obtained from the physicians and other health care professionals who have treated the individual. AHS will explain the disability determination process to individuals and help them complete the required forms.
AHS may determine an individual is disabled in any of the following circumstances:
AHS has responsibility for assuring that adequate information is obtained upon which to base the determination. If additional information is needed to determine whether individuals are disabled or blind according to the Act, consulting examinations may be required. AHS will pay the reasonable charge for any medical examinations required to render a decision on disability or blindness.
(01/15/2017, GCR 16-095)
An individual applying for MABD must meet the criteria of one or more of the following categories.
An individual under the age of 18 who lost their SSI or SSI/AABD eligibility because of the more restrictive definition of disability enacted in August 1996 but who continues to meet all other MABD criteria until their 18th birthday. [24] The definition of disability for this group is the definition of childhood disability in effect prior to the 1996 revised definition.
An individual with a disability if they meet all of the following conditions:
An individual who was eligible for Medicaid in December 1973 and meets at least one of the following criteria:
This section implements section 1902(a)(10)(A)(ii)(IV) of the Act.
An aged, blind, or disabled individual who is in a medical institution and who:
An aged, blind or disabled individual who is living in a medical institution and who:
An individual who qualifies for home and community-based services and who:
An individual who:
A disabled individual who:
An individual who qualifies for home and community-based services and meets the financial eligibility requirements for MWPD as set forth in § 8.05(d).
(01/15/2017, GCR 16-095)
An individual who would be a member of a categorically-needy coverage group, as described in § 8.05, may qualify for MABD as medically needy even if their income or resources exceed coverage group limits.
An otherwise-qualifying individual is eligible for this coverage group if their MABD income for the individual's financial responsibility group (as defined in § 29.03) is at or below the PIL for the individual's Medicaid group (as defined in § 29.04), or, as described in paragraph (d) of this subsection, they incur enough non-covered medical expenses to reduce their income to that level.
To qualify for this coverage group, an individual must have MABD resources for the individual's financial responsibility group that are at or below the SSI/AABD maximum for the individual's Medicaid group, or, as described in paragraph (d) of this subsection, they incur enough expenses to reduce their resources to that level.
The rules in § 30.00 specify how an individual may use non-covered medical expenses to "spend down" their income or resources to the applicable limits.
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(01/15/2017, GCR 16-095)
An individual is eligible for a special Medicaid group if they meet the nonfinancial, categorical, and financial criteria outlined in this section.
(01/15/2017, GCR 16-095)
The individual must meet all of the following nonfinancial eligibility criteria for Medicaid:
(01/15/2017, GCR 16-095)
An individual must meet the criteria for at least one of the following coverage groups:
This sub clause implements §§ 1902(e)(4) and 2112(e) of the Act.
This sub clause implements §§ 1902(a)(10)(A)(i)(I) and 473(b)(3) of the Act.
Medicaid coverage will be provided to an individual under age 21, living in Vermont for whom:
There is no Medicaid income standard that applies. Committed children in the custody of the state who are not IV-E eligible must pass the applicable eligibility tests before their eligibility for Medicaid can be established.
This sub clause implements § 1902(a)(10)(A)(ii) (VIII) of the Act.
Medicaid coverage will be provided to an individual under age 21:
There is no Medicaid income standard that applies.
This sub clause implements § 1902(a)(10)(A)(i)(IX) of the Act.
Medicaid coverage will be provided to an individual who:
There is no Medicaid income standard that applies.
This sub clause implements §§ 1902(a)(10)(A)(ii) (XVIII) and 1902(aa) of the Act.
An individual is considered to need treatment for breast or cervical cancer if, in the opinion of the individual's treating health professional (i.e., the individual who conducts the screen or any other health professional with whom the individual consults), the screen (and diagnostic evaluation following the clinical screening) determines that:
In order to qualify for screening under (f)(2)(i)(C) above, an individual must be determined by BCCEDP to have limited income. In addition to meeting the criteria described in this sub clause, the individual must meet all other Medicaid nonfinancial criteria.
This provision implements §§ 1902(a)(10)(A)(ii) (XXI) and 1902(ii) and clause (XVI) in the matter following 1902(a)(10)(G) of the Act.
Medicaid coverage will be provided to an individual (male and female) who meets all of the following requirements:
The individual has MAGI-based household income (as defined in § 28.03) that is at or below the income standard for a pregnant woman as described in § 7.03(a)(2). The individual's household income is determined in accordance with § 28.03(j).
An individual eligible under this sub clause is covered for family planning and family planning-related benefits.
See, HIV/AIDS Rule 5800 et seq.
See, Refugee Medical Assistance Rule 5100 et seq.
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The VPharm program rules located in Rule 5400 et seq. will remain in effect.
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The Healthy Vermonter Program (HVP) rules located in Rule 5700 et seq. will remain in effect.
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Eligibility for enrollment in a QHP [52]
An individual is eligible for enrollment in a QHP if the individual meets the nonfinancial criteria outlined in this section.
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The individual must meet all of the following nonfinancial criteria:
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An individual is eligible for a QHP enrollment period if they meet the criteria for an enrollment period, as specified in § 71.00.
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(01/15/2017, GCR 16-095)
A tax filer is eligible for APTC on behalf of an individual if the tax filer meets the criteria outlined in this section. A tax filer must be eligible for APTC on behalf of an individual in order for the individual to receive the Vermont Premium Reduction. APTC and the Vermont Premium Reduction are paid directly to the QHP issuer on behalf of the tax filer.
(01/15/2017, GCR 16-095)
An applicable tax filer (within the meaning of § 12.03) is eligible for APTC for any month in which one or more individuals for whom the tax filer expects to claim a personal exemption deduction on their tax return for the benefit year, including the tax filer and their spouse:
(01/15/2017, GCR 16-095)
Except as otherwise provided in this subsection, an applicable tax filer is a tax filer who expects to have household income of at least 100 percent but not more than 400 percent of the FPL for the tax filer's family size for the benefit year.
For purposes of calculating the household income of an applicable tax filer and determining their financial eligibility for APTC, see § 28.05.
An individual is not an applicable tax filer if another tax filer may claim a deduction under 26 USC § 151 for the individual for a benefit year beginning in the calendar year in which the individual's benefit year begins.
An individual who is not lawfully present in the United States or is incarcerated (other than incarceration pending disposition of charges) is not eligible to enroll in a QHP through VHC. However, the individual may be an applicable tax filer for purposes of claiming the premium tax credit if a family member is eligible to enroll in a QHP.
An individual is also an applicable tax filer if:
A tax filer (other than a tax filer described in paragraph (e) of this subsection) whose household income for a benefit year is less than 100 percent of the FPL for the tax filer's family size is treated as an applicable tax filer for purposes of claiming the premium tax credit if:
If a tax filer is treated as an applicable tax filer under paragraph (e) or (f) of this subsection, the tax filer's actual household income for the benefit year is used to compute the premium-assistance amounts under § 60.00.
(01/15/2017, GCR 16-095)
APTC will only be provided on behalf of a tax filer if one or more individuals for whom the tax filer attests that they expect to claim a personal exemption deduction for the benefit year, including the tax filer and spouse, is enrolled in a QHP.
(01/15/2017, GCR 16-095)
AHS may not determine a tax filer eligible for APTC if HHS notifies AHS as part of the process described in § 56.03 that APTCs were made on behalf of the tax filer or either spouse if the tax filer is a married couple for a year for which tax data would be utilized for verification of household income and family size in accordance with § 56.01(a), and the tax filer or their spouse did not comply with the requirement to file an income tax return for that year as required by 26 USC § 6011, 6012, and implementing regulations, and reconcile the APTCs for that period.
(01/15/2017, GCR 16-095)
An individual is eligible for the Vermont Premium Reduction if the individual:
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The following eligibility categories for CSR will be used when making eligibility determinations under this section:
Income and benefit levels are as shown in the chart below. The actuarial value of the plan must be within one percentage point of the actuarial value listed below.
Income as a Percent of Federal Poverty Level | Tier | Actuarial Value of Plan with Federal and State CSR |
Not more than 150% | I | 94% |
More than 150% but not more than 200% | II | 87% |
More than 200% but not more than 250% | III | 77% |
More than 250% but not more than 300% | IV | 73% |
(01/15/2017, GCR 16-095)
To the extent that an enrollment in a QHP under a single policy covers two or more individuals who, if they were to enroll in separate policies would be eligible for different cost sharing, AHS will deem the individuals under such policy to be collectively eligible only for the category of eligibility last listed below for which all the individuals covered by the policy would be eligible.
Example: Person A is the mother of Person B, her 24-year-old son.
Person A and Person B both work and file taxes separately. However, they are covered under the same QHP. Person A's income is equal to 125 percent of the FPL and Person B's income is 225 percent of the FPL. Since Person B's income is at the 225 percent level, the CSR that Person A and Person B will receive will be that available at the 225 percent level, which is in the 200 percent to 250 percent range.
(01/15/2017, GCR 16-095)
An individual is eligible for enrollment in a catastrophic plan [64] if they have met the requirements for eligibility for enrollment in a QHP, as specified in § 11.00, and they:
Part THREE NONFINANCIAL ELIGIBILITY REQUIREMENTS
(01/15/2017, GCR 16-096)
This part catalogs the nonfinancial eligibility requirements that apply across all health benefits. The provisions that assign these requirements to a particular program or benefit are set forth in Part Two of this rule.
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AHS may request the Social Security number of a person who is not applying for Medicaid for themselves provided that:
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Includes status as a "national of the United States" that includes both citizens of the United States and non-citizen nationals of the United States.
An individual who is:
A non-citizen who does not meet the definition of qualified non-citizen ( § 17.01(d)).
An individual who is a non-citizen and who:
Has the same meaning as the term "alien," as defined in section 101(a)(3) of the INA, ( 8 USC § 1101(a)(3)) and includes any individual who is not a citizen or national of the United States, defined at 8 USC § 1101(a)(22).
(01/15/2017, GCR 16-096)
Except as provided in paragraphs (b) through (d) of this subsection, as a condition of eligibility for health benefits, an individual must be a citizen or national of the United States and, for purposes of enrollment in a QHP, must reasonably expect to be a citizen or national for the entire period for which QHP enrollment is sought.
An individual who is a non-citizen is eligible for Medicaid if the individual otherwise satisfies the eligibility requirements and is:
An individual who is a non-citizen who is lawfully present in the United States is eligible for enrollment in a QHP, with or without APTC or CSR, if the individual otherwise satisfies the eligibility requirements for a QHP and is reasonably expected to be a non-citizen who is lawfully present for the entire period for which QHP enrollment is sought.
An individual who is ineligible for Medicaid solely because of immigration status is eligible for the treatment of emergency medical conditions if all of the following conditions are met:
(01/15/2017, GCR 16- 096)
Non-citizens who enter the United States on or after August 22, 1996, as qualified non-citizens are not eligible to receive Medicaid for five years from the date they enter the country. If they are not qualified non- citizens when they enter, the five-year bar begins the date they become a qualified non-citizen. The following qualified non-citizens are subject to the five-year bar:
The following qualified non-citizens are not subject to the five-year bar:
The five-year bar does not apply to:
The following categories of individuals are ineligible non-citizens/non- immigrants and are not eligible for Medicaid:
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As a condition of initial and continuing eligibility, a legally-able individual who is applying for or enrolled in Medicaid must meet the requirements related to the pursuit of medical support, third-party payments, and the requirement to enroll or remain enrolled in a group health insurance plan, as provided for below.
(01/15/2017, GCR 16-096)
An individual who is applying for, or enrolled in Medicaid, with the legal authority to do so, must assign their rights to medical support and third- party payments for medical care. If they have the legal authority to do so, they must also assign the rights of any other individual who is applying for or enrolled in Medicaid to such support and payments.
No assignment is required for:
(01/15/2017, GCR 16-096)
An unmarried pregnant woman with income under 208 percent of the FPL is exempted from the requirement to cooperate in establishing paternity or obtaining medical support and payments from, or derived from, the father of the child she expects to deliver or from the father of any of her children born out-of-wedlock. She shall remain exempt through the end of the calendar month in which the 60-day period beginning with the date of her delivery ends.
(01/15/2017, GCR 16-096)
An individual who is applying for or enrolled in Medicaid may request a waiver of the cooperation requirement under § 18.03. Those to whom a good-cause waiver for noncooperation has been granted are eligible for Medicaid, provided that all other program requirements are met. AHS will grant such waivers when either of the following circumstances has been substantiated to AHS's satisfaction:
An Individual requesting a waiver of the cooperation requirement bears the primary responsibility for providing the documentation AHS deems necessary to substantiate their claims of good cause. AHS will consider an individual who has requested a good-cause waiver and submitted the required documentation to be eligible for Medicaid while a decision on the request is pending.
A review of the continued existence of good cause circumstances upon which a waiver has been granted is required no less frequently than at each redetermination of eligibility for those cases in which determination of good cause is based on a circumstance that may change. A formal decision based upon resubmission of evidence is not required, however, unless AHS determines that a significant change of circumstances relative to good cause has occurred.
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An incarcerated individual, other than an individual who is incarcerated pending the disposition of charges, is ineligible for enrollment in a QHP.
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An incarcerated individual may be an applicable tax filer if a family member is eligible to enroll in a QHP.
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(01/15/2017, GCR 16-096)
Individuals or couples meet the living-arrangement requirement for Medicaid eligibility purposes if they live in:
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An individual living in a correctional facility, including a juvenile facility, is not eligible for Medicaid.
Incarceration begins on the date of admission and ends when the individual moves out of the correctional facility.
While incarcerated, Medicaid is available when the inmate is an inpatient in a medical institution not under the control of the corrections system. Such institutions include a hospital, nursing facility, juvenile psychiatric facility, or intermediate care facility.
Once determined Medicaid eligible, an individual who is incarcerated retains eligibility. However, their case is placed in suspended status during the period of incarceration.
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Residence in an institution is determined by the dates of admission and discharge. An individual at home in the community on a visiting pass is still a resident of the institution.
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A homeless individual is considered to be living in their own home.
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The financial responsibility of relatives varies depending upon the type of living arrangement.
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AHS will provide health benefits to an eligible Vermont resident.
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For purposes of this section, an individual is considered incapable of indicating intent regarding residency if the individual:
(01/15/2017, GCR 16-096)
A resident of the state is any individual who:
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For an individual of any age who is receiving a state supplemental payment (in Vermont, known as AABD), the state of residence is the state paying the state supplemental payment.
A transient worker may claim Vermont as their state of residence and be granted Medicaid if they meet all other eligibility criteria. These individuals may be granted Vermont Medicaid even though they continue to receive a state supplement payment from another state.
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Except as provided in § 21.05, with respect to individuals age 21 and over:
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For an individual of any age who is receiving federal payments for foster care or adoption assistance under Title IV-E of the Act, the state of residence is the state where the individual lives.
(01/15/2017, GCR 16-096)
For an individual under age 21 who is not eligible for Medicaid based on receipt of assistance under Title IV-E of the Act, as addressed in § 21.07, and is not receiving a state supplementary payment, as addressed in § 21.05, the state of residence is as follows:
(01/15/2017, GCR 16-096)
AHS will not:
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A state may have a written agreement with another state setting forth rules and procedures resolving cases of disputed residency. These agreements may establish criteria other than those specified in §§ 21.07 and 21.08, but must not include criteria that result in loss of residency in both states or that are prohibited by § 21.09. The agreements must contain a procedure for providing health benefits to individuals pending resolution of the case. States may use interstate agreements for purposes other than cases of disputed residency to facilitate administration of the program, and to facilitate the placement and adoption of a Title IV-E individual when the child and his or her adoptive parent(s) move into another state.
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If Vermont and any other state cannot resolve which state is the individual's state of residence, the state where the individual is physically located is the state of residence.
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Temporary absences from Vermont do not interrupt or end Vermont residence.
An absence is temporary if the individual leaves the state with the intent to return when the purpose of the absence has been accomplished. Examples include, but are not limited to, absences for the purposes of:
For purposes of Medicaid eligibility, an absence is not temporary if another state verifies that the individual meets the residency standard of such other state [36].
(01/15/2017, GCR 16-096)
An individual must be a resident of Vermont at the time a medical service is rendered in order for Vermont Medicaid to pay for that service. The service, however, does not have to be rendered in Vermont subject to certain restrictions. [37]
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Minimum essential coverage means coverage under any of the following: Government-sponsored programs, eligible employer- sponsored plans, grandfathered health plans, individual health plans and certain other health-benefits coverage.
Individuals and their tax dependents must have minimum essential coverage (MEC) to avoid the shared responsibility payment (penalty) imposed by the Internal Revenue Service unless they qualify for an exemption from this payment. See § 23.06 for details on the eligibility determination for MEC exemptions.
In addition, individuals who are eligible to enroll in health coverage that qualifies as MEC under this section are not eligible to receive federal tax credits and cost-sharing reductions if they enroll in a QHP. See §§ 23.01(b) through 23.01(e) for details on health coverage that qualifies as MEC for purposes of considering eligibility for the federal premium tax credit. As stated in § 23.01(c)(2), for an employer-sponsored plan to be considered as MEC when an employee or related individual applies for APTC, the plan must be affordable and meet minimum value criteria. See § 23.02 for details on affordability, and § 23.03 for details on minimum value.
See §§ 55.02(c) and (d) for descriptions of the process for verifying eligibility for MEC when determining eligibility for APTC and CSR.
Subject to the limitation in paragraph (b)(2), an individual is eligible for government-sponsored MEC for purpose of considering eligibility for the federal premium tax credit if, as of the first day of the first full month the individual may receive benefits under the program, the individual meets the criteria for coverage under one of the following government- sponsored programs:
An individual who meets the eligibility criteria for government-sponsored MEC must complete the requirements necessary to receive benefits. An individual who fails by the last day of the third full calendar month following the event that establishes eligibility under (b)(1) of this subsection to complete the requirements to obtain government- sponsored MEC (other than a veteran's health-care program) is treated as eligible for government-sponsored MEC as of the first day of the fourth calendar month following the event that establishes eligibility.
An individual is eligible for MEC under a health-care program under chapter 17 or 18 of Title 38, USC section only if the individual is enrolled in a health-care program under chapter 17 or 18 of Title 38, USC section identified as MEC in regulations issued under § 5000A of the Code.
If an individual receiving APTC is determined to be eligible for government-sponsored MEC that is effective retroactively (such as Medicaid), the individual is treated as eligible for MEC under that program no earlier than the first day of the first calendar month beginning after the approval.
An individual is treated as not eligible for Medicaid or a similar program for a period of coverage under a QHP if, when the individual enrolls in the QHP, the individual is determined to be not eligible for Medicaid.
The following examples illustrate the provisions of this paragraph (b):
On April 10, 2015, Tax filer D applies for coverage under a government- sponsored health-care program. D's application is approved on July 12, 2015, but her coverage is not effective until September 1, 2015. Under paragraph (b)(1), D is eligible for government-sponsored MEC on September 1, 2015.
Tax filer E turns 65 on June 3, 2015, and becomes eligible for Medicare. Under § 5000A(f)(1)(A)(i), Medicare is MEC. However, E must enroll in Medicare to receive benefits. E enrolls in Medicare in September, which is the last month of E's initial enrollment period. Thus, E may receive Medicare benefits on December 1, 2015. Because E completed the requirements necessary to receive Medicare benefits by the last day of the third full calendar month after the event that establishes E's eligibility (E turning 65), under paragraph (b)(1) and (b)(2) of this subsection, E is eligible for government-sponsored MEC on December 1, 2015, the first day of the first full month that E may receive benefits under the program.
The facts are the same as in Example 2, except that E fails to enroll in the Medicare coverage during E's initial enrollment period. E is treated as eligible for government-sponsored MEC under paragraph (b)(2) of this subsection as of October 1, 2015, the first day of the fourth month following the event that establishes E's eligibility (E turning 65).
In November 2014, Tax filer F enrolls in a QHP for 2015 and receives APTCs. F loses her part-time employment and on April 10, 2015, applies for coverage under the Medicaid program. F's application is approved on May 15, 2015, and her Medicaid coverage is effective as of April 1, 2015. Under paragraph (b)(4), F is eligible for government- sponsored MEC on June 1, 2015, the first day of the first calendar month after approval.
In November 2014, Tax filer G applies to enroll in health coverage for 2015. AHS determines that G is not eligible for Medicaid and estimates that G's household income will be 140 percent of the FPL for G's family size for purposes of determining APTCs. G enrolls in a QHP and begins receiving APTCs. G experiences a reduction in household income during the year and his household income for 2015 is 130 percent of the FPL (within the Medicaid income threshold). However, under paragraph (b)(5), G is treated as not eligible for Medicaid for 2015.
The facts are the same as in Example 5, except that G returns to the Exchange in July 2015 and AHS determines that G is eligible for Medicaid. AHS approves G for coverage and AHS discontinues G's APTCs effective August 1. Under paragraphs (b)(4) and (b)(5), G is treated as not eligible for Medicaid for the months when G is covered by a QHP. G is eligible for government-sponsored MEC for the months after G is approved for Medicaid and can receive benefits, August through December 2015.
For purposes of this subsection and §§ 23.02 through 23.04, a related individual is an individual who is not an employee of an employer offering an eligible employer-sponsored plan, but who can enroll in such plan because of their relationship to the employee. This definition has a similar meaning as the definition of "dependent" for purposes of the Small Employer Health-Benefits Program under Part Six of this rule.
An employee and related individual who may enroll in an eligible employer-sponsored plan are eligible for MEC under the plan for purposes of considering eligibility for the federal premium tax credit for any month only if the plan is affordable ( § 23.02) and provides minimum value ( § 23.03). Government-sponsored programs described in paragraph (b) of this subsection are not eligible employer-sponsored plans.
For purposes of this paragraph, a plan year is an eligible employer- sponsored plan's regular 12-month coverage period (or the remainder of a 12-month coverage period for a new employee or an individual who enrolls during a special enrollment period).
An employee or related individual may be eligible for MEC under an eligible employer-sponsored plan for a month during a plan year if the employee or related individual could have enrolled in the plan for that month during an open or special enrollment period.
An employee or related individual is not eligible for MEC under an eligible employer-sponsored plan during a required waiting period before the coverage becomes effective.
The following example illustrates the provisions of this paragraph (c)(4):
A former employee (including a retiree), or an individual related (within the meaning of this paragraph (c)) to a former employee, who may enroll in eligible employer-sponsored coverage or in continuation coverage required under federal law or a state law that provides comparable continuation coverage is eligible for MEC under this coverage only for months that the former employee or related individual is enrolled in the coverage.
The following types of coverage are designated as MEC for purposes of considering eligibility for the federal premium tax credit [52 ]:
An individual is eligible for MEC under the following programs for purposes of considering eligibility for the federal premium tax credit only if the individual is enrolled in the coverage:
(01/15/2017, GCR 16-096)
An individual will not be eligible for a federal premium tax credit if the employer-sponsored plan in which they may enroll is affordable. The details of affordability are described in this subsection.
Except as provided in paragraph (a)(3) of this subsection, an eligible employer-sponsored plan is affordable for an employee if the portion of the annual premium the employee must pay, whether by salary reduction or otherwise (required contribution), for self-only coverage does not exceed the required contribution percentage (as defined in paragraph (c)) of the applicable tax filer's household income for the benefit year.
Except as provided in paragraph (a)(3) of this subsection, an eligible employer-sponsored plan is affordable for a related individual if the portion of the annual premium the employee must pay for self-only coverage does not exceed the required contribution percentage, as described in (a)(1) of this subsection.
An employee or a related individual who is eligible for a safe harbor as defined in this sub clause will not be subject to repayment of APTC based on the finding that affordable MEC was in fact available to them for all or part of a plan year, should such fact be discovered at a time subsequent to enrollment in a QHP.
Nondiscriminatory wellness program incentives offered by an eligible employer-sponsored plan that affect premiums are treated as earned in determining an employee's required contribution for purposes of affordability of an eligible employer-sponsored plan to the extent the incentives relate exclusively to tobacco use. Wellness program incentives that do not relate to tobacco use or that include a component unrelated to tobacco use are treated as not earned for this purpose. For purposes of this subsection, the term "wellness program incentive" has the same meaning as the term "reward" in 26 CFR § 54.9802 - 1(f)(1)(i).
Amounts newly made available for the current plan year under a health reimbursement arrangement that an employee may use to pay premiums, or may use to pay cost-sharing or benefits not covered by the primary plan in addition to premiums, reduce the employee's required contribution if the health reimbursement arrangement would be integrated, as that term is used in IRS Notice 2013-54 (2013-40 IRB 287), with an eligible employer-sponsored plan for an employee enrolled in the plan. The eligible employer-sponsored plan and the health reimbursement arrangement must be offered by the same employer. Employer contributions to a health reimbursement arrangement reduce an employee's required contribution only to the extent the amount of the annual contribution is required under the terms of the plan or otherwise determinable within a reasonable time before the employee must decide whether to enroll in the eligible employer- sponsored plan.
Amounts made available for the current plan year under a cafeteria plan, within the meaning of 26 USC § 125, reduce an employee's or a related individual's required contribution if:
Affordability under paragraph (a)(1) of this subsection is determined separately for each employment period that is less than a full calendar year or for the portions of an employer's plan year that fall in different benefit years of an applicable tax filer (a part-year period). An eligible employer-sponsored plan is affordable for a part-year period if the employee's annualized required contribution for self-only coverage under the plan for the part-year period does not exceed the required contribution percentage of the applicable tax filer's household income for the benefit year. The employee's annualized required contribution is the employee's required contribution for the part-year period times a fraction, the numerator of which is 12 and the denominator of which is the number of months in the part-year period during the applicable tax filer's benefit year. Only full calendar months are included in the computation under this paragraph.
The required contribution percentage for 2014 is 9.5 percent. For plan years beginning in a calendar year after 2014, the percentage will be adjusted by the ratio of premium growth to income growth for the preceding calendar year and may be further adjusted to reflect changes to the data used to compute the ratio of premium growth to income growth for the 2014 calendar year or the data sources used to compute the ratio of premium growth to income growth. Premium growth and income growth will be determined under IRS-published guidance. In addition, the percentage may be adjusted for plan years beginning in a calendar year after 2018 to reflect rates of premium growth relative to growth in the consumer price index.
The following examples illustrate the provisions of § 23.02. Unless stated otherwise, in each example the tax filer is single and has no tax dependents, the employer's plan is an eligible employer-sponsored plan and provides minimum value, the employee is not eligible for other MEC, and the tax filer, related individual, and employer-sponsored plan have a calendar benefit year:
In 2014 Tax filer C has household income of $ 47,000. C is an employee of Employer X, which offers its employees a health insurance plan that requires C to contribute $ 3,450 for self-only coverage for 2014 (7.3 percent of C's household income). Because C's required contribution for self-only coverage does not exceed 9.5 percent of household income, under paragraph (a)(1), X's plan is affordable for C, and C is eligible for MEC for all months in 2014.
The facts are the same as in Example 1, except that C is married to J and X's plan requires C to contribute $ 5,300 for coverage for C and J for 2014 (11.3 percent of C's household income). Because C's required contribution for self-only coverage ($ 3,450) does not exceed 9.5 percent of household income, under paragraph (a)(2) of this subsection, X's plan is affordable for C and J, and C and J are eligible for minimum essential coverage for all months in 2014.
Determination of unaffordability at enrollment
The facts are the same as in Example 3, except that X's employee health insurance plan year is September 1 to August 31. AHS determines in August 2014 that X's plan is unaffordable for D based on D's projected household income for 2014. D enrolls in a QHP as of September 1, 2014. Under paragraph (a)(3), X's plan is not affordable for D and D is not eligible for MEC under X's plan for the coverage months September to December 2014 and January through August 2015.
Determination of unaffordability for part of plan year (part-year period)
Affordability determined for part of a benefit year (part- year period)
Tax filer G is employed by Employer X. In November 2014, AHS determines that G is eligible for affordable employer-sponsored coverage for 2015. G nonetheless enrolls in a QHP for 2015 but does not receive APTC. G's 2015 household income is less than expected and G's required contribution for employer-sponsored coverage for 2015 exceeds 9.5 percent of G's actual 2015 household income. Under paragraph (a)(1) of this subsection, G is not eligible for MEC under X's plan for 2015.
(01/15/2017, GCR 16- 096)
An individual will not be eligible for a federal premium tax credit if the employer-sponsored plan in which they may enroll provides minimum value. An eligible employer-sponsored plan provides minimum value only if the percentage of the total allowed costs of benefits provided under the plan is greater than or equal to 60 percent, and the benefits under the plan include substantial coverage of inpatient hospital services and physician services.
(01/15/2017, GCR 16- 096)
Except as provided in paragraph (b) of this subsection, the requirements of affordability and minimum value do not apply for months that an individual is enrolled in an eligible employer-sponsored plan.
An employee or related individual is treated as not enrolled in an eligible employer-sponsored plan for a month in a plan year or other period for which the employee or related individual is automatically enrolled if the employee or related individual terminates the coverage before the later of the first day of the second full calendar month of that plan year or other period or the last day of any permissible opt-out period provided by the employer-sponsored plan or in regulations to be issued by the Department of Labor, for that plan year or other period.
The following examples illustrate the provisions of this subsection:
H's required contribution for self-only employer coverage exceeds 9.5 percent of H's 2014 household income. H enrolls in X's calendar year plan for 2014. Under paragraph (a) of this subsection, H is eligible for MEC for 2014 because H is enrolled in an eligible employer-sponsored plan for 2014.
Under paragraph (a) of this subsection, H is eligible for MEC under X's plan for January through June 2014 but is not eligible for MEC under X's plan for July through December 2014.
H terminates the coverage on January 20, 2015. Under paragraph (b) of this subsection, H is not eligible for MEC under X's plan for January 2015.
(01/15/2017, GCR 16-096)
An individual who may enroll in MEC because of a relationship to another person eligible for the coverage, but for whom the other eligible person does not claim a personal exemption deduction, is treated as eligible for MEC under the coverage only for months that the related individual is enrolled in the coverage.
(01/15/2017, GCR 16-096)
Anything in § 23.06 to the contrary notwithstanding, AHS will adopt an exemption eligibility determination made by HHS.
As used in this § 23.06, the following terms have the following meanings:
An individual who is seeking an exemption for themselves through an application submitted to AHS.
An applicant, an individual who is liable for the shared responsibility payment for an applicant, an authorized representative, or, if the applicant is a minor or incapacitated, someone acting responsibly for an applicant.
An exemption from the shared responsibility payment.
An organization:
Any Indian tribe, band, nation, pueblo, or other organized group or community, including any Alaska Native village, or regional or village corporation, as defined in, or established pursuant to, the Alaska Native Claims Settlement Act ( 43 USC § 1601 et seq.) which is recognized as eligible for the special programs and services provided by the United States to Indians because of their status as Indians.
The product of eight percent and the rate of premium growth over the rate of income growth for the calendar year, rounded to the nearest one-hundredth of one percent.
The payment (penalty) imposed by the IRS with respect to a non- exempt individual who does not maintain MEC.
Has the same meaning as it does in § 3.00.
For purposes of this subsection, any attestation that an applicant is to provide under this subsection may be made by the application filer on behalf of the applicant.
For purposes of this subsection, AHS will consider information through electronic data sources, other information provided by the applicant, or other information in AHS's records to be reasonably compatible with an applicant's attestation if the difference or discrepancy does not impact the eligibility of the applicant for the exemption or exemptions for which they applied.
Information, including notices, form, and applications, must be provided to applicants in accordance with the standards specified in § 5.01(c).
Any notice required to be sent by AHS to an individual in accordance with this subsection must be provided in accordance with the standards specified in § 67.00(a).
Except as specified in (7) of this paragraph (b), AHS will determine an applicant eligible for and issue a certificate of exemption for any month if AHS determines that the applicant meets the requirements for one or more of the categories of exemptions described in this paragraph for at least one day of the month.
Except as specified in (3)(ii), (6)(ii), and (7) of this paragraph (b), AHS may provide a certificate of exemption only for the calendar year in which an applicant submitted an application for such exemption.
Except as specified in (2) and (3) of this paragraph (c), AHS will use an application established by HHS to collect information necessary for determining eligibility for and granting certificates of exemption as described in § 23.06(b).
If AHS seeks to use an alternative application, such application, as approved by HHS, must request the minimum information necessary for the purposes identified in (1) of this paragraph (c).
If an individual submits the application described in § 52.02 and then requests an exemption, AHS will use information collected for purposes of the eligibility determination for enrollment in a QHP and health- benefits programs in making the exemption eligibility determination, and will not request duplicate information or conduct repeat verifications to the extent that AHS finds that such information is still applicable, where the standards for such verifications adhere to the standards specified in this subsection.
AHS will:
AHS will determine an applicant's eligibility for an exemption in accordance with the standards specified in § 23.06(b), and grant a certificate of exemption to any applicant determined eligible.
AHS will provide timely written notice to an applicant of any eligibility determination made in accordance with this subsection. In the case of a determination that an applicant is eligible for an exemption, this notification must include the exemption certificate number for the purposes of tax administration.
Unless a request for modification is granted under (9) of this paragraph (d), AHS will verify or obtain information as provided in this paragraph (d) in order to determine that an applicant is eligible for an exemption.
For any applicant who requests an exemption based on religious conscience, AHS will verify that the applicant meets the standards specified in § 23.06(b)(3) by:
Except as otherwise specified in this subsection, for an applicant for whom AHS cannot verify information required to determine eligibility for an exemption, including but not limited to when electronic data is required in accordance with this subsection but data for individuals relevant to the eligibility determination for an exemption are not included in such data sources or when electronic data is required but it is not reasonably expected that data sources will be available within the time period as specified in § 57.00(b), AHS:
For an applicant who does not have documentation with which to resolve the inconsistency through the process described in (7)(ii) of this paragraph (d) because such documentation does not exist or is not reasonably available and for whom AHS is unable to otherwise resolve the inconsistency, AHS may provide an exception, on a case-by-case basis, to accept an applicant's attestation as to the information which cannot otherwise be verified along with an explanation of circumstances as to why the applicant does not have documentation.
HHS may approve modification to the methods to be used by AHS for collection of information and verification as set forth in this subsection, as well as the specific information required to be collected, provided that HHS finds that such modification would reduce the administrative costs and burdens on individuals while maintaining accuracy and minimizing delay, and that applicable requirements under (10) of this paragraph (d), §§ 4.08 and 4.09, and § 6103 of the Code with respect to the confidentiality, disclosure, maintenance, or use of such information will be met.
AHS will not require an applicant to provide information beyond the minimum necessary to support the eligibility process for exemptions as described in this subsection.
AHS will redetermine the eligibility of an individual with an exemption granted by AHS if it receives and verifies new information reported by such an individual, except for the exemption described in § 23.06(b)(7)(ii).
AHS will:
AHS will implement a change resulting from a redetermination under this paragraph for the month or months after the month in which the redetermination occurs, such that a certificate that was provided for the month in which the redetermination occurs, and for prior months remains effective.
If AHS grants an individual a certificate of exemption in accordance with § 23.06(c)(9), AHS will transmit to the IRS at such time and in such manner as the IRS may specify:
Part FOUR SPECIAL RULES FOR MEDICAID COVERAGE OF LONG-TERM CARE SERVICES AND SUPPORTS - ELIGIBILITY AND POST-ELIGIBILITY
(01/15/2017, GCR 16-097)
(01/15/2017, GCR 16-097)
Once AHS determines that an individual is eligible for Medicaid coverage of long-term care services and supports, it computes how much of their income must be paid to the long-term care provider each month for the cost of their care (this is called the "patient share").
A patient share is computed for an individual who qualifies for Medicaid coverage of long-term care services and supports under MABD in a medical institution or in a home and community-based setting under a special income coverage group (see § 8.05(k)) or as medically needy (see § 8.06). An individual's patient share is determined at initial eligibility, eligibility redeterminations, and when changes in circumstances occur.
An individual owes their patient share by the last day of the month in which they receive the income. Payment is made either to the facility in which the individual resided or to the highest-paid provider of long-term care services and supports. Patient-share amounts and payments to long-term care providers may be adjusted when a patient transitions from one setting to another, as specified in § 24.05.
(01/15/2017, GCR 16-097)
A patient share obligation is assessed in the month of admission to long-term care as long as the individual is expected to need long-term care services and supports for at least 30 consecutive days. If long-term care services and supports are expected to be needed for fewer than 30 consecutive days, no patient share is assessed. Instead, the individual's services are covered through Medicaid, other than Medicaid coverage of long-term care services and supports, if the individual meets medical necessity criteria (see Medicaid coverage rule § 7103) and relevant financial, nonfinancial and categorical eligibility criteria.
A long-term care residence period in a general hospital setting begins with the first day that the utilization review committee finds acute hospital care is no longer medically necessary and skilled nursing care is medically necessary.
A long-term care residence period in a long-term care setting, other than a general hospital, begins with the first day that the utilization review committee finds medical need for long-term care or the date of admission, whichever is later.
A long-term care residence period ends with the earliest of:
A long-term care residence period is not ended by a leave of absence from the current setting (see DVHA Rule 7604.
The percentage of the month an individual is in long-term care is determined using the appropriate table below.
Percentage of Month in Long-Term Care: All months except February
Day of the month admitted to long- term care | Percentage of the month in long- term care | Day of the month admitted to long- term care | Percentage of the month in long- term care | Day of the month admitted to long- term care | Percentage of the month in long- term care |
1 | 100% | 11 | 67% | 21 | 33% |
2 | 97% | 12 | 63% | 22 | 30% |
3 | 93% | 13 | 60% | 23 | 27% |
4 | 90% | 14 | 57% | 24 | 23% |
5 | 87% | 15 | 53% | 25 | 20% |
6 | 83% | 16 | 50% | 26 | 17% |
7 | 80% | 17 | 47% | 27 | 13% |
8 | 77% | 18 | 43% | 28 | 10% |
9 | 73% | 19 | 40% | 29 | 7% |
10 | 70% | 20 | 37% | 30-31 | 3% |
Percentage of Month in Long-Term Care: February
Day of the month admitted to long- term care | Percentage of the month in long- term care | Day of the month admitted to long- term care | Percentage of the month in long- term care | Day of the month admitted to long- term care | Percentage of the month in long-term care |
1 | 100% | 11 | 64% | 21 | 29% |
2 | 96% | 12 | 61% | 22 | 25% |
3 | 93% | 13 | 57% | 23 | 21% |
4 | 89% | 14 | 54% | 24 | 18% |
5 | 86% | 15 | 50% | 25 | 14% |
6 | 82% | 16 | 46% | 26 | 11% |
7 | 79% | 17 | 43% | 27 | 7% |
8 | 75% | 18 | 39% | 28 | 4% |
9 | 71% | 19 | 36% | 29 | 0% |
10 | 68% | 20 | 32% |
(01/15/2017, GCR 16-097)
To determine the maximum patient share, the individual's gross income less allowable deductions as specified in § 24.04 is considered. This is the most that an individual receiving Medicaid coverage of long-term care services and supports is obliged to pay toward the cost of their long-term care services and supports. If an individual was in long-term care for less than a full month, the maximum patient share is multiplied by the applicable percentage in the table set forth in § 24.02.
(01/15/2017, GCR 16-097)
When determining the actual patient share payable by an individual, the following are deducted from the individual's gross income:
The following items are then deducted from the individual's patient share in the following order:
A reasonable amount for clothing and other personal needs of an individual is deducted from their monthly income, as follows:
An individual is allowed to allocate their income to certain family members as described in this paragraph.
A deduction from the individual's income is allowed for the following family members unless the countable resources of any such family member exceed $ 12,000:
(01/15/2017, GCR 16-097)
An individual receiving long-term care sometimes moves from one setting to another, such as from one nursing facility to another or from a nursing facility to a hospital and back to the same or another nursing facility. The patient share must be paid toward the cost of the individual's care from income received by the individual during each month of a continuous period of receiving Medicaid coverage of long-term care services and supports. As a general rule, the provider giving long-term care services and supports to the individual on the last day of the preceding month sends the individual a bill for the individual's share of the cost for that month. Payment is made to an institution if the individual was receiving Medicaid coverage of long-term care services and supports in the institution on the last day of the preceding month. Payment is made to the highest-paid provider of long-term care services and supports if the individual was receiving Medicaid coverage of long-term care services and supports in a home and community-based setting on the last day of the preceding month. If payment of a patient share results in a credit to the provider, then the provider sends the excess to AHS. Exceptions to this rule are specified in the paragraphs below.
An individual receiving Medicaid coverage of long-term care services and supports who is hospitalized continues to receive Medicaid coverage of long-term care services and supports, and their patient share amount is not redetermined. Payment of the patient share is allocated to the providers as follows:
The patient share is paid directly to AHS when the individual is hospitalized and receiving acute hospital care on the last day of the month preceding the month in which income is received. Failure to pay the patient share may result in closure of the individual's eligibility for Medicaid coverage of long-term care services and supports.
The patient share is paid to the hospital when the individual is hospitalized and receiving Medicaid coverage of long-term care services and supports in the hospital on the last day of the month preceding the month in which income is received.
The patient share amount is not adjusted when an individual receiving Medicaid coverage of long-term care services and supports in a home and community- based setting enters an institution for respite services. The patient share is paid to the highest-paid provider of the long-term care services and supports, even if the individual is in an institution on the last day of the month.
AHS adjusts the patient share amount when an individual receiving Medicaid coverage of long-term care services and supports in a home and community- based setting enters an institution for services other than respite services and has been in the institution for a full calendar month. The patient share is paid to the institution since the individual was receiving Medicaid coverage of long-term care services and supports in an institution on the last day of the month.
The patient share amount is adjusted when an individual is in an institution for more than one full calendar month and discharged to a home and community- based setting. After the patient-share amount is redetermined using the community maintenance allowance (see § 24.04(c)), the first month's patient share is paid to the institution because the individual resided in the institution on the last day of the previous month. Thereafter, the patient share it is paid to the highest paid provider.
All income an individual receiving Medicaid coverage of long-term care services and supports receives during the month they are discharged from long-term care and any month after discharge when the individual leaves a long-term care living arrangement (see § 30.01) is excluded. A long-term care provider must refund any patient-share payment made by an individual when the individual pays their patient share from income received in the month of their discharge.
An individual receiving Medicaid coverage of long-term care services and supports becomes fully responsible for the total cost of any care they receive when they remain institutionalized after a medical-review team decision that they no longer need skilled nursing or intermediate care, or they become ineligible for other reasons. The individual's responsibility begins after the effective date of the review team's decision. An individual usually must pay in advance for such care as a privately-paying patient. They incur no patient share obligation for the calendar month that the review team's decision takes effect. A long-term care provider must credit payment toward the cost of private care furnished after the effective date of the review team's decision to end Medicaid coverage of long-term care services and supports when an individual receiving Medicaid coverage of long-term care services and supports has already paid their patient share to the provider during the calendar month the review team's decision takes effect.
Income received during the calendar month of the death of an individual receiving Medicaid coverage of long-term care services and supports is counted and applied to the cost of the care the individual received during the prior month. For example, if the individual dies on June 26th, the patient-share payment from income they received during June is due for care provided in May. If the individual dies on July 1st, the patient-share payment from income they received during July is due for care provided in June.
(01/15/2017, GCR 16-097)
(01/15/2017, GCR 16-097)
If AHS determines that a transfer is not allowable, the individual requesting
Medicaid coverage of long-term care services and supports will not be eligible for such coverage until a penalty period has expired. The start date of the penalty period is based on when the individual would, but for the disallowed transfer, be otherwise eligible for Medicaid coverage of long-term care services and supports, as explained in more detail in this section. The duration of the penalty period is based on the value of the disallowed transfer.
(01/15/2017, GCR 16-097)
For the purposes of this section, a transfer of income or resources is any action taken by the individual requesting Medicaid coverage of long-term care services and supports, by the spouse of such individual, or by any other person with lawful access to the income or resources of the individual or such individual's spouse that disposes of the income or resources. The date of the transfer is the date the action was taken. It also applies to certain income and resources to which the individual or such individual's spouse is entitled but does not have access because of an action taken by:
Unless otherwise specified, fair market value is an amount equal to the price of an item on the open market in the individual's locality at the time of a transfer, or contract for sale, if earlier.
(01/15/2017, GCR 16-097)
No penalty period is applied to income or resources transferred for fair market value.
AHS determines whether the individual requesting Medicaid coverage of long- term care services and supports, or the spouse of such individual, as the case may be, received fair market value for a transfer of income or resources by determining the difference, if any, between the fair market value of the income or resource reduced by any applicable deductions at the time of the transfer and the amount received for the income or resource. Any of the following deductions may be used to reduce fair market value:
If the value of a transferred resource is scheduled for receipt after the date of transfer, it is considered a transfer for fair market value only if the transferor can expect to receive the full fair-market value of the resource within their expected lifetime. Expected lifetime is determined as follows:
Expected lifetime of the institutionalized individual is measured at the time of the transfer as determined in accordance with actuarial publications of the Office of the Chief Actuary of the SSA (http://soci a l security.gov/OACT/STATS/table4c6.html) and set forth in Vermont's Medicaid Procedures Manual.
Expected lifetime of the spouse of the institutionalized individual is measured at the time of the transfer as determined in accordance with actuarial publications of the Office of the Chief Actuary of the SSA) (http://soci a lsecurity.gov/OACT/STATS/table4c6.html) and set forth in Vermont's Medicaid Procedures Manual.
A penalty period is not imposed for a transfer for less than fair market value that meets one or more of the following criteria:
The date of the transfer was more than 60 calendar months prior to the first month in which the individual both requests eligibility for Medicaid coverage of long-term care services and supports and meets all other requirements for eligibility.
The transferred income or resources have been returned or otherwise remain available to the individual or the individual's spouse.
The action that constituted the transfer was the removal of the individual's (or spouse's) name from a joint account in a financial institution, and the individual (or spouse) has demonstrated, to AHS's satisfaction, that the funds in the account accumulated from the income and resources of another owner who is not the individual (or their spouse).
The transferor has documented to AHS's satisfaction convincing evidence that the resources were transferred exclusively for a purpose other than for the individual to become or remain eligible for Medicaid coverage of long-term care services and supports. A signed statement by the transferor is not, by itself, convincing evidence. Examples of convincing evidence are documents showing that:
The transfer meets the criteria specified below for transfers involving trusts (see paragraph (d)), transfers of homes (see paragraph (e)), and transfers for the benefit of certain family members (see paragraph (g)).
The transferor has demonstrated to AHS's satisfaction that they intended to dispose of the income or resources either at fair market value, or for other valuable consideration.
A penalty period is not imposed for transfers involving trusts that meet one or more of the following criteria:
A penalty period is not imposed for the transfer of a home that meets the definition at § 29.08(a)(1) provided that title was transferred to one or more of the following persons:
A penalty period is not imposed for the purchase of a life-estate interest in another person's home when:
A penalty period is not imposed for transfers that meet any of the following criteria:
An annuity that does not meet the above criteria is assessed a transfer penalty based on its fair market value. The fair market value of an annuity equals the amount of money used to establish the annuity and any additional amounts used to fund the annuity, plus any earnings and minus any early withdrawals and surrender fees.
For any joint-ownership established on or after January 1, 1994, the portion of the jointly-owned asset subject to the imposition of a penalty period is evaluated based on the specific circumstances of the situation. A n individual is presumed to own a jointly-owned resource using the rules in § 29.09. In the case of a jointly-owned account in a financial institution, for example, since the account is presumed to be owned entirely by the individual (see § 29.09(c)(5)(ii)), a transfer penalty is imposed against the individual for any amount withdrawn from the account by another joint owner on the account. The individual may rebut the presumption of ownership by establishing to AHS's satisfaction that the amount withdrawn was, in fact, the sole property of and contributed to the account by the other joint owner (or owners), and thus did not belong to the individual.
For a joint ownership established before January 1, 1994, the date of the transfer is the date the other person (or persons) became a joint owner. The value of the transfer equals the amount that the resource available to the individual or, if married, the individual's spouse was reduced in value when the other person (or persons) became a joint owner.
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Examples:
If a transfer is disallowed, a penalty period of restricted Medicaid coverage to an otherwise eligible individual is imposed. During this period, no Medicaid payments are made for the individual's long-term care services and supports. Payments are made for all other covered Medicaid services provided to the individual during the period of restricted coverage.
The penalty date is the beginning date of each penalty period imposed for a disallowed transfer. The penalty date starts on the first day in which the individual would have been otherwise eligible for Medicaid coverage of long-term care services and supports (see paragraph (a) of this subsection for explanation of "otherwise eligible").
Penalty periods run consecutively rather than concurrently, in the order in which the transfers occurred. If, after establishing a penalty period for disallowed transfers, it is determined that additional disallowed transfers were made in a subsequent month but before the end of the first penalty period, the first day following the end of the first penalty period will be designated as the penalty date for the subsequent penalty period.
The number of days in a penalty period are equal to the total value of all disallowed transfers made during a given calendar month divided by the average daily cost to a privately-paying patient of nursing facility services in the state as of the date of application or the date of discovery, if additional disallowed transfers are discovered after the initial determination of eligibility for Medicaid coverage of long-term care services and supports.
Penalty periods for transfers in different calendar months are consecutive and established in the order in which the disallowed transfers occurred.
A penalty period runs continuously from the first date of the penalty period, even if the individual stops receiving long-term care services and supports.
The following rules are applied to the assignment of penalty periods when both members of a couple are requesting or receiving Medicaid coverage of long-term care services and supports.
For spouses determined otherwise eligible for Medicaid coverage of long-term care services and supports at the same time, the value of the disallowed transfer is divided by two to determine the number of days of restricted coverage for each member of the couple.
If the penalty period established for one member of the couple has not yet expired when the other member of the couple requests and is determined otherwise eligible for Medicaid coverage of long-term care services and supports, the number of days remaining in the penalty period is divided by two to determine the number of days of restricted coverage for each member of the couple.
When the member of the couple for whom a penalty period has been established dies, the days remaining in that member's penalty period are not reassigned to their spouse if the spouse requests and is determined otherwise eligible for Medicaid coverage of long-term care services and supports.
When a penalty period is established for a disallowed transfer by the second member of the couple to request and be determined otherwise eligible for Medicaid coverage of long-term care services and supports, that penalty period is assigned to the spouse who made the transfer provided that it was made after the determination of disallowed transfers for the first spouse.
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AHS does not establish a penalty period resulting from a disallowed transfer when it determines that restricted coverage will result in an undue hardship. Undue hardship is considered only in cases where AHS has first determined that a transfer has been made for less than fair market value and that no transfer exception applies (see § 25.03).
In determining the existence of undue hardship, all circumstances involving the transfer and the situation of the individual are considered. Undue hardship is established when one or more of the following circumstances, or any other comparable reasons, exist:
Part FIVE FINANCIAL METHODOLOGIES
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For purposes of this section:
Adjusted gross income (within the meaning of § 62 of the Code) increased by:
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For purposes of MAGI-based Medicaid, the term "tax dependent" has the same meaning as the term "dependent" under § 152 of the Code, and also includes an individual for whom another individual claims a deduction for a personal exemption under § 151 of the Code for the benefit year.4
Except as specified in paragraphs (h), (i), and (j) of this subsection, financial eligibility for MAGI-based Medicaid is determined based on household income, as defined in paragraph (c) of this subsection. Household composition is determined separately for each individual; see paragraph (e) of this subsection for details on household composition.
Except as provided in paragraphs (c)(2) through (c)(4) of this subsection, household income for MAGI-based Medicaid is the sum of the MAGI-based income, as defined in paragraph (d) of this subsection, of every person included in the individual's household, as defined in paragraph (e) of this subsection.
In the case of an individual described in paragraph (e)(3)(i) of this subsection (individual other than a spouse or child who expects to be claimed as a tax dependent by another tax filer), household income does not include cash support provided by the person claiming such individual as a tax dependent.
Effective January 1, 2014, in determining the eligibility of an individual for Medicaid under the eligibility group with the highest income standard under which the individual may be determined eligible using MAGI-based methodologies, an amount equivalent to 5 percentage points of the FPL for the applicable family size is deducted from household income.
For the purposes of this subsection, MAGI-based income means income calculated using the same financial methodologies used to determine MAGI, with the following exceptions:
For purposes of household composition:
In the case of an individual who expects to file a federal tax return for the benefit year in which an initial determination or renewal of eligibility is being made, and who does not expect to be claimed as a tax dependent by another tax filer, the household consists of the tax filer and, subject to paragraph (e)(6) of this subsection, all persons whom such individual expects to claim as a tax dependent.
In the case of an individual who expects to be claimed as a tax dependent by another tax filer for the benefit year in which an initial determination or renewal of eligibility is being made, the household is the household of the tax filer claiming such individual as a tax dependent, except that the household must be determined in accordance with paragraph (e)(4) of this subsection in the case of:
In the case of an individual who does not expect to file a federal tax return and does not expect to be claimed as a tax dependent for the benefit year in which an initial determination or renewal of eligibility is being made, or who is described in paragraph (e)(3)(i), (e)(3)(ii), or (e)(3)(iii) of this subsection, the household consists of the individual and, if living with the individual:
In the case of a couple living together, each spouse is included in the household of the other spouse, regardless of whether they expect to file a joint federal tax return [10] or whether one spouse expects to be claimed as a tax dependent by the other spouse.
For purposes of paragraph (e)(2) of this subsection, if, consistent with the procedures adopted by the state in accordance with § 56.00, a tax filer cannot reasonably establish that another person is a tax dependent of the tax filer for the benefit year in which Medicaid is sought, the inclusion of such person in the household of the tax filer is determined in accordance with paragraph (e)(4) of this subsection.
In the case of an individual whose financial eligibility for Medicaid is determined in accordance with this subsection, AHS will not:
Financial eligibility for Medicaid for applicants, and other individuals not receiving Medicaid benefits at the point at which eligibility for Medicaid is being determined, must be based on current monthly household income and family size.
For an individual who has been determined financially eligible for Medicaid using the MAGI-based methods set forth in this section, AHS will base financial eligibility on projected annual household income and family size for the remainder of the current calendar year.
If an individual who meets the non-financial eligibility requirements for Medicaid is determined to be financially ineligible for Medicaid using the MAGI-based Medicaid methodologies set forth in this subsection, but their household income is determined to be less than 100 percent of the FPL using the MAGI methodologies for determining eligibility for APTC and CSR, as set forth in § 28.05, the individual's eligibility for Medicaid will be determined using the MAGI methodologies set forth in § 28.05.
The financial methodologies described in this subsection are not applied in determining the Medicaid eligibility of individuals described in this paragraph. Except for the individuals described in (1) of this paragraph (i), the financial methods described in § 29.00 (MABD financial eligibility standards) will be used to determine Medicaid eligibility for such individuals.
In the case of an individual whose eligibility is being determined under § 9.03(g) (family planning services), AHS will:
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Income eligibility of an individual requesting medically-needy MCA is determined by calculating the individual's MAGI-based income as described in § 28.03(d). The individual's MAGI-based income is then adjusted, if applicable, by apportioning the income of financially responsible family members according to the requirements set forth in paragraph (b) of this subsection.
For the individuals who may qualify for medically-needy MCA, see § 7.03(a)(8).
The income spenddown provisions set forth in § 30.00 apply to an individual requesting medically-needy MCA. For purposes of the spenddown provisions at § 30.00, anyone identified in paragraph (b) above as financially responsible for the individual is considered a member of the individual's financial responsibility group as that term is used throughout § 30.00.
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For purposes of APTC and CSR, the term "tax dependent" has the same meaning as the term "dependent" under § 152 of the Code.
Financial eligibility for APTC and CSR is determined based on household income as defined in paragraph (c) of this subsection.
Household income is the sum of:
The household consists of the tax filer, the tax filer's spouse (if married within the meaning of 26 CFR § 1.7703-1) , and all individuals claimed as the tax filer's tax dependents. As described in § 58.02(b)(2), married couples must file joint federal tax returns in order to be considered for APTC and CSR, unless the tax filer meets the exception criteria defined in § 12.03(b) (victim of domestic abuse or spousal abandonment). Parties to a civil union may qualify for APTC and CSR by filing separate tax returns.
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An individual who meets the nonfinancial and categorical requirements for MABD must also meet the financial requirements specified in this section. AHS determines financial eligibility for MABD, including Medicaid coverage of long-term care services and supports under MABD.
To determine an individual's financial eligibility for MABD, AHS calculates the countable income and countable resources of the individual's financial responsibility group and compares those amounts to standards based on the size of the individual's Medicaid group. The first step in determining financial eligibility is to identify the members of the individual's financial responsibility group and the members of the individual's Medicaid group. An aged, blind, or disabled individual requesting MABD is always a member of both groups.
The rules for forming the financial responsibility group are specified in § 29.03.
The rules for forming the Medicaid group are specified in § 29.04. The rules on resources are specified in §§ 29.07 through 29.10.
The rules on income are specified in §§ 29.11 through 29.15.
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As used in this § 29.00, the following terms have the following meanings:
An individual who is not a child.
For purposes of deeming, as described in § 29.05, a child who is a natural or adopted child under the age of 18, who lives in a household with one or both parents, is not married, and meets the non-financial eligibility requirements for MABD.
For deeming purposes, a child, as defined in (a) of this subsection, who does not meet the non-financial criteria for MABD, lives in the same household as the individual requesting MABD, and is:
For deeming purposes, a person who does not meet the non- financial criteria for MABD, lives with an eligible child, and is:
For deeming purposes, the spouse who lives with the individual requesting MABD and does not meet the nonfinancial eligibility criteria for MABD.
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The financial responsibility group for MABD consists of the individuals whose income and resources are considered available to the Medicaid group in the eligibility determination. With some exceptions, spouses are considered financially responsible for each other, and parents are considered financially responsible for their children. The following paragraphs set forth the rules for determining membership in the financial responsibility group and the portion of the group's income considered available to the Medicaid group.
The financial responsibility group for an adult requesting MABD, including Medicaid coverage of long-term care services and supports under MABD, is the same as the adult's Medicaid group.
The financial responsibility group for a child requesting MABD includes the child and any parents living with the child until the child reaches the age of 18.
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The Medicaid group consists of individuals whose needs are included in the financial eligibility determination for MABD. The following paragraphs set forth the rules for determining membership in the Medicaid group. AHS compares countable income and resources of the financial responsibility group to maximums based on the size of the Medicaid group.
A single adult requesting MABD, including Medicaid coverage of long-term care services and supports under MABD, is treated as a Medicaid group of one.
An adult requesting MABD with a spouse is treated as a Medicaid group of one in the following circumstances:
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MABD financial eligibility is based on the financial eligibility rules for the SSA's SSI program. Like SSI, the term "deeming" is used to identify countable resources and income from other people as belonging to the individual requesting MABD. When the deeming rules apply, it does not matter whether the resources or income of the other person are actually available to the individual.
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For purposes of deeming, during a temporary absence, the absent person continues to be considered a member of the individual's household.
A temporary absence occurs when the individual or their ineligible spouse, parent, or an ineligible child leaves the household but intends to and does return in the same month or the next month.
An eligible child is considered temporarily absent from their parent's (or parents') household if they are away at school but come home on some weekends or lengthy holidays and are subject to the control of their parent(s).
If the individual's ineligible spouse or parent is absent from the household due solely to a duty assignment as a member of the armed forces on active duty, that person is considered to be living in the same household as the individual, unless evidence indicates that the individual's spouse or parent should no longer be considered to be living in the same household. When such evidence exists, AHS stops deeming their resources and income beginning with the month after the spouse or parent no longer lived in the same household.
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This paragraph describes some of the kinds of resources the availability of which are considered in determining MABD eligibility. The descriptions are divided into two categories - nonliquid resources and liquid resources. Except for cash, any kind of property may be either liquid or nonliquid. The liquidity (or nonliquidity) of a resource has no effect on the resource's countability for MABD eligibility purposes.
A nonliquid resource means property that is not cash, including real and personal property that cannot be converted to cash within 20 work days. Real property, life estates, life insurance and burial funds, described below, are some of the more common kinds of nonliquid resources. Certain other noncash resources, though they may occasionally be liquid, are nearly always nonliquid. These include, but are not limited to, household goods and personal effects, vehicles, livestock, and machinery.
Land and generally whatever is erected, growing on, or affixed to land. See § 29.08(a) for information on the resource exclusion of real property.
Life estate means a legal arrangement entitling the owner of the life estate (sometimes referred to as the "life tenant") to possess, rent, and otherwise profit from real or personal property during their lifetime. The owner of a life estate sometimes may have the right to sell the life estate, but does not normally have future rights to the property. Ownership of a life estate may be conditioned upon other circumstances, such as a new spouse. The document granting the life estate includes the conditions for the life estate and the right of the owner of the life estate to sell or bequeath it, if these property rights were retained. See § 29.08(a)(6) for information on the resource exclusion of life estates.
A contract that provides for its purchaser to pay premiums to the insurer, who agrees to pay a specific sum to a designated beneficiary upon the death of the insured. Life insurance is usually sold by an insurance company but may also be sold by other financial institutions, such as brokerage firms. See § 29.08(b) for information on the resource exclusion of life insurance.
The following are terms related to life insurance:
The amount the life insurance policy pays the designated beneficiary upon the death of the insured.
A life insurance policy that does not accumulate any cash value as premiums are paid.
A life insurance policy that accumulates cash value as premiums are paid. It may also pay periodic dividends on this value when all premiums have been paid. These dividends may be paid to the owner, or they may be added to the cash surrender value (defined below) of the policy.
The amount the owner would receive if the life insurance policy were terminated before the insured dies. It is a form of equity that accumulates over time as life insurance premiums are paid. The owner may borrow against the CSV according to the terms of the policy. A loan against a policy reduces its CSV.
A life insurance policy that is usually issued through a company or organization insuring the participating employees or members and, perhaps, their families. The group policy may be paid partially by the employer. A group insurance policy generally has no CSV.
A liquid resource means cash or other property that can be converted to cash within 20 work days. Accounts in financial institutions; retirement funds; stocks, bonds, mutual funds, and money market funds; annuities; mortgages and promissory notes; and home equity conversion plans, described below, are some of the more common kinds of liquid resources.
A contract reflecting payment to an insurance company, bank, charitable organization, or other registered or licensed entity; it may also be a private contract between two parties. There are two phases to an annuity: An accumulation phase and a pay- out phase, and their countability as a resource for MABD eligibility purposes is impacted by the phase the annuity is in (see below). Annuities vary in how they accumulate and pay out money. Annuities may accumulate money by payment of a single lump sum or by payments on a schedule, which accumulate interest over time. Once an annuity has reached its pay-out phase (often referred to as "matured"), money is paid to the beneficiary according to the terms of the annuity contract.
There are many types of annuities. For MABD purposes, AHS considers whether annuities of any type are available as a liquid resource. Since annuities are trust-like instruments, terminology similar to trusts is used when it describes the availability of cash from annuities.
An annuity that names revocable beneficiaries is available to the owner because the owner can change the beneficiary. This type of an annuity is considered a countable resource for purposes of the owner's MABD eligibility. See subsection 29.09(d)(1) for information on how to value an annuity when it is a countable resource.
An annuity that can be surrendered, cashed in or assigned by the owner is presumed to be a revocable annuity. A revocable annuity is considered a countable resource for purposes of the owner's MABD eligibility. An annuity is presumed to be revocable when the annuity contract is silent on revocability. See § 29.09(d)(1) for information on how to value an annuity when it is a countable resource.
An annuity is an unavailable resource for purposes of MABD eligibility when the owner of the annuity is not the individual requesting MABD or the individual's spouse, or the individual or their spouse has abandoned all rights of ownership. However, if payments from the annuity are being made to the individual (or spouse), those payments may be counted as income to the individual (or spouse).
Any resource set aside by a member of the individual's financial responsibility group to be used for self-support upon their withdrawal from active life, service, or business.
Retirement funds include but are not limited to IRAs, Keogh plans, 401K plans, pensions, mutual funds, stocks, bonds, securities, money market accounts, whole life insurance, and annuities. The value of a retirement fund is the amount of money that can currently be withdrawn from the fund. See § 29.08(i)(5) for information on the resource exclusion of retirement funds. See § 29.08(f) for information on the exclusion of early withdrawal and surrender penalties.
Accounts used to set aside funds to meet medical expenses. Unless the individual can demonstrate that the funds in their HSA are not available to them, the HSA is a countable resource.
Resources, liquid and nonliquid, managed by a third party include, but are not limited to, trusts, guardianship accounts, and retirement funds. Resources of a member of the financial responsibility group managed by a third party (e.g., trustee, guardian, conservator, or agent under a power of attorney) are considered available to the member as long as the member can direct the third party to dispose of the resource or the third party has the legal authority to dispose of the resource on the member's behalf without the member's direction.
A person or institution appointed by a court in any state to act as a legal representative for another person, such as a minor or a person with disabilities. Guardianship funds are presumed to be available for the support and maintenance of the protected person. That person may rebut the presumption of the availability of guardianship funds by presenting evidence to the contrary, including, but not limited to, restrictive language in the court order establishing the account or in a subsequent court order regarding withdrawal of funds.
A written document signed by a person giving another person authority to make decisions on behalf of the person signing it, according to the terms of the document. Vermont law requires a power of attorney to be executed according to certain formalities, such as being signed, witnessed, and acknowledged. Funds managed by an agent under a power of attorney are not property of the agent and cannot be counted as resources of the agent.
An individual, agency, or institution selected by a court or the SSA to receive and manage benefits on behalf of another person. A representative payee has responsibilities to use these payments only for the use and benefit of that person, to notify the payer of any event that will affect the amount of benefits the person receives or circumstances that would affect the performance of the representative payee's responsibilities, and account periodically for the benefits received. Funds managed by a representative payee are not property of the representative payee and cannot be counted as resources of the representative payee.
A trust is a property interest where property is held by an individual or an entity (called a "trustee") subject to a fiduciary duty to use the property for the benefit of another person (the "trust beneficiary"). A trust includes a legal instrument or device that is similar to a trust but may not be called a trust. See § 29.08(e) for information on resource exclusion of trusts. The following are terms related to trusts:
The person or entity (such as a bank or insurance company) that holds, manages, or administers trust property for the benefit of the trust's grantee(s). In most cases, a trustee does not have the legal right to use the trust property for their own benefit. Some, but not all, trusts grant discretion to the trustee to use judgment as to when or how to handle trust principal or trust income. A trust may provide reasonable compensation to the trustee for managing the trust as well as reimbursement for reasonable costs associated with managing the trust property.
The person or entity that receives the benefit of a trust. A trust can have more than one grantee at the same time; it can also have different grantees under different circumstances.
Monies earned by the trust property. It may take various forms, such as interest, dividends, or rental payments. These amounts may be countable unearned income to any person legally able to use them for their support and maintenance.
The property that the grantor transfers to the trustee for the benefit of the grantee(s).
The sum of the trust principal and the trust income.
The person or entity named in the trust to receive the trust property upon termination of the trust.
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This subsection specifies the resources whose value is excluded in determining MABD eligibility.
Home means the property in which an individual resides and has an ownership interest and which serves as the individual's principal place of residence. This property includes the shelter in which the individual resides, the land on which the shelter is located, related outbuildings, and surrounding property not separated from the home by intervening property owned by others. Public rights of way, such as roads that run through the surrounding property and separate it from the home, will not affect the exemption of the property. The home includes contiguous land and any other nonresidential buildings located on the contiguous land that are related to the home.
Home equity conversion plans are financial instruments used to secure loans with real property as collateral. Home equity conversion plans include reverse mortgages, reverse annuity mortgages, sale-leaseback arrangements, time-sale agreements, and deferred payment loans.
In the month of receipt, funds an owner of the real property receives from any home equity conversion arrangements on their real property are excluded as a resource. Any funds received from a home equity conversion plan that are retained after the month of receipt are counted as a resource beginning the month after receipt.
For information on the treatment of the funds for purposes of income eligibility, see § 29.13(b)(30).
An owner's interest in jointly-owned real property is excluded as a resource if the sale of the property would cause the other joint owner (or owners) undue hardship due to loss of housing.
Undue hardship would result when:
For a life estate ownership in real property created on or after July 1, 2002:
For a life estate ownership created before July 1, 2002:
Non-business real property is excluded as a resource of the owner when used by the owner to produce goods for only home consumption (e.g., a garden plot used to raise vegetables to be eaten at home or a wood lot used to provide fuel to heat the home). When real property is used to produce goods for both home consumption and income production, only the part used to produce goods for home consumption is excluded. The part of the property used for income production is evaluated for exclusion under (7) above.
Regardless of its face value, a term life insurance policy is not a countable resource.
A state plan amendment that provides for the disregard of any assets or resources in an amount equal to the insurance benefit payments that are made under a long-term care insurance policy (including a certificate issued under a group insurance contract), but only if:
A jointly-owned account in a financial institution is excluded as a resource only if the owner rebuts the presumption of availability by:
A deposit in a financial institution in the name of an owner naming one or more fiduciaries. The owner makes a clear statement about how the money can be used, and the fiduciary is required to follow those instructions and keep track of how the money is spent.
When an individual owns a joint fiduciary account, it is counted as a resource. When an individual is designated a fiduciary of a joint fiduciary account, the joint fiduciary account is an excluded resource for the fiduciary.
Any written agreement, contract, or accord (including modifications) for reasonable and necessary medical care, assistive technology devices, or home modifications not covered by Medicare, private insurance, or Medicaid and determined by AHS to be needed to keep an individual at home and out of a skilled nursing facility.
Care not covered under AHS's Choices for Care program, including but not limited to, general supervision when required by the cognitive impairment of the individual and/or unstable medical condition that requires monitoring of the individual.
Any item, piece of equipment or product system whether acquired commercially off the shelf, modified, or customized, to increase, maintain, or improve the individual's functional capabilities.
Physical adaptations to the individual's home that ensure the health and welfare of the individual, or that improve the individual's ability to perform activities of daily living or instrumental activities of daily living.
Resources set aside under a contract or contracts for medical care, assistive technology devices, or home modifications are considered to be available resources unless all of the following criteria are met:
Tax refunds on real property, income, and food are excluded as resources.
Any portion of any grant, scholarship, or fellowship used to pay fees, tuition, or other expenses necessary to securing an education is excluded. Portions used to defray costs of food or shelter must be counted.
Savings from excluded income and resources are excluded as resources. This includes, but is not limited to, the following:
The following are excluded by federal law from both income and resources:
The following resources are excluded for specific periods:
Retroactive payments of SSI, the AABD supplement to SSI, or Social Security benefits for nine months beginning with the month after the month of receipt. These payments are also excluded as resources during the month of receipt.
Cash and interest earned on that cash received from any source, including casualty insurance, for the purpose of repairing or replacing an excluded resource that is lost, stolen, or damaged, if used to replace or repair that resource. The exclusion is allowed for nine months from the month of receipt. An extension of an additional nine months can be granted for good cause.
State and federal earned income tax credit refunds and advance payments for nine months beginning with the month after the month of receipt.
Cash received for medical or social services for the calendar month following the month of receipt. In the month following the month of receipt, it is counted as a resource if it has been retained.
State-administered victims' compensation payments for nine months after the month of receipt.
State and local government relocation payments for nine months after the month of receipt.
Payments, gifts, and inheritances occasioned by the death of another person provided that they are spent on costs resulting from the last illness and burial of the deceased by the end of the calendar month following the month of receipt.
An additional resource disregard of $ 3,000 to the standard $ 2,000 resource disregard is allowed for an aged or disabled individual without a spouse who resides in and has an ownership interest in their principal place of residence and chooses Medicaid coverage of long-term care services and supports under MABD to be provided in their residence provided all other eligibility criteria are met. This additional resource disregard remains available until the individual begins receiving Medicaid coverage of long term care services and supports under MABD in an institution or in a residential care home that provides enhanced residential care services. Thereafter, if the individual meets the requirements for a home upkeep deduction (see § 24.04(d)), they are eligible to continue this resource disregard for up to 6 months.
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Unless an exception under paragraph (d) below applies, the ownership interests of resources of the members of the financial responsibility group are valued according to these general rules.
With the exception noted in (ii) below and subject to the presumption under § 29.09(d)(3) regarding real property joint ownerships created within 60 months prior to the date of the MABD application, AHS assumes, absent evidence to the contrary, that each owner of shared property owns only their fractional interest in the property. The total value of the property is divided among all of the owners in direct proportion to the ownership share held by each.
For an account in a financial institution, AHS assumes that all of the funds in the account belong to the individual. If another member (or members) of the individual's financial responsibility group is on the account, AHS assumes the funds in the account belong to those account owners in equal shares.
The following paragraphs describe exceptions to the general valuation rules described in paragraph (a) above.
Unless an annuity is excluded as a resource under § 29.08(d)(1) or, for purposes of Medicaid coverage of long term care services and supports, treated as a transfer under § 25.03(h), the fair market value of an annuity is counted. The fair market value is equal to the amount of money used to establish the annuity and any additional payments used to fund the annuity, plus any earnings and minus any early withdrawals and surrender fees. If evidence is furnished from a reliable source showing that the annuity is worth a lesser amount, AHS will consider a lower value. Reliable sources include banks, other financial institutions, insurance companies, and brokers, as well as any other source AHS considers, in its discretion, to be reliable.
Unless a life estate interest in property is excluded under § 29.08(a)(6) or the fair market value of the entire property (the life estate and the remainder) is counted as a resource, the fair market value of a life estate interest in property is established by multiplying the fair market value of the property at the time the life estate interest was created by the number in the life expectancy table that corresponds with the individual's age at that time. The life estate table is found in the SSA's POMS at SI 01140.120 ( https://secure.ssa.gov/apps10/poms.nsf/lnx/0501140120). If an individual submits evidence supporting another method of establishing the fair market value of a life estate, AHS will make a decision about what method to use. If AHS decides not to use the method submitted, it will provide the individual with a written notice stating the basis for its decision.
Regardless of a co-owner's refusal to sell jointly-owned real property pursuant to the resource exclusion under § 29.08(a)(5)(i), AHS presumes that a member of the financial responsibility group that owns real property jointly with another person (or persons) owns the entire equity value of the real property if the joint ownership was created less than 60 months prior to the date of the MABD application. This presumption may be rebutted by a showing, through reliable sources, that the other joint owner (or owners) purchased shares of the property at fair market value. Reliable sources include cancelled checks or property transfer tax returns. When it has been established that one or more other co-owners purchased their shares of the property, the proportional interest owned by the member is counted.
Unless a U. S. savings bond is excluded under § 29.08(i)(11), it is counted as a resource beginning on the date of purchase. To establish the value of the bond, the Savings Bond Calculator or the Comprehensive Savings Bond Value Table on the U. S. Bureau of Public Debt's internet website at www.publicdebt.treas.gov/sav/savcalc.htm is used. Alternately, AHS obtains the value by telephone from a local bank. The following general rules apply to valuation:
The value of a home based on the town's assessment adjusted by the common level of appraisal (CLA), minus the total amount owed on it in mortgages, liens, or other encumbrances. When an individual requesting Medicaid owns their home in a joint ownership with someone other than their spouse, absent evidence to the contrary, the individual's equity interest in the home is reduced by the amount of the other joint owner's equity interest when the other joint owner resides in the home.
An individual who is ineligible for Medicaid coverage of long- term care services and supports due to excess equity in their home may request an undue hardship waiver based on the criteria specified at § 25.05.
An individual is permitted to use a home equity conversion plan (reverse mortgage) or a home equity loan to reduce their equity interest in their home. In such circumstances, the funds are valued as follows:
Lump sum payments and streams of income are subject to transfer penalties if given away in the month of receipt or thereafter.
(01/15/2017, GCR 16-098)
Countable resources are determined by combining the resources of the members of the financial responsibility group, as described in § 29.03, and comparing them to the resource standard of the Medicaid group, as described in § 29.04. Countable resources are determined for different types of Medicaid groups: adults without spouses, adults with spouses, children, and individuals requesting Medicaid coverage of long- term care services and supports. If the resources of the Medicaid group fall below or are equal to the applicable resource standard, the resource test is passed. If an excess resource amount remains after all exclusions have been applied (see § 29.08), the individual has not passed the resource test. An individual may become eligible for MABD by spending down or giving away excess resources as provided in § 30.00 subject to transfer of resource rules (see § 25.00) for those seeking Medicaid coverage of long-term care services and supports.
The general rule in paragraph (a) above is followed to determine whether total resources, after exclusions, of an individual other than a child falls below the resource maximum for one.
The general rule in paragraph (a) above is followed to determine whether the total resources, after exclusions, of an individual living with their spouse and requesting MABD, other than Medicaid coverage of long-term care services and supports under MABD, falls below the resource maximum for two.
For an individual requesting Medicaid coverage of long-term care services and supports under MABD who has a spouse, the resource evaluation process of assessment and allocation is performed as set forth in this paragraph at the beginning of the first continuous period of long-term care. An individual discharged from long-term care and readmitted later does not undergo these steps again; only the resources of, and any new transfers by, the readmitted individual are counted. An institutionalized spouse (sometimes referred to in this rule as the "IS") who receives additional resources after allocating less than the community spouse resource allocation (CSRA) maximum to their community spouse (sometimes referred to in this rule as the "CS") and being found eligible for Medicaid coverage of long-term care services and supports under MABD, may, until the first annual review of their eligibility, continue to transfer resources to the CS up to a combined total transfer of no more than the CSRA maximum. After the IS's first regularly- scheduled annual redetermination of eligibility, no further transfers are allowed even if the CSRA maximum has not been allocated to the CS; the rules regarding transfers apply after the IS's first regularly-scheduled annual redetermination (see § 25.00).
At the time of admission to long-term care and application for Medicaid coverage of long-term care services and supports under MABD, including long-term care services and supports in a home and community-based setting, AHS completes an assessment of resources. An individual or their spouse may also request a resource assessment prior to admission to long- term care. AHS provides a copy of the assessment to each spouse and retains a copy. The assessment must include at least:
(01/15/2017, GCR 16-098)
Any form of cash payment from any source received by an individual or by a member of the individual's financial responsibility group. Income is considered available and counted in the month it is received or credited to the individual with the exception of a lump sum receipt of earnings such as sale of crops or livestock. These receipts are only counted if received during the six-month accounting period and are averaged over the six-month period.
(01/15/2017, GCR 16-098)
This subsection describes the kinds of income considered when determining MABD eligibility.
Earned income includes the following:
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The following are excluded from earned income:
Unearned income exclusions are limited to the following:
(01/15/2017, GCR 16-098)
Common financial responsibility groups of one include a single adult, an individual residing in a residential care home, and a child seeking Katie Beckett coverage. AHS determines countable income for an individual seeking MABD, other than Medicaid coverage of long-term care services and supports under MABD, with a financial responsibility group of one as follows:
Countable income for MABD for any individual with a financial responsibility group of two is determined according to the rules under paragraph (b) above, as well as the following additional rules:
These groups include a parent who is aged, blind, or disabled and a child who is blind or disabled. When a parent and a child in the same household both request MABD, countable income is determined as a financial responsibility group of two as follows:
Countable income for an individual requesting Medicaid coverage of long-term care services and supports under MABD is determined as follows:
(01/15/2017, GCR 16-098)
Deductions from earned income, including self employment, and from unearned income are allowed.
A deduction of $ 65.00 and one-half of the remainder applies to all determinations of earned income.
Deductions of business expenses from self-employment income are limited to the following:
In addition to other allowable deductions, work expenses from income of a blind individual include the following [21]:
In addition to other allowable deductions, work expenses from income of a disabled individual include the following [22]:
Amounts used to comply with the terms of court-ordered support or Title IV-D support payments are deducted from unearned income.
(01/15/2017, GCR 16-098)
As stated in § 28.04(c), the income spenddown provisions under this section apply to an individual requesting MCA, including Medicaid coverage of long-term care services and supports under MCA, whose income exceeds the applicable income standard for eligibility for MCA and who is seeking MCA eligibility as medically needy and is subject to an income spenddown in order to be eligible. For this purpose, all references to "countable income" in this section shall mean the individual's MAGI-based income as described in § 28.03(d) adjusted, if applicable, by apportioning the income of financially responsible family members according to the requirements set forth in § 28.04(b). Since there is no resource test for MCA eligibility, none of the resource spenddown provisions under this section apply.
See § 7.03(a)(8)(i) for the individuals who may qualify for MCA as medically needy.
(01/15/2017, GCR 16-098)
The one-month or six-month span of time used to budget the income of an individual requesting Medicaid.
An individual requesting Medicaid coverage of long-term care services and supports, including services and supports in a home and community-based setting, is considered to be in a long-term care living arrangement. Medicaid eligibility is determined according to the applicable long-term care Medicaid eligibility rules.
An individual receiving hospice services is considered to be in a long-term care living arrangement. An individual receiving hospice services is:
The amount of qualifying medical expenses an individual must incur to reduce their excess income to the maximum applicable to their Medicaid coverage category.
The amount an individual must spend to reduce their excess resources to the resource standard applicable to the appropriate Medicaid coverage category.
(01/15/2017, GCR 16-098)
The length of the accounting period used to compute spenddown requirements depends on the living arrangement of the individual requesting Medicaid. For the purposes of Medicaid eligibility, an individual may be in a community living arrangement or a long-term care living arrangement.
(01/15/2017, GCR 16-098)
An individual who passes all nonfinancial eligibility tests may qualify for Medicaid by spending down the income or resources, if applicable, that are in excess of the maximums applicable to them. The income and resource maximums for each MABD eligibility category are specified in the descriptions found in §§ 8.05 and 8.06. Income and resource maximums can also be found in Vermont's Medicaid Procedures Manual. The income maximums for the MCA categories are specified in the descriptions found in § 7.03(a).
(01/15/2017, GCR 16-098)
One or more of the following actions may be taken to reduce excess resources in order to qualify for MABD up to three months prior to the month of application as long as all other eligibility tests are passed:
(01/15/2017, GCR 16-098)
AHS determines that an individual requesting Medicaid with excess income has passed the income test upon proof that medical expenses have been paid or incurred at least equal to the difference between the countable income and the applicable income maximum for the accounting period.
Medical expenses of any member of the individual's financial responsibility group, whether they are paid or incurred but not paid, may be used to meet the individual's income spenddown requirement; references in § 30.06 to the medical expenses of the "individual" include the medical expenses of any member of the individual's financial responsibility group.
Medical expenses are deducted from income in the following order:
In general, an expense is incurred on the date liability for the expense begins. However, there are four types of predictable medical expenses that may be deducted before they are incurred, if it can be reasonably assumed that the expense will continue during the accounting period:
Continuing liability for unpaid medical expenses, including liability on a bona fide loan used to pay medical expenses, incurred before the current accounting period is established when any of the following conditions is met. The liability was incurred:
(01/15/2017, GCR 16-098)
A deduction is allowed for necessary medical and remedial expenses recognized by state law but not covered by Medicaid in the absence of an exception for Medicaid coverage under DVHA Rule 7104. In determining whether a medical expense meets these criteria, AHS may require medical or other related information to verify that the service or item for which the expense was incurred was medically necessary and was a medical or remedial expense. The patient's physician shall verify medical necessity with a written statement or prescription specifying the need, quantity, and time period covered. Examples of medical expenses not covered by Medicaid include, but are not limited to, expenses for the services and items listed in (1) through (6) below. Any medical bills, including those incurred during a period of Medicaid eligibility, that are the current liability of the individual and have not been used to meet a previous spenddown requirement may be deducted from excess income. Generally, the individual is required to present a bill or receipt to verify that medical expenses have been incurred or paid.
Either standard deductions or actual costs, if greater, may be used to deduct noncovered over-the-counter drugs and supplies.
Noncovered commercial and private transportation costs may be deducted.
A deduction for noncovered personal care services provided in an individual's own home or in a level IV residential care home is allowed when they are medically necessary in relation to an individual's medical condition.
Deductible personal care services include the personal care services described in DVHA Rule 7406.2 and assistance with managing money. They also include general supervision of physical and mental well-being where a physician states such care is required due to a specific diagnosis, such as Alzheimer's disease or dementia or like debilitating diseases or injuries. Room and board is not a personal care service.
A plan of care can be submitted to AHS using a form provided by AHS or using a statement, signed by the physician, that contains information sufficient, as determined by AHS, to document the individual's need for personal care services.
A deduction for noncovered assistive community care services (ACCS) provided to an individual residing in a licensed level III residential care home is allowed. The individual may also deduct medically-necessary personal-care services included under the list at DVHA Rule 7406.2 but not part of the list at DVHA Rule 7411.4.
Dental services in excess of the allowable annual maximum may be deducted.
Private-duty nursing services for an individual age 21 and older may be deducted.
Part SIX SMALL EMPLOYER HEALTH-BENEFITS PROGRAM RULES
(01/15/2017, GCR 16-099)
As used only in Part Six, the following terms have the following meanings:
Annual employee open enrollment period [1]
A period in which a qualified employee enrolling in a qualified health plan through Vermont Health Connect (VHC) may:
The annual employee open enrollment period shall precede the end of the employer's current plan year and shall follow the annual employer election period.
Annual employer election period [2]
The employer election period comes before both the employee open enrollment period and the completion of the employer's current plan year. During the employer election period, the qualified employer may change its participation in VHC for the next plan year, and elect the following:
Dependent
Any individual who is or may become eligible for coverage under the terms of a group health plan because of a relationship to a participant. [3]
Employee [4]
Any individual employed by an employer. An employee does not include an individual and his or her spouse with respect to a trade or business, whether incorporated or unincorporated, which is wholly owned by the individual or by the individual and his or her spouse, and does not include a partner in a partnership and his or her spouse.
Employer [5]
Full-time employee [7]
Qualified employee [8]
An employee made eligible to enroll in coverage through VHC through an offer of coverage from a qualified employer.
Qualified employer [9]
A qualified employer is a small employer that:
Seasonal employee [10]
The term seasonal employee means an employee who is hired into a position for which the customary annual employment is six months or less and the employee does not have any hour of service for the employer for a period of at least 13 consecutive weeks before resuming employment
Customary means that by the nature of the position an employee in this position typically works for a period of six months or less, and that period should begin each calendar year in approximately the same part of the year, such as summer or winter.11
In certain unusual instances, the employee can still be considered a seasonal employee even if the seasonal employment is extended in a particular year beyond its customary duration (regardless of whether the customary duration is six months or is less than six months). For example, if ski instructors at a resort have a customary period of annual employment of six months, but are asked in a particular year to work an additional month because of an unusually long or heavy snow season, they would still be considered seasonal employees.12
Employers may but are not required to provide seasonal employees with coverage for purposes of being a qualified employer.
Seasonal worker [13]
An employee who performs labor or services on a seasonal basis, including ordinarily, when the employment pertains to or is of the kind exclusively performed at certain seasons or periods of the year and which, from its nature, may not be continuous or carried on throughout the year. A worker who moves from one seasonal activity to another, while employed in agriculture or performing agricultural labor, is employed on a seasonal basis even though she may continue to be employed during a major portion of the year. Seasonal workers include retail workers employed exclusively during holiday seasons.
Seasonal workers are not counted when determining whether an employer is a small employer.
Small employer [14]
(01/15/2017, GCR 16-099)
A qualified employer which ceases to be a small employer solely because of an increase in the number of employees shall continue to be treated as a qualified employer until the qualified employer otherwise fails to meet eligibility criteria or elects to no longer purchase coverage for qualified employees through VHC.
To the extent permitted by HHS:
VHC must use a single application to determine employer eligibility and to collect information necessary for purchasing coverage. Such application must collect the following:
VHC must provide the tools to file an application
For the purpose of verifying employer eligibility VHC:
When the information submitted on the VHC employer application is inconsistent with the eligibility definitions and standards described in §§ 31.00, 32.00(b), and 33.00, VHC must:
Upon request, VHC must provide a small employer with an eligibility determination as to whether it is a qualified employer and a notice of approval or denial of eligibility, and the employer's right to appeal such eligibility determination.
(01/15/2017, GCR 16-099)
VHC must use a single application for eligibility determination, QHP selection, and enrollment for qualified employees, and their dependents (if the employer offers dependent coverage).
For the purpose of verifying employer and employee eligibility, VHC
For an employee requesting eligibility to enroll in a QHP through VHC for whom VHC receives information on the application inconsistent with the employer provided information, VHC must--
VHC shall not provide to the employer any information collected on the employee application with respect to spouses or dependents other than the name, address, and birth date of the spouse or dependent.
For an employee requesting an eligibility determination as to whether the employee is a qualified employee, VHC must notify the employee and employer of the determination and the employee's right to appeal such eligibility determination.
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Two models of employer choice
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VHC will provide qualified employers with a standard election period prior to the completion of the employer's plan year and before the annual employee open enrollment period.
VHC shall ensure that employers are notified of the annual election period in advance of the start of the employer election period.
(01/15/2017, GCR 16-099)
VHC will provide a standardized annual open enrollment period for qualified employees prior to the completion of the applicable qualified employer's plan year and after that employer's annual election period.
VHC must provide notification to a qualified employee of the annual open enrollment period in advance of the open enrollment period.
For an employee who becomes a qualified employee outside of the initial or annual open enrollment period, a 30-day enrollment period begins on the first day of becoming a qualified employee. The enrollment period must end no sooner than 15 days prior to the date that any applicable employee waiting period longer than 45 days would end if the employee made a plan selection on the first day of becoming eligible.
(01/15/2017, GCR 16-099)
A qualified employee or dependent of a qualified employee who experiences a qualifying event described above has 60 days from the date of a triggering event to select a QHP through VHC.
Loss of minimum essential coverage is determined using the provisions of § 71.03(e).
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The effective dates of coverage are determined using the provisions of § 70.03(b)(2).
VHC must ensure that a QHP issuer notifies a qualified employee enrolled in a QHP of the effective date of coverage.
(01/15/2017, GCR 16-099)
If a qualified employee enrolled in a QHP through VHC remains eligible for coverage, such employee will remain in the QHP selected the previous year unless:
(01/15/2017, GCR 16-099)
The provisions of this section apply when enrollment in a QHP takes place through Vermont Health Connect.
(01/15/2017, GCR 16-099)
A qualified employer may withdraw from coverage through VHC with advance notice in accordance with applicable state and federal law.
VHC will ensure that:
(01/15/2017, GCR 16- 099)
Nothing in this section modifies existing obligations related to the administration of coverage required under 29 U.S.C. 1161, et seq., as described in 26 CFR part 54.
(01/15/2017, GCR 16-099)
(01/15/2017, GCR 16-099)
The effective dates of termination resulting from events not described in this section are determined using the provisions of § 76.00(d).
(01/15/2017, GCR 16-099)
VHC and QHP issuers must maintain records of termination of coverage in compliance with § 76.00(c).
(01/15/2017, GCR 16-099)
When a primary subscriber and his or her dependents live at the same address, a separate termination notice need not be sent to each dependent at that address, provided that the notice sent to each primary subscriber at that address contains all required information about the termination for the primary subscriber and his or her dependents at that address.
(01/15/2017, GCR 16-099)
An employer may appeal:
An employee may appeal:
Notices of the right to appeal a denial of eligibility must be written and include --
VHC and AHS must:
Upon receipt of a valid appeal request, AHS must --
AHS:
AHS must provide the employer, or the employer and employee if an employee is appealing, the opportunity to submit relevant evidence for review of the eligibility determination.
Employer or employee appeals must:
Appeal decisions must:
AHS must issue written notice of the appeal decision to the employer or to the employer and employee if an employee's eligibility is implicated, and to VHC within 90 days of the date the appeal request is received.
VHC must promptly implement the appeal decision upon receiving the notice of appeal decision under (j) of this section.
(01/15/2017, GCR 16-099)
VHC will notify an employer that an employee has been determined eligible for advance payments of the premium tax credit and cost-sharing reductions and has enrolled in a qualified health plan through VHC in accordance with § 71.01(e).
An employer may, in response to a notice of an employee's eligibility for advance payments of the premium tax credit and cost-sharing reductions to an employer, appeal a determination that the employer does not provide minimum essential coverage through an employer sponsored plan or that the employer does provide that coverage but it is not affordable coverage with respect to an employee. The employer will file the appeal with the HHS appeals entity or other entity as directed by VHC in the notice in (a) of this section.
(01/15/2017, GCR 16-099)
VHC must perform the following functions related to premium payment administration:
QHP Issuer must accept payment from the VHC on behalf of a qualified employer or an enrollee.
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Part SEVEN ELIGIBILITY-AND-ENROLLMENT PROCEDURES
(01/15/2017, GCR 16-100)
A separate application for Medicaid is not required from an individual who receives SSI or AABD.
(01/15/2017, GCR 16-100)
(01/15/2017, GCR 16-100)
An individual will be afforded the opportunity to apply for health benefits at any time, without delay. [3]
(01/15/2017, GCR 16-100)
A single, streamlined application will be used to determine eligibility and to collect information necessary for:
AHS will:
AHS will provide assistance to any individual seeking help with the application or renewal process, in the manner prescribed in § 5.01.
An application will be accepted from:
An applicant will be required to provide only the information necessary to make an eligibility determination or for a purpose directly connected to the administration of health-benefits programs.
Information regarding citizenship, status as a national, or immigration status will not be requested for an individual who is not seeking health benefits for themselves.
An initial application must be signed under penalty of perjury.
Electronic, including telephonically-recorded, signatures and handwritten signatures transmitted via any other electronic transmission will be accepted.
Any application or supplemental form must be accessible to individuals who are limited English proficient and individuals who have disabilities, consistent with the provisions of § 5.01.
(01/15/2017, GCR 16-100)
The income and eligibility verification requirements set forth in §§ 53.00 through 56.00 are based on §§ 1137, 1902(a)(4), 1902(a)(19), 1902(a)(46)(B), 1902(ee), 1903(r)(3), 1903(x), and 1943(b)(3) of the Act, and § 1413 of the ACA.
AHS will verify or obtain information as provided in §§ 53.00 through 56.00 before making a determination about an individual's eligibility for health benefits. Such information will be used in making the eligibility determination. See § 58.00 for details on the eligibility determination process.
Except where the law requires other procedures (such as for citizenship and immigration-status information), attestation of information needed to determine the eligibility of an individual for health benefits will be accepted (either self-attestation by the individual or attestation by an adult who is in the individual's household, an authorized representative, or, if the individual is under age 18 [10] or incapacitated, someone acting responsibly for the individual) without requiring further information (including documentation) from the individual.
To the extent that information related to determining eligibility for health benefits is available through an electronic service established by HHS, AHS will obtain the information through such service, unless AHS has secured HHS approval of alternative procedures described in (e) below. [12]
Subject to approval by HHS, AHS may request and use information from a source or sources alternative to those listed in § 56.01(b), or through a mechanism other than the electronic service described in (d) above, provided that such alternative source or mechanism will reduce the administrative costs and burdens on individuals and the state while maximizing accuracy, minimizing delay, and meeting applicable requirements relating to confidentiality, disclosure, maintenance, or use of information.
Before it requests information for an individual from another agency or program, AHS will inform the individual that it will obtain and use information available to it to verify income, resources (when applicable), and eligibility or for other purposes directly connected to the administration of a health-benefits program or to enrollment in a QHP.
Information exchanged electronically between AHS and any other agency or program will be sent and received via secure electronic interfaces, as specified in § 4.09. Any such exchange of data will be made pursuant to written agreements with such other agencies or programs, which will provide for appropriate safeguards limiting the use and disclosure of information as required by federal or state law or regulations.
Evidence of immigration status may not be used to determine that an individual is not a Vermont resident.
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For definitions relevant to citizenship and immigration status, see § 17.00.
(01/15/2017, GCR 16- 100)
Except as provided in § 54.06 for certain individuals applying for Medicaid, and except for employees enrolling in a qualified employer- sponsored plan, an individual seeking health benefits must sign a declaration that they are:
For the effect that citizenship and immigration status has on eligibility for health benefits, see § 17.00
(01/15/2017, GCR 16-100)
Verification or documentation of citizenship is a one-time activity; once an individual's citizenship is documented and recorded, subsequent changes in eligibility should not require repeating the documentation unless later evidence raises a question about the individual's citizenship.
Immigration status, including lawful presence, must be verified or documented at the time of initial application and at the time of eligibility renewal. In verifying immigration status at the time of renewal, AHS will first rely on information provided at the time of initial application to determine ongoing eligibility. AHS will only require the individual to provide further documentation or to re-verify satisfactory status if it cannot verify continued eligibility based on the information already available to it.
(01/15/2017, GCR 16-100)
For an individual who attests to citizenship and has a Social Security number, AHS will transmit their Social Security number and other identifying information to HHS, which will submit it to the SSA for verification.
For an individual who has documentation that can be verified through DHS and who either attests to lawful immigration status or lawful presence, or who attests to citizenship and for whom AHS cannot substantiate a claim of citizenship through SSA, AHS will transmit information from the individual's documentation and other identifying information to HHS, which will submit necessary information to DHS for verification.
(01/15/2017, GCR 16-100)
Except as provided in § 54.06, for an individual who attests to citizenship or eligible immigration status, and for whom such attestation cannot be verified through SSA or DHS, AHS will:
During the opportunity period described in paragraphs (a)(1)(i) and (ii) of this subsection, AHS will:
If, by the end of the opportunity period described in paragraphs (a)(1)(i) and (ii) of this subsection, the individual's citizenship or immigration status has not been verified in accordance with paragraph (a) of this subsection, AHS will:
AHS will maintain a record of having verified citizenship or immigration status for each individual in a case record or electronic database.
(01/15/2017, GCR 16-100)
The following individuals are not required to document citizenship or national status as a condition of receipt of Medicaid benefits:
(01/15/2017, GCR 16- 100)
Document exists and can be obtained within the period of time specified in § 54.05.
The following will be accepted as satisfactory documentary evidence of citizenship:
If an applicant does not provide documentary evidence from the list in paragraph (b) of this subsection, the following must be accepted as satisfactory evidence to establish citizenship if also accompanied by an identity document listed in paragraph (d) of this subsection:
AHS may rely, without further documentation of citizenship or identity, on a verification of citizenship made by a federal or state agency, if such verification was done on or after July 1, 2006.
AHS will assist individuals who need assistance to secure satisfactory documentary evidence of citizenship in a timely manner.
A photocopy, facsimile, scanned, or other copy of a document will be accepted to the same extent as an original document under this subsection, unless information on the submitted document is inconsistent with other information available to AHS, or AHS otherwise has reason to question the validity of the document or the information on the document.
(01/15/2017, GCR 16-100)
If verification of immigration status cannot be obtained through the process described in § 54.04, a non-citizen individual seeking health benefits as a qualified non-citizen must provide United States Citizenship and Immigration Services (USCIS) documents to establish immigration status, as specified below:
USCIS Form I-94 endorsed to show grant of parole under § 212(d)(5) of the INA and a date showing granting of parole for at least one year.
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Some non-citizens may be lawfully admitted but only for a temporary or specified period of time as legal non-immigrants. These non-citizens are never qualified non-citizens. Because of the temporary nature of their admission status, they generally will be unable to establish residency and are not eligible for health benefits as qualified non- citizens. For example, a non-citizen in possession of a student visa is not a qualified non-citizen. In rare instances, an ineligible non-citizen may be able to establish residency and meet all other Medicaid eligibility criteria and therefore be eligible for treatment of emergency medical conditions only (see § 17.02(d)).
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For purposes of Medicaid eligibility, visitors, tourists, and some workers and diplomats are also ineligible non-citizens and non-immigrants.
These non-citizens would have the following types of documentation:
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Unless information from an individual is not reasonably compatible with other information provided or otherwise available to AHS, as described in § 57.00(b)(3), attestation of information needed to determine the following eligibility requirements will be accepted without requiring further information from the individual:
(01/15/2017, GCR 16-100)
An individual's attestations of information needed to determine the following eligibility requirements will be verified by AHS:
For more information about Social Security numbers and eligibility for health benefits, see § 16.00.
When determining an individual's eligibility for enrollment in a QHP, the individual's attestation regarding incarceration status will be verified by:
When determining eligibility for APTC and CSR:
When determining eligibility for APTC and CSR, AHS will verify whether an individual reasonably expects to be enrolled in an eligible employer- sponsored plan or is eligible for qualifying coverage in an eligible employer-sponsored plan for the benefit year for which coverage is requested.
AHS will:
(01/15/2017, GCR 16-100)
(01/15/2017, GCR 16-100)
For all individuals whose income is counted in making a health-benefits eligibility determination, AHS will request non-tax data from other agencies in the state and other state and federal programs, as follows:
(01/15/2017, GCR 16-100)
In determining an individual's eligibility for Medicaid:
For purposes of MAGI-based Medicaid eligibility, attestation of information needed to determine family size in accordance with the procedure set forth in § 55.01 will be accepted (attestation only).
Income will be verified by comparing the individual's attestations with tax- and non-tax data obtained pursuant to § 56.01. If the attestations are not reasonably compatible, as that term is defined in § 57.00(a)(2), with such data or if such data is not available, AHS will proceed in accordance with the provisions in § 57.00(c).
For purposes of MABD (non-MAGI-based Medicaid) eligibility, resources will be verified by comparing the individual's attestations with available data sources. If the attestations are not compatible with such sources, or if no such sources exist, or if sources exist but are not available, AHS will proceed in accordance with the provisions in § 57.00(c).
(01/15/2017, GCR 16-100)
An individual must be eligible for APTC and have household income at or below 300% of the FPL in order for the individual to be eligible for the Vermont Premium Reduction and Vermont CSR. To receive the federal and Vermont CSR, an individual who is not an Indian must be enrolled in a silver-level QHP.
In determining eligibility for APTC and CSR:
(01/15/2017, GCR 16-100)
Eligibility for alternate verification procedures for decreases in annual household income and situations in which tax data are unavailable [45]
AHS will determine a tax filer's annual household income for purposes of APTC and CSR based on the alternate APTC and CSR verification procedures described in §§ 56.05 through 56.07 if:
(01/15/2017, GCR 16-100)
If a tax filer qualifies for an alternate APTC and CSR verification process and the individual's attestation to the tax filer's projected annual household income is no more than ten percent below the tax-based income calculation ( § 56.03(b)(2)), the individual's attestation will be accepted without further verification.
(01/15/2017, GCR 16-100)
AHS will attempt to verify the individual's attestation of the tax filer's projected annual household income with the process specified in paragraph (b) of this subsection and in §§ 56.07 and 56.08 if the tax filer qualifies for an alternate APTC and CSR verification process under § 56.04 and:
The alternate APTC and CSR verification process is as follows:
(01/15/2017, GCR 16-100)
Except as provided in paragraph (b) of this subsection, the individual's attestation for the tax filer's household will be accepted without further verification if:
( § 56.06(b)(1)); and
Additional documentation will be requested using the procedures specified in § 57.00 if AHS finds that an individual's attestation of a tax filer's annual household income is not reasonably compatible with other information provided by the individual or the non-tax data available to AHS under § 56.01(b).
(01/15/2017, GCR 16-100)
If, following the 90-day period described in § 57.00(c)(2)(ii) as required by § 56.06(b)(3), an individual has not responded to a request for additional information and the tax data or non-tax data indicate that an individual in the tax filer's household is eligible for Medicaid, the application for a health-benefits program (for example, Medicaid, APTC or CSR) will be denied.
If, following the 90-day period described in § 57.00(c)(2)(ii) as required by § 56.06(b)(3), AHS remains unable to verify the individual's attestation, AHS will determine the individual's eligibility based on AHS's tax-based income calculation ( § 56.03(b)(2)), notify the individual of such determination, and implement such determination in accordance with the effective dates specified in § 73.06.
If, following the 90-day period described in § 57.00(c)(2)(ii) as required by § 56.06(b)(3), AHS remains unable to verify the individual's attestation for the tax filer and tax data necessary for a tax-based income calculation ( § 56.03(b)(2)) are unavailable, AHS will determine the tax filer ineligible for APTC and CSR, notify the individual of such determination, and discontinue any APTC or CSR in accordance with the effective dates specified in § 73.06.
(01/15/2017, GCR 16-100)
(01/15/2017, GCR 16-100)
Education and assistance will be provided to an individual regarding the processes specified in this section.
(01/15/2017, GCR 16-100)
Except as otherwise specified in this rule, the procedures outlined in this section will be used when:
In circumstances described in paragraph (b) of this section, AHS will:
Eligibility will not be denied or terminated nor benefits reduced for any individual on the basis of verification information received in accordance with this part Seven unless additional information from the individual has been sought in accordance with this section, and proper notice and hearing rights have been provided to the individual.
(01/15/2017, GCR 16-100)
(01/15/2017, GCR 16-100)
For each individual who has submitted an application for a health- benefits program (i.e., health benefits other than enrollment in a QHP without APTC or CSR), or whose eligibility is being renewed, and who meets the nonfinancial requirements for eligibility (or for whom AHS is providing an opportunity to verify citizenship or immigration status), AHS will do the following:
In the case of an individual who has attained at least age 65 and an individual who has attained at least age 19 and who is entitled to or enrolled for Medicare benefits under part A or B or Title XVIII of the Act, non-MAGI-based income standards will be used, except that in the case of such an individual:
For purposes of paragraph (a)(2) of this subsection, an individual includes:
AHS will notify an applicant of the opportunity to request a full determination of eligibility for Medicaid on a basis other than the applicable MAGI-based income standard, and will provide such an opportunity. Such notification will also be made to an enrollee, and such opportunity provided in any redetermination of eligibility.
If an individual is identified as potentially eligible for Medicaid on a basis other than the applicable MAGI-based income standard or an individual requests a full determination for Medicaid under paragraph (d) of this subsection, and the individual provides all additional information needed to determine eligibility for such benefits, eligibility will be determined promptly and without undue delay, as provided in this section.
An individual who is described in paragraph (e) of this subsection and has not been determined eligible for Medicaid based on MAGI-based income standards will be considered as ineligible for Medicaid for purposes of eligibility for APTC or CSR until the individual is determined eligible for Medicaid.
(01/15/2017, GCR 16-100)
(01/15/2017, GCR 16-100)
(01/15/2017, GCR 16-100)
(01/15/2017, GCR 16-100)
AHS must determine an individual eligible for the special cost-sharing rule described in § 1402(d)(2) of the ACA (items or services furnished through Indian health providers) if the individual is an Indian, without requiring the individual to request an eligibility determination for health- benefits programs in order to qualify for this rule.
(01/15/2017, GCR 16-100)
To the extent that an individual attests that they are an Indian, such attestation will be verified by:
(01/15/2017, GCR 16- 100)
(01/15/2017, GCR 16-100)
This section explains the calculation of the federal and state premium assistance of QHPs. A tax filer's premium assistance credit amount for a benefit year is the sum of the premium-assistance amounts determined under § 60.04 for all coverage months for individuals in the tax filer's household.
(01/15/2017, GCR 16-100)
For purposes of this section:
Coverage family
The term "coverage family" means, in each month, the members of the tax filer's household for whom the month is a coverage month.
(01/15/2017, GCR 16-100)
A month is a coverage month for an individual if:
If an individual enrolls in a QHP and the enrollment is effective on the date of the individual's birth, adoption or placement for adoption or in foster care, or on the effective date of a court order, the individual is treated as enrolled as of the first day of that month for purposes of this subsection.
Premiums another person pays for coverage of the tax filer, tax filer's spouse, or tax dependent are treated as paid by the tax filer.
The following examples illustrate the provisions of this § 60.03:
Q's tribe pays the portion of Q's QHP premiums not covered by APTCs. Under paragraph (c) of this subsection, the premiums that Q's tribe pays for Q are treated as paid by Q. Thus, the months when Q is covered by a QHP and not eligible for other MEC are coverage months under paragraph (c) of this subsection in computing Q's premium tax credit under § 60.01.
(01/15/2017, GCR 16-100)
Except as provided in paragraph (b) of this subsection, the premium- assistance amount for a coverage month is the lesser of:
(01/15/2017, GCR 16-100)
The monthly premium for an ABP is the premium an issuer would charge for the ABP to cover all members of the tax filer's coverage family. The monthly premium is determined without regard to any premium discount or rebate under the wellness discount demonstration project under § 2705(d) of the PHS Act ( 42 USC §§ 300gg-4(d) ) and may not include any adjustments for tobacco use. The monthly premium for an ABP for a coverage month is determined as of the first day of the month.
(01/15/2017, GCR 16-100)
The ABP helps determine the total amount of premium assistance. The ABP is the QHP from which the product of the applicable percentage and household income is subtracted to obtain the subsidy amount that will be provided on behalf of the qualified individual. Except as otherwise provided in this subsection, the ABP for each coverage month is the second-lowest-cost silver plan offered through VHC for:
The ABP for family coverage is the second-lowest-cost silver plan that applies to the members of the tax filer's coverage family (such as a plan covering two adults if the members of a tax filer's coverage family are two adults).
If one or more silver-level plans for family coverage do not cover all members of a tax filer's coverage family under one policy (for example, because of the relationships within the family), the premium for the ABP determined under paragraphs (a) and (b) of this subsection may be the premium for a single policy or for more than one policy, whichever is the second-lowest-cost silver option. (See, example 10 in paragraph (g) of this subsection.)
The benchmark plan premium determined under paragraphs (a) and (b) of this subsection for family members who live in different states and enroll in separate QHPs is the sum of the premiums for the ABPs for each group of family members living in the same state.
A QHP that is not open to enrollment by a tax filer or a member of the tax filer's household at the time the tax filer or member enrolls in a QHP is disregarded in determining the ABP.
A QHP that is the ABP under this subsection for a tax filer does not cease to be the ABP solely because the plan or a lower cost plan terminates or closes to enrollment during the benefit year.
The following examples illustrate the rules of this subsection. Unless otherwise stated, in each example the plans are open to enrollment to a tax filer or a member of the tax filer's household at the time of enrollment and are offered through VHC:
Tax filer M is single, has no dependents and enrolls in a QHP. Under paragraph (a)(1) of this subsection, M's ABP is the second-lowest-cost silver plan providing self-only coverage for M.
The facts are the same as in Example 1, except that M, her spouse, N, and their tax dependent enroll in a QHP. Under paragraphs (a)(2) and (b) of this subsection, M's and N's ABP is the second-lowest-cost silver plan covering M, N, and their tax dependent.
Tax filer O is single and resides with his daughter, K, but may not claim K as a tax dependent. O purchases family coverage for himself and K. Under paragraphs (a)(1)(i) and (a)(1)(iii) of this subsection, O's ABP is the second-lowest-cost silver plan providing self-only coverage for O. However, K may qualify for a premium tax credit if K is otherwise eligible. See § 60.08.
The facts are the same as in Example 3, except that O also resides with his teenage son, L, and claims L as a tax dependent. O purchases family coverage for himself, K, and L. Under paragraphs (a)(2) and (b) of this subsection, O's ABP is the second-lowest-cost silver plan covering O and L.
The facts are the same as in Example 4, except that O enrolls only K and L in the coverage. Under paragraph (a)(1)(iii) of this subsection, O's ABP is the second-lowest-cost silver plan providing self-only coverage for L.
Tax filers P and Q, who are married, reside with Q's two teenage daughters, M and N, whom they claim as tax dependents. P and Q purchase self-only coverage for P and family coverage for Q, M, and N. Under paragraphs (a)(2) and (b) of this subsection, P's and Q's ABP is the second-lowest-cost silver plan covering P, Q, M, and N.
Tax filer R is single and has no tax dependents when she enrolls in a QHP for 2014. On August 1, 2014, R has a child, O, whom she claims as a tax dependent for 2014. R enrolls in a QHP covering R and O effective August 1. Under paragraph (a)(1) of this subsection, R's ABP for January through July is the second-lowest-cost silver plan providing self-only coverage for R. Under paragraphs (a)(2) and (b) of this section, R's ABP for the months August through December is the second-lowest-cost silver plan covering R and O.
Tax filer S claims his daughter, P, as a tax dependent. S and P enroll in a QHP for 2014. S, but not P, is eligible for government-sponsored MEC for September to December 2014. Thus, under paragraph (a)(3) of § 60.03, January through December are coverage months for P and January through August are coverage months for S. Because, under § 60.04 and paragraph (a) of this subsection, the premium-assistance amount for a coverage month is computed based on the ABP for that coverage month, S's ABP for January through August is the second- lowest-cost silver plan under paragraphs (a)(2) and (b) of this subsection covering S and P. Under paragraph (a)(1)(iii) of this subsection, S's ABP for September through December is the second- lowest-cost silver plan providing self-only coverage for P.
The facts are the same as in Example 8, except that S is not eligible for government-sponsored MEC for any months and P is eligible for government-sponsored MEC for the entire year. Under paragraph (a)(1)(iii) of this subsection, S's ABP is the second-lowest-cost silver plan providing self-only coverage for S.
[Reserved]
Tax filer Y has two tax dependents, R and S. Y, R, and S enroll in a QHP. The Exchange offers silver-level plans J, K, L, and M, which are the first, second, third, and fourth lowest cost silver plans covering Y's family. When Y's family enrolls, Plan J is closed to enrollment. Under paragraph (e) of this subsection, Plan J is disregarded in determining Y's ABP, and Plan L is Y's ABP.
Benchmark plan closes to new enrollees during the year
Benchmark plan terminates for all enrollees during the year
The facts are the same as in Example 14, except that Plan 2 terminates for all enrollees on June 30. Under paragraphs (a), (b), and (f) of this subsection, Plan 2 is the ABP for X and Y for all coverage months during the year, and Plan 3 is the ABP for Z.
(01/15/2017, GCR 16-100)
The applicable percentage multiplied by a tax filer's household income determines the tax filer's required share of premiums for the ABP. This required share is subtracted from the monthly premium for the ABP when computing the premium-assistance amount. The applicable percentage is computed by first determining the percentage that the tax filer's household income bears to the FPL for the tax filer's family size. The resulting FPL percentage is then compared to the income categories described in the table in paragraph (b) of this subsection (or successor tables). An applicable percentage within an income category increases on a sliding scale in a linear manner and is rounded to the nearest one-hundredth of one percent. For taxable years beginning after December 31, 2014, the applicable percentages in the table will be adjusted by the ratio of premium growth to growth in income for the preceding calendar year and may be further adjusted to reflect changes to the data used to compute the ratio of premium growth to income growth for the 2014 calendar year or the data sources used to compute the ratio of premium growth to income growth. Premium growth and income growth will be determined in accordance with IRS-published guidance. In addition, the applicable percentages in the table may be adjusted to taxable years beginning after December 31, 2018, to reflect rates of premium growth relative to growth in the consumer price index.
Household income percentage of FPL | 2014 initial percentage | 2014 final percentage |
Less than 133% | 2.0 | 2.0 |
At least 133% but less than 150% | 3.0 | 4.0 |
At least 150% but less than 200% | 4.0 | 6.3 |
At least 200% but less than 250% | 6.3 | 8.05 |
At least 250% but less than 300% | 8.05 | 9.5 |
At least 300% but not more than 400% | 9.5 | 9.5 |
The State reduces the APTC's applicable percentage by 1.5% for an individual expected to have household income, as defined in § 28.05(c), that does not exceed 300 percent of the FPL for the benefit year for which coverage is requested.
Household income percentage of FPL | 2014 initial percentage | 2014 final percentage |
Less than 133% | 0.5 | 0.5 |
At least 133% but less than 150% | 1.5 | 2.5 |
At least 150% but less than 200% | 2.5 | 4.8 |
At least 200% but less than 250% | 4.8 | 6.55 |
At least 250% but less than 300% | 6.55 | 8.0 |
At least 300% but not more than 400% | 9.5 | 9.5 |
The following examples illustrate the rules of this subsection:
In the table in paragraph (b) of this subsection, the initial percentage for a tax filer with household income of 250 to 300 percent of the FPL is 6.55 and the final percentage is 8.0. A's FPL percentage of 275 percent is halfway between 250 percent and 300 percent. Thus, rounded to the nearest one-hundredth of one percent, A's applicable percentage is 7.28, which is halfway between the initial percentage of 6.55 and the final percentage of 8.0.
210 -200 = 10
250 -200 = 50
10/50 =.20.
.20 x 1.75 =.35
4.8 +.35 = 5.15.
(01/15/2017, GCR 16-100)
If a QHP covers more than one household under a single policy, each applicable tax filer covered by the plan may claim a premium tax credit, if otherwise allowable. Each tax filer computes the credit using that tax filer's applicable percentage, household income, and the ABP that applies to the tax filer under § 60.06. In determining whether the amount computed under § 60.04(a) (the premiums for the QHP in which the tax filer enrolls) is less than the amount computed under § 60.04(b) (the benchmark plan premium minus the product of household income and the applicable percentage), the premiums paid are allocated to each tax filer in proportion to the premiums for each tax filer's ABP.
The following example illustrates the rules of this subsection:
(01/15/2017, GCR 16-100)
(01/15/2017, GCR 16-100)
If a QHP offers benefits in addition to the essential health benefits a QHP must provide, the portion of the premium for the plan properly allocable to the additional benefits is excluded from the monthly premiums under § 60.04(a) or (b). Premiums are allocated to additional benefits before determining the ABP.
The portion of the premium properly allocable to additional benefits is determined under guidance issued by the Secretary of HHS. [80 ]
The following examples illustrate the rules of this subsection:
The facts are the same as in Example 1, except that the plan in which B enrolls provides no benefits in addition to the essential health benefits required to be provided by the plan. Thus, under this subsection, B's benchmark plan premium ($ 440) is reduced by the portion of the premium allocable to the additional benefits provided under that plan ($ 40). B's enrollment premiums ($ 370) are not reduced under this subsection. B's premium assistance amount for a coverage month is $ 340, the lesser of $ 370 (B's enrollment premiums) and $ 340 (B's benchmark plan premium, reduced by the portion of the premium allocable to additional benefits ($ 400), minus B's 60 contribution amount).
(01/15/2017, GCR 16-100)
For purposes of determining the amount of the monthly premium a tax filer pays for coverage under § 60.04(a), if an individual enrolls in both a QHP and a stand-alone dental plan, the portion of the premium for the stand-alone dental plan that is properly allocable to pediatric dental benefits that are essential benefits required to be provided by a QHP is treated as a premium payable for the individual's QHP.
The portion of the premium for a stand-alone dental plan properly allocable to pediatric dental benefits is determined under guidance issued by the Secretary of HHS.
The following example illustrates the rules of this subsection:
(01/15/2017, GCR 16-100)
If one or more individuals for whom a tax filer is allowed a deduction under § 151 of the Code are not lawfully present (see § 17.01(g) for definition of lawfully present), the percentage a tax filer's household income bears to the FPL for the tax filer's family size for purposes of determining the applicable percentage under § 60.07 is determined by excluding individuals who are not lawfully present from family size and by determining household income in accordance with paragraph (b) of this subsection.
For purposes of (a) of this subsection, household income is equal to the product of the tax filer's household income (determined without regard to this paragraph (b)) and a fraction:
The IRS Commissioner may describe a comparable method in additional published guidance. [83]
(01/15/2017, GCR 16-100)
When an individual files a complete, accurate and web-based application and relevant data can be fully verified through the use of available electronic means, an individual can expect a real-time or near-real-time eligibility determination.
In cases involving such factors as described in paragraph (a) of this section, eligibility determinations may require additional time to complete. In any event, a decision on a health-benefits application will be made as soon as possible, but no later than:
A determination may take longer in unusual situations, such as:
Individuals will be informed of the timeliness standards set forth in this section.
(01/15/2017, GCR 16-100)
An in-person interview will not be required as part of the application process for a determination of eligibility using MAGI-based income. However, an interview may be required for eligibility determinations for which MAGI-based methods do not apply or when an individual is applying for Medicaid coverage of long-term care services and supports.
(01/15/2017, GCR 16-100)
If an individual would be eligible under more than one Medicaid category, the individual may choose to have eligibility determined for the category of the individual's choosing.
An individual may request only an eligibility determination for enrollment in a QHP without APTC or CSR. However, if the individual is requesting an eligibility determination for a health-benefits program, the individual may not request an eligibility determination for less than all of the health-benefits programs. For example, if an individual seeks a subsidy to help pay for the cost of QHP coverage, they may not limit their application to APTC or CSR. Rather, they must likewise submit to a determination of eligibility for Medicaid.
(01/15/2017, GCR 16-100)
(01/15/2017, GCR 16-100)
An individual who is enrolled in a QHP, as well as some individuals enrolled in Medicaid's Dr. Dynasaur program, are required to pay monthly premiums.
The Vermont legislature sets Medicaid premium methodologies and amounts. Premium schedules are made publicly available via website.
Example. If A and B live together and are under the same premium payer account, and if A's calculated premium is $ 60.00 based on A's Medicaid household income and B's calculated premium is $ 15.00 based on B's Medicaid household income, AHS will not generate separate bills for A and B. Rather, AHS will generate one premium bill for a total of $ 60.00 and, when paid, the premium payment will cover eligibility for both A and B.
An individual will be notified as provided in § 67.00 each time a premium amount is recalculated based on a reported change, whether or not the recalculation results in a change in the premium amount. In other cases (e.g., periodic system-generated recalculations), the individual will be notified only in cases where there is a change in the premium amount.
Premium payments are generally nonrefundable. See § 64.11 for exceptions related to Medicaid premiums. With respect to QHPs, premiums may be refundable in certain cases, including death, overpayment (including retroactive adjustment of APTC), and invoicing errors.
If an individual advises AHS that they have unpaid medical bills incurred during one or more of the three months prior to their application, they may be able to obtain an island of retroactive coverage for any or all of those months (called a "Dr. Dynasaur retroactive island"). If so, AHS will bill the individual for the premium applicable to the Dr. Dynasaur retroactive island. Premium payments for Dr. Dynasaur retroactive islands are subject to allocation as provided under § 64.05(b).
(01/15/2017, GCR 16-100)
A public schedule will be available describing current Medicaid premiums and cost-sharing requirements containing the following information:
The public schedule will be available to the following in a manner that ensures that affected individuals and providers are likely to have access to the notice:
(01/15/2017, GCR 16-100)
(01/15/2017, GCR 16-100)
(01/15/2017, GCR 16-100)
When there is only a single premium obligation, payment of the full amount due is required to maintain coverage and eligibility. A payment of less than the full amount due will be considered by AHS as nonpayment.
An individual who wishes to specify a different payment allocation for the premiums due may do so by calling AHS at the number listed on the bill. The individual must make such a request prior to the time the payment is received by AHS.
(01/15/2017, GCR 16-100)
(01/15/2017, GCR 16-100)
(01/15/2017, GCR 16-100)
(01/15/2017, GCR 16-100)
(01/15/2017, GCR 16-100)
Medicaid premium payment balances that result from partial payments or overpayments will be credited to the premium payer's account and will be applied to subsequent Medicaid premium bills.
(01/15/2017, GCR 16-100)
A paid Medicaid premium will automatically be refunded to the premium payer when, prior to the beginning of the coverage month associated with the premium payment, no one under the premium payer's account is subject to a premium obligation.
A paid Medicaid premium will not be refunded if a change occurs after the beginning of the coverage month associated with the premium payment.
(01/15/2017, GCR 16-100)
(01/15/2017, GCR 16-100)
If an individual subject to a premium appeals a decision by AHS that ends their Medicaid eligibility, reduces their benefits or services, or increases the amount of their Medicaid premium, the individual must continue to pay the premium amount in effect prior to the decision that resulted in their appeal in order to have their Medicaid coverage continue pending the outcome of their appeal.
AHS may recover from the individual the difference between the premium level that would have become effective had the individual not appealed AHS's decision and the premium level actually paid during the fair hearing period when the individual withdraws the fair hearing request before the decision is made or following a final disposition of the matter in favor of AHS.
An individual who appeals the amount of their QHP premium must pay the billed amount until the appeal is decided for coverage to continue. If the individual wins the appeal, any overpayment will be refunded.
(01/15/2017, GCR 16-100)
(01/15/2017, GCR 16-100)
(01/15/2017, GCR 16-100)
Copayments are never required from individuals who are:
(01/15/2017, GCR 16-100)
See DVHA Rules 7101.2(C) and 7101.3(E) for the services that require copayments and the required amounts.
(01/15/2017, GCR 16-100)
(01/15/2017, GCR 16-100)
This section implements § 1902(a)(47)(B) of the Act.
(01/15/2017, GCR 16-100)
Medicaid will be provided during a presumptive eligibility period to an individual who is determined by a qualified hospital, on the basis of preliminary information, to be presumptively eligible in accordance with the policies and procedures established by AHS consistent with this section.
A qualified hospital is a hospital that:
Hospitals may only make determinations of presumptive eligibility under this section based on income for:
(01/15/2017, GCR 16-100)
AHS will provide Medicaid services to an individual during the presumptive-eligibility period that follows a determination by a qualified hospital that, on the basis of preliminary information, the individual has gross income at or below the Medicaid income standard established for the individual.
AHS will:
For purposes of making a presumptive eligibility determination under this section, an individual (or another person having reasonable knowledge of the individual's status) must attest to the individual being a:
(01/15/2017, GCR 16-100)
No retroactive coverage may be provided as a result of a presumptive eligibility determination.
An individual may receive only one presumptive Medicaid eligibility period in a calendar year. A pregnant woman may receive only one presumptive Medicaid eligibility period for each pregnancy, even if she has not yet otherwise received a presumptive Medicaid eligibility period during the current calendar year.
(01/15/2017, GCR 16-100)
Notice and fair hearing regulations in Part Eight of this rule do not apply to determinations of presumptive eligibility under this section.
(01/15/2017, GCR 16-100)
Any notice required to be sent by AHS must be written and include:
All applications, forms, and notices, including the single, streamlined application and notice of redetermination, will conform to the standards outlined in § 5.01(c).
(01/15/2017, GCR 16-100)
Effective no later than January 1, 2015, an individual will be provided with a choice to receive notices and information required under these rules in electronic format or by regular mail. If the individual elects to receive communications electronically, AHS will:
Notice or other communications will be provided electronically only if the individual:
(01/15/2017, GCR 16-100)
(01/15/2017, GCR 16-100)
AHS will send to an individual notice of any decision affecting their eligibility, including an approval, denial, termination or suspension of eligibility in accordance with federal and state laws. A notice of a decision that adversely affects an enrollee's eligibility, including a notice of termination or suspension, will comply with the requirements under § 68.02.
Any notice of decision will contain:
In addition to the information in paragraph (b)(1) of this subsection, a notice of approval of eligibility will contain:
[Reserved]
Notice will be provided:
(01/15/2017, GCR 16-100)
AHS will send a notice of a decision that adversely affects an enrollee's eligibility, including a notice of termination or suspension, (adverse action) at least 11 days before the date the adverse action is to take effect (date of action), except as permitted under paragraph (b) of this subsection.
A notice may be sent not later than the date of action if:
The period of advance notice may be shortened to 5 days before the date of action if:
(01/15/2017, GCR 16-100)
Corrective payments will be promptly made, retroactive to the date an incorrect action was taken if:
(01/15/2017, GCR 16-100)
(01/15/2017, GCR 16-100)
Except when a spenddown is necessary, an individual approved for Medicaid without a premium obligation will be enrolled in Medicaid on the first day of the month within which their application is received by AHS provided they are eligible for that month.
(01/15/2017, GCR 16- 100)
An individual who is approved for Medicaid with a premium obligation will be notified of the premium obligation and premium amount in a bill that will be sent at the time of approval. The individual will not be enrolled in Medicaid until AHS receives payment of the initial premium. The bill will include payment instructions.
When a premium payment is made for the initial months of coverage, and the payment covers the premiums due for at least one, but fewer than all, of the months included in the bill, the payment will be allocated in reverse chronological order, beginning with the latest month included in the bill and extending back as follows:
Coverage will begin on the first day of the earliest month for which a full premium has been paid in accordance with the allocation method described above.
Once an individual is in an ongoing billing cycle due to the issuance of a bill for a subsequent month not included in the bill for the initial months, payments will be applied to the coverage month for which the latest bill was issued and to future coverage months. See § 64.04 for a description of the ongoing billing and payment process.
(01/15/2017, GCR 16-100)
(01/15/2017, GCR 16-100)
AHS will accept a QHP selection from an individual who is determined eligible for enrollment in a QHP in accordance with § 11.00, and will:
AHS will:
Records of all enrollments in QHPs will be maintained.
AHS will reconcile enrollment information with QHP issuers and HHS no less than on a monthly basis.
AHS will notify an employer that an employee has been determined eligibility for advance payments of the premium tax credit and cost- sharing reductions and has enrolled in a qualified health plan through VHC within a reasonable timeframe following a determination that the employee is eligible for advance payments of the premium tax credit and cost-sharing reductions and enrollment by the employee in a qualified health plan through VHC. Such notice must:
(01/15/2017, GCR 16-100)
AHS will provide a written AOEP notification to each enrollee no earlier than the first day of the month before the open enrollment period begins and no later than the first day of the open enrollment period.
The AOEP will be in accordance with federal law.
(01/15/2017, GCR 16-100)
Except as specified in paragraphs (b)(2) and (3) of this subsection, for a QHP selection received by AHS from a qualified individual:
Subject to demonstrating to HHS that all of the participating QHP issuers agree to effectuate coverage in a timeframe shorter than discussed in paragraph (b)(1) or (b)(2)(ii) of this subsection, one or both of the following may be done for all applicable individuals:
Notwithstanding the standards of this subsection, APTC, Vermont Premium Reduction and federal and state CSR will adhere to the effective dates specified in § 73.06.
A qualified individual or their dependent who is described in one of the following paragraphs of this subsection has 60 days before and after the date of the triggering event to select a QHP:
AHS will allow a qualified individual or enrollee, and, when specified below, their dependent, to enroll in or change from one QHP to another if one of the following triggering events occur:
(01/15/2017, GCR 16-100)
To the extent that an individual who is determined eligible for enrollment in a QHP does not select a QHP within their enrollment period, or is not eligible for an enrollment period, in accordance with § 71.00, and seeks a new enrollment period prior to the date on which their eligibility is redetermined in accordance with § 75.00 (annual redetermination), AHS will require the individual to attest as to whether information affecting their eligibility has changed since their most recent eligibility determination before determining their eligibility for a special enrollment period, and will process any changes reported in accordance with the procedures specified in § 73.00 (mid-year redetermination).
(01/15/2017, GCR 16- 100)
(01/15/2017, GCR 16-100)
AHS must redetermine the eligibility of an individual in a health-benefits program or for enrollment in a QHP during the benefit year if it receives and verifies new information reported by the individual or identifies updated information through the data matching described in § 73.04, and such new information may affect eligibility.
(01/15/2017, GCR 16-100)
In general [138]
AHS will:
(01/15/2017, GCR 16-100)
(01/15/2017, GCR 16-100)
AHS will periodically examine the available data sources described in § 56.01.
For QHP enrollees:
(01/15/2017, GCR 16- 100)
If AHS verifies updated information reported by an individual, AHS will:
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(01/15/2017, GCR 16-100)
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(01/15/2017, GCR 16-100)
(01/15/2017, GCR 16-100)
Except as specified in §§ 75.02(k) and 75.02(l), eligibility of an individual in a health-benefits program or for enrollment in a QHP will be renewed on an annual basis.
In the case of an individual who requested an eligibility determination for a health-benefits program (i.e., health benefits other than enrollment in a QHP without APTC or CSR), AHS will request updated tax return information, if the individual has authorized the request of such tax return information, data regarding Social Security benefits, and data regarding income (as described in § 56.01) for use in the individual's eligibility renewal.
(01/15/2017, GCR 16-100)
AHS will conduct annual renewals of QHPs using one of the following:
An individual who is enrolled in a QHP and whose QHP remains available will not be required to reapply or take other actions to renew coverage for the following year.
For renewal of an individual's eligibility for enrollment in a QHP, AHS will provide an annual renewal notice to an individual, including the following:
Any information reported by an individual under paragraph (e) of this subsection will be verified by AHS using the processes specified in §§ 53.00 through 56.00, including the relevant provisions in those subsections regarding inconsistencies, prior to using such information to determine eligibility.
A determination under this section is effective on the first day of the coverage year following the year in which the notice in paragraph (c) of this subsection was provided, or in accordance with the rules specified in § 73.06 regarding effective dates, whichever is later.
If an individual remains eligible for coverage in a QHP upon annual redetermination, such individual will remain in the QHP selected the previous year unless such individual terminates coverage from such plan, including termination of coverage in connection with enrollment in a different QHP, in accordance with § 76.00.
To the extent that a qualified individual has requested an eligibility determination for a health-benefits program in accordance with § 63.00(b) and AHS does not have an active authorization to obtain tax data as a part of the annual redetermination process, AHS will redetermine the qualified individual's eligibility only for enrollment in a QHP and notify the enrollee in accordance with the timing described in paragraph (d) of this subsection. AHS will not proceed with a redetermination for a health-benefits program until such authorization has been obtained or the qualified individual continues their request for an eligibility determination for a health-benefits program.
A qualified individual's eligibility will not be redetermined in accordance with this subsection if the qualified individual's eligibility was redetermined under this subsection during the prior year, and the qualified individual was not enrolled in a QHP at the time of such redetermination, and has not enrolled in a QHP since such redetermination.
(01/15/2017, GCR 16-100)
If eligibility cannot be renewed in accordance with paragraph (a)(2) of this subsection, AHS will:
(01/15/2017, GCR 16-100)
AHS will determine the form and manner in which enrollment in a QHP may be terminated.
AHS may initiate termination of an individual's enrollment in a QHP, and must permit a QHP issuer to terminate such coverage or enrollment, in the following circumstances:
AHS will:
(01/15/2017, GCR 16-100)
In the event that a tax filer is determined eligible for APTC and the Vermont Premium Reduction, if applicable, or an individual is eligible for federal or state CSR, or that such eligibility for such programs has changed, AHS will, simultaneously:
AHS will comply with the requirements of § 78.00 regarding reporting to the IRS and to tax filers.
All information required in accordance with paragraphs (a) and (b) of this section will be transmitted promptly and without undue delay.
If one or more advance payments of the premium tax credit, including the Vermont Premium Reduction, if applicable, are to be made on behalf of a tax filer (or two tax filers covered by the same plan(s)), and individuals in the tax filers' households are enrolled in more than one QHP or stand-alone dental plan, then the advance payment, including the Vermont Premium Reduction, must be allocated as follows:
If a tax filer is eligible for APTC including the Vermont Premium Reduction, if applicable, AHS will:
If AHS discovers that it did not reduce an individual's premium by the amount of the APTC including the Vermont Premium Reduction, if applicable, AHS will notify the individual of the improper reduction within 45 calendar days of discovering the improper reduction and refund the individual any excess premium paid by or for the individual as follows:
(01/15/2017, GCR 16-100)
AHS will report to the IRS the following information for each QHP:
For each calendar month, AHS will report to the IRS for each QHP, the information described in (1) above and the following information:
AHS will submit the annual report required under § 78.00(a)(1) on or before January 31 of the year following the calendar year of coverage. AHS will submit the monthly reports required under § 78.00(a)(2) as required by federal law.
On or before January 31 of the year following the calendar year of coverage, AHS will furnish to each tax filer or responsible adult a written statement showing the name and address of the recipient and the information described in (a)(1) of this section.
AHS will comply with all guidance published by the Commissioner of the IRS 173 for the manner of reporting under this section.
(01/15/2017, GCR 16-100)
Part EIGHT FAIR HEARINGS/EXPEDITED ADMINISTRATIVE APPEALS
(01/15/2017, GCR 16-101)
Fair hearing request
A clear expression, either orally or in writing, by an individual (applicant or enrollee) to have any action by AHS affecting the individual's eligibility or level of benefits or services reviewed by the AHS Human Services Board. A request for an expedited administrative appeal will also be considered a request for a fair hearing and will be forwarded to the Human Services Board.
Fair hearings entity
The Human Services Board, the body designated by law to hear fair hearings of eligibility determinations or redeterminations. AHS reviews requests for expedited administrative appeals pursuant to § 80.07.
(01/15/2017, GCR 16-101)
Fair hearings are processed in accordance with fair hearing rules as promulgated by the Human Services Board pursuant to 3 VSA § 3091(b).
An individual may submit a fair hearing request either orally or in writing by contacting AHS or the Human Services Board. See § 80.04(a) for the methods individuals may use to submit a fair hearing request. A fair hearing request may be submitted by the individual, their authorized representative as defined in § 3.00, their legal counsel, a relative, a friend, or another spokesperson. The fair hearing request process must comply with accessibility requirements in § 5.01(c). [4]
If an appeal involves a QHP or MCA, other than Medicaid coverage of long- term care services and supports under MCA, an individual may request an expedited administrative appeal by indicating that the time otherwise permitted for a fair hearing could jeopardize their life or health or ability to attain, maintain or regain maximum function. For the rule on expedited administrative appeals, see § 80.07.
AHS will, at the times specified in § 68.01(c), provide every individual in writing with an explanation of their fair-hearing rights as described in § 68.01(b)(2) and their right to request an expedited administrative appeal pursuant to § 80.07.
(01/15/2017, GCR 16-101)
AHS will grant an opportunity for a hearing to any individual who requests it because AHS terminates, suspends, denies or reduces their eligibility, reduces their level of benefits or services, their claim is not acted upon with reasonable promptness, they are aggrieved by any other action taken by AHS affecting their receipt of assistance, benefits or services or by agency policy as it affects their situation, or they believe an action by AHS has been taken erroneously. This includes, if applicable:
An applicant for or recipient of SSI/AABD benefits who is denied SSI/AABD benefits or has their SSI/AABD benefits terminated because the SSA or its agent found the individual to be not disabled, may not appeal the Medicaid denial or termination that results from this action by the SSA or its agent to the Human Services Board (see Disability Determination Appeal under § 81.00).
There is no right to a fair hearing or an expedited administrative appeal when either state or federal law requires automatic case adjustments for classes of enrollees, unless the reason for an individual's appeal is incorrect eligibility determination.
(01/15/2017, GCR 16-101)
An individual, or an authorized representative on behalf of an individual, or a person identified at § 80.02(b), may submit a fair hearing request:
AHS will:
An individual must request a fair hearing within 90 days from the date that notice of action is sent by AHS (see § 68.01(b)(1)).
If an individual has been denied eligibility for Medicaid, AHS will treat an appeal of a determination of eligibility for APTC or CSR as including a request for an appeal of the Medicaid determination.
(01/15/2017, GCR 16-101)
An individual may, at the same time or independent of an HHS appeal (as described in (c) of this subsection), if applicable, appeal a decision of the AHS Secretary, made pursuant to § 80.05(a)(2), to the Supreme Court. Such appeals shall be pursuant to Rule 13 of the Vermont Rules of Appellate Procedure. The Supreme Court may stay the Secretary's decision upon the individual's showing of a fair ground for litigation on the merits. The Supreme Court will not stay the Secretary's order insofar as it relates to a denial of retroactive benefits.
(01/15/2017, GCR 16-101)
Upon receiving a final and binding decision as described in § 80.05(a)(2), AHS will promptly implement the decision.
(01/15/2017, GCR 16-101)
The provisions of this subsection are limited to expedited administrative appeals involving QHPs or MCA, other than Medicaid coverage of long- term care services and supports under MCA. With respect to such appeals:
An individual, treating provider, or other person identified at § 80.02(b) may request an expedited administrative appeal. A request for an expedited administrative appeal may be made to AHS orally, in writing, or by any other method identified at § 80.04(a). AHS will consider a fair hearing request as an expedited administrative appeal request if the individual, or other person appealing on the individual's behalf, indicates that the individual has an immediate need for health services and that taking the time otherwise permitted for a fair hearing could jeopardize the individual's life or health or ability to attain, maintain or regain maximum function. AHS will not take any punitive action against a provider who requests an expedited administrative appeal or supports an individual's request.
(01/15/2017, GCR 16-101)
If AHS has made a disability determination under the circumstances specified in § 8.04, the decision may be appealed to the Human Services Board.
(01/15/2017, GCR 16- 101)
When an individual appeals a decision by AHS that ends their Medicaid eligibility, reduces their benefits or services, or imposes or increases a premium, the individual has the right, under certain conditions, to have their Medicaid eligibility, benefit and service level, and premium level continue as before the decision that resulted in the fair hearing request until the fair hearing is resolved, provided the individual submits the request before the effective date of the adverse action and pays any required premiums. If the last day before the adverse action date is on a weekend or holiday, the individual has until the end of the first subsequent working day to request the fair hearing. If the individual was subject to a premium prior to the adverse action that resulted in the fair hearing request, the individual must continue to pay premiums at the same level as the premiums prior to the adverse action in order for Medicaid eligibility to continue pending resolution of the fair hearing.
An individual may waive their right to continued Medicaid benefits. If they do so and are successful on a fair hearing, benefits will be paid retroactively.
The state may recover from the individual the value of any continued Medicaid benefits paid during the fair hearing period when the individual withdraws the fair hearing before the decision is made, or following a final disposition of the matter in favor of the state.
When an SSI/AABD enrollee is determined "not disabled" by the SSA and appeals this determination, their Medicaid benefits continue as long as their SSI/AABD benefits are continued (or could have been continued but the individual chose not to receive them during the appeal period) pending a SSA decision on the appeal. When eligibility for SSI/AABD benefits is terminated following a determination of "not disabled", Medicaid benefits end unless the individual applies and is found eligible for Medicaid on the basis of a categorical factor other than disability.
When an individual enrolled in Medicaid applies for SSI/AABD and is determined "not disabled" by the SSA and files a timely appeal of this determination with the SSA, their Medicaid benefits continue until a final decision is made on the appeal, provided the SSA's determination of "not disabled" is the only basis on which they might be found ineligible for Medicaid. If they continue to appeal unfavorable decisions by SSA, the "final decision" is made by the SSA Appeals Council.
After receipt of a valid fair hearing request or notice that concerns an appeal of a redetermination, if the individual (appellant) accepts eligibility pending an appeal, AHS will continue to consider the individual (appellant) eligible, while the fair hearing is pending, for QHP, APTC, the Vermont Premium Reduction and federal or state CSR, as applicable, in accordance with the level of eligibility immediately before the redetermination being appealed.
(01/15/2017, GCR 16-101)
13-001 Code Vt. R. 13-170-001-X
EFFECTIVE DATE: October 1, 2013 Secretary of State Rule Log #13-029
AMENDED: July 30, 2014 Secretary of State Rule Log #14-026; July 15, 2015 Secretary of State Rule Log #15-030 [15-02]; May 11, 2016 Secretary of State Rule Log #16-E04; August 1, 2016 Secretary of State Rule Log #16-026; January 15, 2017 Secretary of State Rule Log #16-072, #16-073, #16-074, #16-075, #16-076, #16-077, #16-078, #16-079