reglab/statecodes huggingface dataset:
2023 Vermont Statutes › Title 33 - Human Services › Chapter 18 - Public-Private Universal Health Care System › § 1804. Qualified employers

§ 1804. Qualified employers
(a)(1) Until January 1, 2016, a qualified employer shall be an entity that employed an average of not more than 50 employees on working days during the preceding calendar year, and the term “qualified employer” includes self-employed persons to the extent permitted under the Affordable Care Act. Calculation of the number of employees of a qualified employer shall not include a part-time employee who works fewer than 30 hours per week or a seasonal worker as defined in 26 U.S.C. § 4980H(c)(2)(B).
(2) An employer with 50 or fewer employees that offers a qualified health benefit plan to its employees through the Vermont Health Benefit Exchange may continue to participate in the Exchange even if the employer’s size grows beyond 50 employees, as long as the employer continuously makes qualified health benefit plans in the Vermont Health Benefit Exchange available to its employees.
(b)(1) On and after January 1, 2016, a qualified employer shall be an entity that employed an average of not more than 100 employees on working days during the preceding calendar year, and the term “qualified employer” includes self-employed persons to the extent permitted under the Affordable Care Act. The number of employees shall be calculated using the method set forth in 26 U.S.C. § 4980H(c)(2).
(2) An employer with 100 or fewer employees that offers a qualified health benefit plan to its employees through the Vermont Health Benefit Exchange may continue to participate in the Exchange even if the employer’s size grows beyond 100 employees, as long as the employer continuously makes qualified health benefit plans in the Vermont Health Benefit Exchange available to its employees.
(c) [Repealed.] (Added 2011, No. 171 (Adj. Sess.), § 2; amended 2013, No. 79, § 28, eff. Oct. 1, 2013; 2015, No. 54, § 14, eff. June 5, 2015; 2015, No. 151 (Adj. Sess.), § 2.)
2023 Vermont Statutes › Title 33 - Human Services › Chapter 18 - Public-Private Universal Health Care System › § 1807. Navigators

§ 1807. Navigators
(a)(1) The Vermont Health Benefit Exchange shall establish a navigator program to assist individuals and employers in enrolling in a qualified health benefit plan offered under the Vermont Health Benefit Exchange. The Vermont Health Benefit Exchange shall select individuals and entities qualified to serve as navigators and shall award grants to navigators for the performance of their duties.
(2) The Vermont Health Benefit Exchange shall ensure that navigators are available to provide assistance in person or through interactive technology to individuals in all regions of the State in a manner that complies with the Americans with Disabilities Act.
(3) Consistent with Section 1311(i)(4) of the Affordable Care Act, health insurers shall not serve as navigators, and no navigator shall receive any compensation from a health insurer in connection with enrolling individuals or employees in qualified health benefit plans.
(b) Navigators shall have the following duties:
(1) conduct public education activities to raise awareness of the availability of qualified health benefit plans;
(2) distribute fair and impartial information concerning enrollment in qualified health benefit plans and concerning the availability of premium tax credits and cost-sharing reductions;
(3) facilitate enrollment in qualified health benefit plans, Medicaid, Dr. Dynasaur, VPharm, and other public health benefit programs;
(4) provide referrals to the Office of the Health Care Advocate and any other appropriate agency for any enrollee with a grievance, complaint, or question regarding his or her health benefit plan, coverage, or a determination under that plan or coverage;
(5) provide information in a manner that is culturally and linguistically appropriate to the needs of the population being served by the Vermont Health Benefit Exchange; and
(6) distribute information to health care professionals, community organizations, and others to facilitate the enrollment of individuals who are eligible for Medicaid, Dr. Dynasaur, VPharm, other public health benefit programs, or the Vermont Health Benefit Exchange in order to ensure that all eligible individuals are enrolled.
(7) [Repealed.] (Added 2011, No. 48, § 4; amended 2011, No. 171 (Adj. Sess.), § 2b; 2013, No. 79, §§ 22, 35h, eff. Jan. 1, 2014; 2019, No. 15, § 1, eff. May 6, 2019.)
2023 Vermont Statutes › Title 33 - Human Services › Chapter 18 - Public-Private Universal Health Care System › § 1808. Financial integrity

§ 1808. Financial integrity
(a) The Vermont Health Benefit Exchange shall:
(1) keep an accurate accounting of all activities, receipts, and expenditures and submit this information annually as required by federal law; and
(2) cooperate with the Secretary of the U.S. Department of Health and Human Services or the Inspector General of the U.S. Department of Health and Human Services in any investigation into the affairs of the Vermont Health Benefit Exchange, any examination of the properties and records of the Vermont Health Benefit Exchange, or any requirement for periodic reports in relation to the activities undertaken by the Vermont Health Benefit Exchange.
(b) In carrying out its activities under this subchapter, the Vermont Health Benefit Exchange shall not use any funds intended for the administrative and operational expenses of the Vermont Health Benefit Exchange for staff retreats, promotional giveaways, excessive executive compensation, or promotion of federal or State legislative or regulatory modifications. (Added 2011, No. 48, § 4.)
2023 Vermont Statutes › Title 33 - Human Services › Chapter 18 - Public-Private Universal Health Care System › § 1809. Publication of costs and satisfaction surveys

§ 1809. Publication of costs and satisfaction surveys
(a) The Vermont Health Benefit Exchange shall publish the average costs of licensing, regulatory fees, and any other payments required by the Exchange, as well as the administrative costs of the Exchange, on a website intended to educate consumers about such costs. This information shall include information on monies lost to waste, fraud, and abuse.
(b) The Vermont Health Benefit Exchange shall publish the deidentified results of the satisfaction surveys and other evaluation mechanisms required pursuant to subdivision 1805(13) of this title on a website intended to enable consumers to compare the qualified health benefit plans offered through the Exchange. (Added 2011, No. 48, § 4.)
2023 Vermont Statutes › Title 33 - Human Services › Chapter 18 - Public-Private Universal Health Care System › § 1812. Financial assistance to individuals

§ 1812. Financial assistance to individuals
(a)(1) An individual or family eligible for federal premium tax credits under 26 U.S.C. § 36B with income less than or equal to 300 percent of federal poverty level shall be eligible for premium assistance from the State of Vermont.
(2) The Department of Vermont Health Access shall establish a premium schedule on a sliding scale based on modified adjusted gross income for the individuals and families described in subdivision (1) of this subsection. The Department shall reduce the premium contribution for these individuals and families by 1.5 percent below the premium amount established in 26 U.S.C. § 36B.
(3) Premium assistance shall be available for the same qualified health benefit plans for which federal premium tax credits are available.
(b)(1) An individual or family with income at or below 300 percent of the federal poverty level shall be eligible for cost-sharing assistance, including a reduction in the out-of-pocket maximums established under Section 1402 of the Affordable Care Act.
(2) The Department of Vermont Health Access shall establish cost-sharing assistance on a sliding scale based on modified adjusted gross income for the individuals and families described in subdivision (1) of this subsection. Cost-sharing assistance shall be established as follows:
(A) for households with income at or below 150 percent of the federal poverty level (FPL): 94 percent actuarial value;
(B) for households with income above 150 percent FPL and at or below 200 percent FPL: 87 percent actuarial value;
(C) for households with income above 200 percent FPL and at or below 250 percent FPL: 77 percent actuarial value;
(D) for households with income above 250 percent FPL and at or below 300 percent FPL: 73 percent actuarial value.
(3) Cost-sharing assistance shall be available for silver-level qualified health benefit plans purchased through the Vermont Health Benefit Exchange and shall be administered using the same methods as set forth in Section 1402 of the Affordable Care Act to the extent practicable.
(c) To the extent feasible, the Department shall use the same mechanisms provided in the Affordable Care Act to establish financial assistance under this section in order to minimize confusion and complication for individuals, families, and health insurers. (Added 2013, No. 50, § E.307.1, eff. Oct. 1, 2013; amended 2015, No. 23, § 54; 2017, No. 88 (Adj. Sess.), § 4, eff. Feb. 20, 2018.)
2023 Vermont Statutes › Title 33 - Human Services › Chapter 18 - Public-Private Universal Health Care System › § 1813. Reflective health benefit plans

§ 1813. Reflective health benefit plans
(a)(1) In the event that federal cost-sharing reduction payments to insurers are suspended or discontinued, registered carriers may offer to individuals and employees of small employers nonqualified reflective health benefit plans that do not include funding to offset the loss of the federal cost-sharing reduction payments. These plans shall be similar to, but contain at least one variation from, qualified health benefit plans offered through the Vermont Health Benefit Exchange that include funding to offset the loss of the federal cost-sharing reduction payments.
(2) In its review and approval of premium rates pursuant to 8 V.S.A. § 4062, the Green Mountain Care Board shall ensure that:
(A) the rates for some or all qualified health benefit plans offered through the Vermont Health Benefit Exchange include funding to offset the loss of the federal cost-sharing reduction payments; and
(B) the rates for the reflective health benefit plans described in subdivision (1) of this subsection (a) do not include funding to offset the loss of the federal cost-sharing reduction payments.
(3) To the extent not expressly prohibited under federal law, the Green Mountain Care Board shall ensure that funding to offset the loss of the federal cost-sharing reduction payments is included exclusively in silver-level qualified health benefit plans offered through the Vermont Health Benefit Exchange.
(b) A reflective health benefit plan shall comply with the requirements of section 1806 of this title except that the plan shall not be offered through the Vermont Health Benefit Exchange. (Added 2017, No. 88 (Adj. Sess.), § 5, eff. Feb. 20, 2018; amended 2019, No. 19, § 6, eff. Jan. 1, 2020.)
2023 Vermont Statutes › Title 33 - Human Services › Chapter 18 - Public-Private Universal Health Care System › § 1814. Maximum out-of-pocket limit for prescription drugs in bronze plans

§ 1814. Maximum out-of-pocket limit for prescription drugs in bronze plans
(a)(1) Notwithstanding any provision of 8 V.S.A. § 4089i to the contrary, the Green Mountain Care Board may approve modifications to the out-of-pocket prescription drug limit established in 8 V.S.A. § 4089i for one or more bronze-level plans, as long as the Board finds that the offering of such plans will not adversely impact the plan options available to consumers with high prescription drug needs who benefit from the out-of-pocket prescription drug limit established in 8 V.S.A. § 4089i.
(2) The Department of Vermont Health Access shall certify at least two standard bronze-level plans that include the out-of-pocket prescription drug limit established in 8 V.S.A. § 4089i, as long as the plans comply with federal requirements. Notwithstanding any provision of 8 V.S.A. § 4089i to the contrary, the Department may certify one or more bronze-level qualified health benefit plans with modifications to the out-of-pocket prescription drug limit established in 8 V.S.A. § 4089i.
(b)(1) For each individual enrolled in a bronze-level qualified health benefit plan for the previous two plan years who had out-of-pocket prescription drug expenditures that met the out-of-pocket prescription drug limit established in 8 V.S.A. § 4089i for the most recent plan year for which information is available, the health insurer shall, absent an alternative plan selection or plan cancellation by the individual, automatically reenroll the individual in a bronze-level qualified health plan for the forthcoming plan year with an out-of-pocket prescription drug limit at or below the limit established in 8 V.S.A. § 4089i.
(2) Prior to reenrolling an individual in a plan pursuant to subdivision (1) of this subsection, the health insurer shall notify the individual of the insurer’s intent to reenroll the individual automatically in a bronze-level qualified health plan for the forthcoming plan year with an out-of-pocket prescription drug limit at or below the limit established in 8 V.S.A. § 4089i unless the individual contacts the insurer to select a different plan and of the availability of bronze-level plans with higher out-of-pocket prescription drug limits. The health insurer shall collaborate with the Department of Vermont Health Access and the Office of the Health Care Advocate as to the notification’s form and content. (Added 2017, No. 210 (Adj. Sess.), § 12, eff. June 1, 2018.)
2023 Vermont Statutes › Title 33 - Human Services › Chapter 18 - Public-Private Universal Health Care System › § 1821. Purpose

§ 1821. Purpose
The purpose of Green Mountain Care is to provide, as a public good, comprehensive, affordable, high-quality, publicly financed health care coverage for all Vermont residents in a seamless and equitable manner regardless of income, assets, health status, or availability of other health coverage. Green Mountain Care shall contain costs by:
(1) providing incentives to residents to avoid preventable health conditions, promote health, and avoid unnecessary emergency room visits;
(2) establishing innovative payment mechanisms to health care professionals, such as global payments;
(3) encouraging the management of health services through the Blueprint for Health; and
(4) reducing unnecessary administrative expenditures. (Added 2011, No. 48, § 4.)
2023 Vermont Statutes › Title 33 - Human Services › Chapter 18 - Public-Private Universal Health Care System › § 1826. Blueprint for Health

§ 1826. Blueprint for Health
(a) It is the intent of the General Assembly that within five years following the implementation of Green Mountain Care, each individual enrolled in Green Mountain Care will have a primary health care professional who is involved with the Blueprint for Health established in 18 V.S.A. chapter 13.
(b) Consistent with the provisions of 18 V.S.A. chapter 13, if an individual enrolled in Green Mountain Care does not have a medical home through the Blueprint for Health, the individual may choose a primary health care professional who is not participating in the Blueprint to serve as the individual’s primary care point of contact.
(c) The Agency shall determine a method to approve a specialist as a patient’s primary health care professional for the purposes of establishing a medical home or primary care point of contact for the patient. The Agency shall approve a specialist as a patient’s medical home or primary care point of contact on a case-by-case basis and only for a patient who receives the majority of his or her health care from that specialist.
(d) Green Mountain Care shall be integrated with the Blueprint for Health established in 18 V.S.A. chapter 13. (Added 2011, No. 48, § 4.)
2023 Vermont Statutes › Title 33 - Human Services › Chapter 18 - Public-Private Universal Health Care System › § 1828. Budget proposal

§ 1828. Budget proposal
The Green Mountain Care Board, in collaboration with the Agencies of Administration and of Human Services, shall be responsible for developing each year a three-year Green Mountain Care budget for proposal to the General Assembly and to the Governor, to be adjusted annually in response to realized revenues and expenditures, that reflects any modifications to the benefit package and includes recommended appropriations, revenue estimates, and necessary modifications to tax rates and other assessments. (Added 2011, No. 48, § 4.)
2023 Vermont Statutes › Title 33 - Human Services › Chapter 18 - Public-Private Universal Health Care System › § 1829. Green Mountain Care Fund

§ 1829. Green Mountain Care Fund
(a) The Green Mountain Care Fund is established in the State Treasury as a special fund to be the single source to finance health care coverage for Green Mountain Care.
(b) Into the Fund shall be deposited:
(1) transfers or appropriations from the General Fund, authorized by the General Assembly;
(2) if authorized by a waiver from federal law, federal funds for Medicaid, Medicare, and the Vermont Health Benefit Exchange established in chapter 18, subchapter 1 of this title; and
(3) the proceeds from grants, donations, contributions, taxes, and any other sources of revenue as may be provided by statute or by rule.
(c) The Fund shall be administered pursuant to 32 V.S.A. chapter 7, subchapter 5, except that interest earned on the Fund and any remaining balance shall be retained in the Fund. The Agency shall maintain records indicating the amount of money in the Fund at any time.
(d) All monies received by or generated to the Fund shall be used only for:
(1) the administration and delivery of health services covered by Green Mountain Care as provided in this subchapter; and
(2) expenses related to the duties and operation of the Green Mountain Care Board pursuant to 18 V.S.A. chapter 220. (Added 2011, No. 48, § 4.)
2023 Vermont Statutes › Title 33 - Human Services › Chapter 18 - Public-Private Universal Health Care System › § 1830. Collective bargaining rights

§ 1830. Collective bargaining rights
Nothing in this subchapter shall be construed to limit the ability of collective bargaining units to negotiate for coverage of health services pursuant to 3 V.S.A. § 904 or any other provision of law. (Added 2011, No. 48, § 4.)
2023 Vermont Statutes › Title 33 - Human Services › Chapter 18 - Public-Private Universal Health Care System › § 1831. Public process

§ 1831. Public process
The Agency of Human Services shall provide a process for soliciting public input on the Green Mountain Care benefit package on an ongoing basis, including a mechanism by which members of the public may request inclusion of particular benefits or services. The process may include receiving written comments on proposed new or amended rules or holding public hearings or both. (Added 2011, No. 48, § 4.)
2023 Vermont Statutes › Title 33 - Human Services › Chapter 18 - Public-Private Universal Health Care System › § 1832. Rulemaking

§ 1832. Rulemaking
The Secretary of Human Services may adopt rules pursuant to 3 V.S.A. chapter 25 to carry out the purposes of this subchapter. When establishing rules relating to the Green Mountain Care benefit package, the Secretary shall ensure that the rules are consistent with the benefit package defined by the Green Mountain Care Board pursuant to section 1825 of this title and to 18 V.S.A. chapter 220. (Added 2011, No. 48, § 4.)
2023 Vermont Statutes › Title 33 - Human Services › Chapter 19 - Medical Assistance › § 1900. Definitions

§ 1900. Definitions
As used in this subchapter, unless otherwise indicated:
(1) “Agency” means the Agency of Human Services.
(2) “Commissioner” means the Commissioner of Vermont Health Access.
(3) “Department” means the Department of Vermont Health Access.
(4) “Insurer” means any insurance company, prepaid health care delivery plan, self-funded employee benefit plan, pension fund, hospital or medical service corporation, managed care organization, pharmacy benefit manager, prescription drug plan, retirement system, or similar entity that is under an obligation to make payments for medical services as a result of an injury, illness, or disease suffered by an individual.
(5) “Legally liable representative” means a parent or person with an obligation of support to a recipient whether by contract, court order, or statute.
(6) “Provider” means any person who has entered into an agreement with the State to provide any medical service.
(7) “Recipient” means any person or group of persons who receive Medicaid.
(8) “Secretary” means the Secretary of Human Services.
(9) “Third party” means a person having an obligation to pay all or any portion of the medical expense incurred by a recipient at the time the medical service was provided. The obligation is not discharged by virtue of being undiscovered or undeveloped at the time a Medicaid claim is paid. Third parties include:
(A) Medicare;
(B) health insurance, including health and accident but not that portion specifically designated for “income protection” that has been considered in determining recipient eligibility to participate in the Medicaid program;
(C) medical coverage provided in conjunction with other benefit or compensation programs, including military and veteran programs or workers’ compensation;
(D) liability for medical expenses as agreed to or ordered in negligence suits, support settlements, or trust funds; and
(E) managed care organizations, pharmacy benefit managers, self-insured plans, and other entities that are, by statute, contract, or agreement, legally responsible for the payment of a claim for a health care item or service.
(10) “Tobacco” means all products listed in 7 V.S.A. § 1001(3).
(11) “Tobacco manufacturer” means any person engaged in the process of designing, fabricating, assembling, producing, constructing, or otherwise preparing a product containing tobacco, including packaging or labeling of these products, with the intended purpose of selling the product for gain or profit. “Tobacco manufacturer” does not include persons whose activity is limited to growing natural leaf tobacco or to selling tobacco products at wholesale or retail to customers. “Tobacco manufacturer” also does not include any person who manufactures or produces firearms, dairy products, products containing alcohol, or other nontobacco products, unless such person also manufactures or produces tobacco products. (Added 2013, No. 131 (Adj. Sess.), § 38, eff. May 20, 2014.)
2023 Vermont Statutes › Title 33 - Human Services › Chapter 19 - Medical Assistance › § 1901a. Medicaid budget

§ 1901a. Medicaid budget
(a) The General Assembly shall approve each year a Medicaid budget. The annual Medicaid budget shall include an annual financial plan, and a five-year financial plan accounting for expenditures and revenues relating to Medicaid and any other health care assistance program administered by the Agency of Human Services.
(b) The Secretary of Human Services or his or her designee and the Commissioner of Finance and Management shall provide quarterly to the Joint Fiscal Committee such information and analysis as the Committee reasonably determines is necessary to assist the General Assembly in the preparation of the Medicaid budget. (Added 2001, No. 142 (Adj. Sess.), § 148a; amended 2005, No. 215 (Adj. Sess.), § 309, eff. May 31, 2006; 2019, No. 144 (Adj. Sess.), § 31.)
2023 Vermont Statutes › Title 33 - Human Services › Chapter 19 - Medical Assistance › § 1901b. Pharmacy program enrollment

§ 1901b. Pharmacy program enrollment
(a) The Department of Vermont Health Access and the Department for Children and Families shall monitor actual caseloads, revenue, and expenditures; anticipated caseloads, revenue, and expenditures; and actual and anticipated savings from implementation of the preferred drug list, supplemental rebates, and other cost containment activities in each State pharmaceutical assistance program, including VPharm. When applicable, the Departments shall allocate supplemental rebate savings to each program proportionate to expenditures in each program.
(b) As used in this section, “State pharmaceutical assistance program” means any health assistance programs administered by the Agency of Human Services providing prescription drug coverage, including the Medicaid program, VPharm, the State Children’s Health Insurance Program, the State of Vermont AIDS Medication Assistance Program, the General Assistance Program, the Pharmacy Discount Plan Program, and any other health assistance programs administered by the Agency providing prescription drug coverage. (Added 2001, No. 142 (Adj. Sess.), § 148b; amended 2005, No. 174 (Adj. Sess.), § 94; 2005, No. 215 (Adj. Sess.), §§ 316, 317; 2009, No. 156 (Adj. Sess.), § I.44; 2011, No. 171 (Adj. Sess.), § 41c; 2013, No. 79, § 47, eff. Jan. 1, 2014.)
2023 Vermont Statutes › Title 33 - Human Services › Chapter 19 - Medical Assistance › § 1901d. State Health Care Resources Fund

§ 1901d. State Health Care Resources Fund
(a) The State Health Care Resources Fund is established in the State Treasury as a special fund to be a source of financing for health care coverage for beneficiaries of the State health care assistance programs under the Global Commitment to Health waiver approved by the Centers for Medicare and Medicaid Services under Section 1115 of the Social Security Act.
(b) Into the Fund shall be deposited:
(1)-(4) [Repealed.]
(5) premium amounts paid by individuals unless paid directly to the insurer; and
(6) the proceeds from grants, donations, contributions, taxes, recoveries, and any other sources of revenue as may be provided by statute, rule, agreement, or act of the General Assembly.
(7) [Repealed.]
(c) The Fund shall be administered pursuant to 32 V.S.A. chapter 7, subchapter 5, except that interest earned on the Fund and any remaining balance shall be retained in the Fund. The Agency shall maintain records indicating the amount of money in the Fund at any time.
(d) All monies received by or generated to the Fund shall be used only as allowed by appropriation of the General Assembly for the administration and delivery of health care covered through State health care assistance programs administered by the Agency under the Global Commitment to Health Medicaid Section 1115 waiver, immunizations under 18 V.S.A. § 1130, and the development and implementation of the Blueprint for Health under 18 V.S.A. § 702. (Added 2005, No. 93 (Adj. Sess.), § 16a, eff. July 1, 2006; amended 2005, No. 191 (Adj. Sess.), § 41; 2007, No. 65, § 387, eff. June 4, 2007; 2011, No. 45, § 36o; 2011, No. 75 (Adj. Sess.), § 110; 2013, No. 50, § E.307.4; 2019, No. 6, § 65, eff. April 22, 2019; 2021, No. 20, § 298.)
2023 Vermont Statutes › Title 33 - Human Services › Chapter 19 - Medical Assistance › § 1901e. Global Commitment Fund

§ 1901e. Global Commitment Fund
(a) The Global Commitment Fund is created in the Treasury as a special fund. The Fund shall consist of the revenues received by the Treasurer as payment of the actuarially certified premium from the Agency of Human Services to the managed care organization within the Department of Vermont Health Access for the purpose of providing services under the Global Commitment to Health waiver approved by the Centers for Medicare and Medicaid Services under Section 1115 of the Social Security Act.
(b) The monies in the Fund shall be disbursed as allowed by appropriation of the General Assembly, and shall be disbursed by the Treasurer on warrants issued by the Commissioner of Finance and Management, when authorized by the Commissioner of Vermont Health Access and approved by the Commissioner of Finance and Management consistent with the interdepartmental agreements between the managed care organization within the Department of Vermont Health Access and departments delivering eligible services under the waiver. The Department of Vermont Health Access shall not modify an appropriation through an interdepartmental agreement or any other mechanism. A department or agency authorized to spend monies from this Fund under an interdepartmental agreement may spend monies appropriated as a base Medicaid expense for an allowable managed care organization investment under the terms and conditions of the Global Commitment to Health Medicaid Section 1115 waiver only after receiving approval from the Agency of Human Services.
(c) Annually, on or before October 1, the Agency shall provide a detailed report to the Joint Fiscal Committee that describes the managed care organization’s investments under the terms and conditions of the Global Commitment to Health Medicaid Section 1115 waiver, including the amount of the investment and the agency or departments authorized to make the investment. (Added 2005, No. 93 (Adj. Sess.), § 16c, eff. Oct. 1, 2005; amended 2005, No. 215 (Adj. Sess.), § 307, eff. May 31, 2006; 2009, No. 156 (Adj. Sess.), § I.46; 2013, No. 131 (Adj. Sess.), § 40, eff. May 20, 2014; 2015, No. 172 (Adj. Sess.), § E.306.5; 2021, No. 20, § 299.)
2023 Vermont Statutes › Title 33 - Human Services › Chapter 19 - Medical Assistance › § 1901f. Medicaid program enrollment and expenditure reports

§ 1901f. Medicaid program enrollment and expenditure reports
By March 1, June 1, September 1, and December 1 of each year, the Commissioner of Vermont Health Access or designee shall submit to the General Assembly a quarterly report on enrollment and total expenditures by Medicaid eligibility group for all programs paid for by the Department of Vermont Health Access during the preceding calendar quarter and for the fiscal year to date. Total expenditures for Medicaid-related programs paid for by other departments within the Agency of Human Services shall be included in this report by Medicaid eligibility group to the extent such information is available. (Added 2011, No. 75 (Adj. Sess.), § 111, eff. March 7, 2012; amended 2015, No. 58, § E.307.2.)
2023 Vermont Statutes › Title 33 - Human Services › Chapter 19 - Medical Assistance › § 1901g. Medicaid coverage for home telemonitoring services

§ 1901g. Medicaid coverage for home telemonitoring services
(a) The Agency of Human Services shall provide Medicaid coverage for home telemonitoring services performed by home health agencies or other qualified providers as defined by the Agency of Human Services for Medicaid beneficiaries who have serious or chronic medical conditions that can result in frequent or recurrent hospitalizations and emergency room admissions. Beginning on July 1, 2014, the Agency shall provide coverage for home telemonitoring for one or more conditions or risk factors for which it determines, using reliable data, that home telemonitoring services are appropriate and that coverage will be budget-neutral. The Agency may expand coverage to include additional conditions or risk factors identified using evidence-based best practices if the expanded coverage will remain budget-neutral or as funds become available.
(b) A home health agency or other qualified provider shall ensure that clinical information gathered by the home health agency or other qualified provider while providing home telemonitoring services is shared with the patient’s treating health care professionals. The Agency of Human Services may impose other reasonable requirements on the use of home telemonitoring services.
(c) As used in this section:
(1) “Home health agency” means an entity that has received a certificate of need from the State to provide home health services and is certified to provide services pursuant to 42 U.S.C. § 1395x(o).
(2) “Home telemonitoring service” means a health service that requires scheduled remote monitoring of data related to a patient’s health, in conjunction with a home health plan of care, and access to the data by a home health agency or other qualified provider as defined by the Agency of Human Services. (Added 2013, No. 153 (Adj. Sess.), § 1.)
2023 Vermont Statutes › Title 33 - Human Services › Chapter 19 - Medical Assistance › § 1901j. Medicaid reimbursement for long-acting reversible contraceptives

§ 1901j. Medicaid reimbursement for long-acting reversible contraceptives
(a) As used in this section, “health care provider” has the same meaning as in 18 V.S.A. § 9402.
(b) The Department of Vermont Health Access shall reimburse health care providers for the full cost of a device providing long-acting reversible contraception when the device is inserted during a Medicaid beneficiary’s postpartum hospital stay. (Added 2017, No. 138 (Adj. Sess.), § 1.)
2023 Vermont Statutes › Title 33 - Human Services › Chapter 19 - Medical Assistance › § 1901k. Medicaid coverage for hearing aids and audiology services

§ 1901k. Medicaid coverage for hearing aids and audiology services
Vermont Medicaid shall provide coverage for medically necessary hearing aids and audiology services when delivered by a health care professional practicing within the scope of the professional’s license, including audiologic examinations, hearing screenings, fitting of hearing aids, prescriptions for hearing aid batteries, and other services as defined by the Agency of Human Services by rule. (Added 2021, No. 108 (Adj. Sess.), § 3, eff. May 11, 2022.)
2023 Vermont Statutes › Title 33 - Human Services › Chapter 19 - Medical Assistance › § 1901l. Medication for opioid use disorder

§ 1901l. Medication for opioid use disorder
(a) The Agency of Human Services shall provide coverage to Medicaid beneficiaries for medically necessary medication for opioid use disorder when prescribed by a health care professional practicing within the scope of the professional’s license and participating in the Medicaid program.
(b) Pending approval of the Drug Utilization Review Board, the Agency shall cover at least one medication in each therapeutic class for methadone, buprenorphine, and naltrexone as listed on Medicaid’s preferred drug list without requiring prior authorization. (Added 2023, No. 22, § 7, eff. September 1, 2023.)
2023 Vermont Statutes › Title 33 - Human Services › Chapter 19 - Medical Assistance › § 1902. Qualification for medical assistance

§ 1902. Qualification for medical assistance
(a) In determining whether a person is medically indigent, the Secretary of Human Services shall prescribe and use an income standard and requirements for eligibility that will permit the receipt of federal matching funds under Title XIX of the Social Security Act.
(b) Workers with disabilities whose income is less than 250 percent of the federal poverty level shall be eligible for Medicaid. The income also must not exceed the Medicaid protected income level for one or the Supplemental Security Income (SSI) payment level for two, whichever is higher, after disregarding the earnings of the working individual with disabilities; Social Security disability insurance benefits, including Social Security retirement benefits converted automatically from Social Security Disability Insurance (SSDI), if applicable; any veteran’s disability benefits; and, if the working individual with disabilities is married, all income of the spouse. Earnings of the working individual with disabilities shall be documented by evidence of Federal Insurance Contributions Act tax payments, Self-Employment Contributions Act tax payments, or a written business plan approved and supported by a third-party investor or funding source. The resource limit for this program shall be $10,000.00 for an individual and $15,000.00 for a couple at the time of enrollment in the program. Assets attributable to earnings made after enrollment in the program shall be disregarded. (Added 1967, No. 147, § 6; amended 1987, No. 89, § 314b; 2005, No. 56, § 4, eff. June 13, 2005; 2015, No. 157 (Adj. Sess.), § G.1, eff. June 2, 2016; 2017, No. 210 (Adj. Sess.), § 1, eff. June 1, 2018.)
2023 Vermont Statutes › Title 33 - Human Services › Chapter 19 - Medical Assistance › § 1902a. Confidentiality of Medicaid applications and records; disclosure to authorized representative

§ 1902a. Confidentiality of Medicaid applications and records; disclosure to authorized representative
(a) All applications submitted and records created under the authority of this chapter concerning any applicant for or recipient of Medicaid are confidential and shall be made available only to persons authorized by the Agency, the State, or the United States for purposes directly related to plan administration. In addition, the Agency shall maintain a process to allow a Medicaid applicant or recipient or his or her authorized representative to have access to confidential information when necessary for an eligibility determination and the appeals process.
(b) Applications and records considered confidential are those that disclose one or more of the following:
(1) the name and address of the applicant or recipient;
(2) medical services provided;
(3) the applicant’s or recipient’s social and economic circumstances;
(4) the Agency’s evaluation of personal information;
(5) medical data, including diagnosis and past history of disease or disability; or
(6) any information received for the purpose of verifying income eligibility and determining the amount of medical assistance payments.
(c) A person found to have violated this section may be assessed an administrative penalty of not more than $1,000.00 for a first violation and not more than $2,000.00 for any subsequent violation.
(d) As used in this section:
(1) “Authorized representative” means any person designated by a Medicaid applicant or recipient to review confidential information about the Medicaid applicant or recipient pertaining to the eligibility determination and the appeals process.
(2) “Purposes directly related to plan administration” include establishing eligibility, determining the amount of medical assistance, providing services to recipients, conducting or assisting with an investigation or prosecution, and civil or criminal proceedings, or audits, related to the administration of the State Medicaid program. (Added 2015, No. 172 (Adj. Sess.), § E.306.9; amended 2019, No. 15, § 2, eff. May 6, 2019.)
2023 Vermont Statutes › Title 33 - Human Services › Chapter 19 - Medical Assistance › § 1903. Contract authorized

§ 1903. Contract authorized
(a) The Commissioner of Vermont Health Access may contract with a private organization to operate, under his or her control and supervision, parts of the medical assistance program.
(b) The contract shall provide that either party may cancel it upon reasonable notice to the other party.
(c) In furtherance of the purposes of the contract, the Commissioner of Vermont Health Access may requisition funds for the purposes of this subchapter, with the approval of the Governor, and the Commissioner of Finance and Management shall issue a warrant in favor of the contracting party to permit the contracting party to make payments to vendors under the contract. The Commissioner of Vermont Health Access shall quarterly, and at other times as the Commissioner of Finance and Management requires, render an account in a form as the Commissioner of Finance and Management prescribes of the expenditures of monies so advanced. (Added 1967, No. 147, § 6; amended 1983, No. 195 (Adj. Sess.), § 5; 2005, No. 174 (Adj. Sess.), § 96; 2009, No. 156 (Adj. Sess.), § I.47.)
2023 Vermont Statutes › Title 33 - Human Services › Chapter 19 - Medical Assistance › § 1903a. Care management program

§ 1903a. Care management program
(a) The Commissioner of Vermont Health Access shall coordinate with the Director of the Blueprint for Health to provide chronic care management through the Blueprint and, as appropriate, create an additional level of care coordination for individuals with one or more chronic conditions who are enrolled in Medicaid or Dr. Dynasaur. The program shall not include individuals who are in an institute for mental disease as defined in 42 C.F.R. § 435.1009.
(b) The Commissioner shall include individuals with a broad range of chronic conditions in the Blueprint for Health and the care management program. (Added 2005, No. 191 (Adj. Sess.), § 6; amended 2007, No. 70, §§ 22, 23; 2009, No. 146 (Adj. Sess.), § C33; 2013, No. 79, § 24, eff. Jan. 1, 2014.)
2023 Vermont Statutes › Title 33 - Human Services › Chapter 19 - Medical Assistance › § 1905. Disproportionate share program

§ 1905. Disproportionate share program
The Secretary of Human Services shall adopt a disproportionate share program for hospitals consistent with the requirements of Title XIX of the Social Security Act. (Added 1991, No. 253 (Adj. Sess.), § 10.)
2023 Vermont Statutes › Title 33 - Human Services › Chapter 19 - Medical Assistance › § 1905a. Medicaid reimbursements to certain outpatient providers

§ 1905a. Medicaid reimbursements to certain outpatient providers
(a) To the extent permitted under federal law, the Department of Vermont Health Access shall not use provider-based billing for outpatient medical services provided at an off-campus outpatient department of a hospital as a result of the provider’s transfer to or acquisition by the hospital.
(b) As used in this section, “off-campus” means a facility located more than 250 yards from the main hospital campus. (Added 2015, No. 143 (Adj. Sess.), § 3.)
2023 Vermont Statutes › Title 33 - Human Services › Chapter 19 - Medical Assistance › § 1906. Recoupment of amounts spent on child medical care

§ 1906. Recoupment of amounts spent on child medical care
(a) The State Medicaid agency, any State agency administering health benefits or a health benefit plan for which Medicaid is a source of funding, or the Office of Child Support may recoup the amounts paid by the State for child medical expenses from any person who is required by court or administrative order to provide coverage of the cost of health services to a child eligible for medical assistance under Medicaid; and who either:
(1) Has received payment from a third party for the costs of such services, but has not used the payments to reimburse either the other parent or guardian of the child or the provider of the services. Claims for current and past due child support shall take priority over these claims.
(2) Has failed to give any notice required by 15 V.S.A. § 663(d).
(b) In addition to any other remedies available at law, all remedies available for the collection and enforcement of child support under 15 V.S.A. chapter 11 shall apply to medical support recoupment under this section. (Added 1993, No. 231 (Adj. Sess.), § 4; amended 2015, No. 23, § 56.)
2023 Vermont Statutes › Title 33 - Human Services › Chapter 19 - Medical Assistance › § 1906a. Recovery against estate; homestead exemptions

§ 1906a. Recovery against estate; homestead exemptions
No recovery of medical expenses shall be made under this subchapter against a homestead, provided that the homestead would pass to one or more lineal heirs or siblings of the decedent who either have income below 300 percent of the federal poverty level or who have contributed significantly, monetarily or otherwise, to the decedent so as to allow the decedent to delay or avoid nursing home placement. If a maximum homestead value exemption is allowed by federal law, then any recoveries due to the U.S. Department of Health and Human Services on homesteads valued between such maximum and $125,000.00 shall be paid through State general funds provided the caregiving or poverty standards set forth in this section are also met and the probate estate was opened after June 30, 2000. (Added 1999, No. 62, § 125; amended 1999, No. 152 (Adj. Sess.), § 117a, eff. May 29, 2000; 2013, No. 131 (Adj. Sess.), § 42, eff. May 20, 2014.)
2023 Vermont Statutes › Title 33 - Human Services › Chapter 19 - Medical Assistance › § 1907. Subrogation

§ 1907. Subrogation
To the extent that payment for covered expenses has been made under the Medicaid program or through any State agency administering health benefits or a health benefit plan for which Medicaid is a source of funding for health care items or services furnished to an individual, in any case where a third party has a legal liability to make payments, the State is considered to have acquired the rights of the individual to payment by any other party for those health care items or services. An insurer shall accept the Agency’s right to recovery and the assignment to the Agency of any right of a person to payment from the third party for medical services for which the Agency has made payment under this chapter. (Added 1993, No. 231 (Adj. Sess.), § 5; amended 2007, No. 65, § 110b; 2013, No. 131 (Adj. Sess.), § 43, eff. May 20, 2014.)
2023 Vermont Statutes › Title 33 - Human Services › Chapter 19 - Medical Assistance › § 1909. Direct payments to Agency; discharge of insurer’s obligation

§ 1909. Direct payments to Agency; discharge of insurer’s obligation
(a) When a recipient who is covered by the recipient’s or a legally liable representative’s insurer receives medical benefits under this subchapter, payment for covered services or notice of denial shall be issued directly to the provider.
(b) A provider shall indicate on any claim form submitted to an insurer for covered services whether or not the person receiving treatment is a recipient.
(c)(1) An insurer that receives notice that the Agency has made payments to the provider shall pay benefits or send notice of denial directly to the Agency. Receipt of an Agency claim form by an insurer constitutes notice that payment of the claim was made by the Agency to the provider and that form supersedes any contract requirements of the insurer relating to the form of submission.
(2) An insurer shall respond to any request made by the Agency regarding a claim for payment for any health care item or service that is submitted not later than three years after the date of the provision of such health care item or service.
(3) An insurer shall not:
(A) deny a claim submitted by the Agency solely on the basis of the date of submission of the claim, the type or format of the claim form, or a failure to present proper documentation at the point-of-sale that is the basis of the claim, if the claim is submitted by the Agency within the three-year period beginning on the date on which the item or service was furnished and any action by the Agency to enforce its rights with respect to a claim is commenced within six years following the Agency’s submission of the claim; or
(B) deny a claim submitted by the Agency on the basis of failing to obtain a prior authorization for the item or service for which the claim is being submitted, if the Agency has transmitted authorization that the item or service is covered by the Medicaid state plan or waiver under subdivision 1908(d)(2) of this title.
(d) An insurer that has been notified of a claim by the Agency under this section and proceeds to pay the claim to a person other than the Agency is not discharged from payment of the Agency’s claim.
(e) Payment to the Agency by an insurer under this section discharges the insurer’s obligation for further payment on the claim to the extent of the amount paid. (Added 1995, No. 152 (Adj. Sess.), § 3; amended 2007, No. 65, § 110d; 2023, No. 51, § 2, eff. July 1, 2023.)