Code of Vermont Rules › Agency 13 - AGENCY OF HUMAN SERVICES › Sub-Agency 170 - DEPARTMENT FOR CHILDREN AND FAMILIES (DCF) › Chapter 780 - IMMIGRANT HEALTH INSURANCE PLAN › Section 13 170 780 - IMMIGRANT HEALTH INSURANCE PLAN

Current through June, 2024
Section 1.00 General Provisions.
The Agency of Human Services (AHS) is the adopting authority
				  for the Immigrant Health Insurance Plan administrative rule. The Immigrant
				  Health Insurance Plan was enacted by the Vermont General Assembly in Act 48 of
				  2021 and is codified in state statute at 33 V.S.A. chapter 19, subchapter
				  9.
The Immigrant Health Insurance Plan was created to establish
				  Dr. Dynasaur-like coverage for certain Vermont residents (children under 19
				  years of age and pregnant individuals) who have an immigration status for which
				  Medicaid coverage is not available, including migrant workers who are employed
				  in seasonal occupations in Vermont, and who are otherwise uninsured.
This Immigrant Health Insurance Plan rule refers to other
				  Agency of Human Services' administrative rules in some sections to best align
				  the Immigrant Health Insurance Plan with the Dr. Dynasaur program. There are
				  two bodies of rules referenced:
Health Benefits Eligibility and Enrollment (HBEE) Rules - The
				  HBEE rules provide the eligibility standards for Medicaid and other health care
				  programs in Vermont.
Health Care Administrative Rules (HCAR) - HCAR is the
				  collection of regulations adopted by the Agency of Human Services that govern
				  the administration of Vermont Medicaid, including general provisions,
				  eligibility, benefit delivery, covered services, reimbursement, specialized
				  services, beneficiary rights, and provider responsibilities.
Current HCAR and HBEE adopted rules can be found on the
				  Agency of Human Services' website.
Section 2.00 Definitions.
As used in this rule, the following terms are used as defined
				  below:
Alternate reporter means a person who is authorized to
				  receive original notices or copies of notices on behalf on an
				  individual.
Applicant means an individual seeking eligibility for
				  Immigrant Health Insurance Plan health benefits for themselves through an
				  application submission.
Application means a non-Medicaid application for Immigrant
				  Health Insurance Plan health benefits, submitted by or on behalf of an
				  applicant to determine eligibility, or, for an individual who applies for the
				  Immigrant Health Insurance Plan by completing an application for Vermont
				  Medicaid and being approved for Medicaid coverage of emergency medical
				  conditions only (pursuant to HBEE § 17.02(d)), it means the Vermont
				  Medicaid application.
Application date means the day the application is received by
				  AHS, if it is received on a business day; or the first business day after the
				  application is received, if it is received on a day other than a business
				  day.
Assister Program means the professionals who are trained and
				  certified by the Department of Vermont Health Access to help Vermont residents
				  enroll and maintain health coverage through Vermont's state- based health
				  insurance marketplace, Medicaid, or other state health care programs.
Authorized representative means 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.
Case record means the permanent collection of documents and
				  information required to process eligibility.
Categorical eligibility criteria means the age or pregnancy
				  status that an individual must have to be eligible for the Immigrant Health
				  Insurance Plan.
Child means an individual under 19 years of age.
Electronic account means an electronic file that includes all
				  information collected and generated regarding each individual's health benefit
				  eligibility, including all required documents and information collected or
				  generated as part of the State fair hearing process conducted with regard to
				  health benefits eligibility and enrollment.
Eligibility decision or determination means an approval,
				  denial, or termination of eligibility.
Eligible means the status of an individual determined to meet
				  all financial, nonfinancial, and categorical requirements for a health benefits
				  program.
Enrollee means an individual who has been approved for
				  benefits under the Immigrant Health Insurance Plan.
Federal poverty level (FPL) means 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 period of time used to determine an individual's
				  income eligibility for health benefits.
Human Services Board means AHS's fair hearings entity for
				  Immigrant Health Insurance Plan appeals.
In an institution refers to an individual who is admitted to
				  live in an institution and receive treatment or services provided there.
Individual means an applicant or enrollee for Immigrant
				  Health Insurance Plan health benefits.
Institution means, for purposes of Section 5.00 of this rule,
				  the same as the definition of institution and medical institution in
				  42 CFR §
											435.1010. For purposes of an out of state
				  placement in an institution, the term also includes foster care homes, as set
				  forth in
				  45
				  CFR §
											1355.20, that provide food,
				  shelter and supportive services to one or more persons unrelated to the
				  proprietor. For purposes of subsection 6.03 of this rule, institution means an
				  establishment that furnishes food, shelter, and some treatment or services to
				  four or more individuals unrelated to the proprietor.
Interpreter means a person who orally translates for an
				  individual who has limited English proficiency or an impairment.
Limited English proficiency means 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 services and supports means services and supports
				  provided to individuals of all ages who have functional limitations and/or
				  chronic illnesses that have the primary purpose of supporting the ability of
				  the individual to live or work in the setting of their choice, which may
				  include the individual's home, a worksite, a provider-owned or controlled
				  residential setting, a nursing facility, or other institutional setting,
				  including medically complex nursing care or assistance with activities of daily
				  living (such as eating, bathing, dressing, preparing meals, and managing
				  medication).
Medicaid means the medical assistance provided under the
				  State Plan approved under Title XIX of the Social Security Act, and the terms
				  and conditions of the Global Commitment to Health Waiver, as approved by the
				  Centers for Medicare & Medicaid Services, that are administered by AHS in
				  Vermont.
Medicaid applicants means an individual seeking eligibility
				  for health benefits authorized in Title XIX of the Social Security Act for
				  themselves through an application submission.
Medicaid enrollees means an individual who has been approved
				  and is currently receiving health benefits authorized in Title XIX of the
				  Social Security Act.
Minimum Essential Coverage means 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 as provided in
				  42 C.F.R. §
											435.4.
Modified Adjusted Gross Income (MAGI) has the same meaning as
				  defined in HBEE § 28.02(b) for Medicaid applicants and enrollees.
MAGI-based income is defined in subsection 6.02(b) of this
				  rule.
Plain language means language that the intended audience,
				  including individuals with limited English proficiency, can readily understand
				  and use because the language is concise, well-organized, and follows other best
				  practices of plain language writing.
Pregnant person means an individual during pregnancy and the
				  post partum period. The post partum period shall have the same meaning as
				  defined in HBEE § 7.03(a)(2) for Medicaid applicants and enrollees.
Quality control means a system of continuing review to
				  measure the accuracy of eligibility decisions. It is also the name of the AHS
				  unit that is responsible for administering quality control measures.
Redetermination means to determine eligibility following a
				  change of circumstance, or to determine eligibility as a result of a State fair
				  hearing request before the request is sent to the Human Services Board.
Renew means to determine eligibility again at a specified
				  periodic interval (e.g., annual renewal of eligibility).
Third party means any person, entity, or program that is or
				  may be responsible to pay all or part of the expenditure for another person's
				  medical benefits.
Uninsured means to lack minimum essential coverage including
				  under government sponsored programs (e.g., Medicaid, Medicare), employer
				  sponsored plans, individual health plans, and other health benefits coverage
				  (e.g., Refugee Medical Assistance).
Section 3.00 Rights and responsibilities,
				authorized representatives, accessibility and nondiscrimination, AHS
				assistance, case records, privacy, quality control, and fraud.
3.01 Rights of applicants and enrollees
(a) Notice of rights and responsibilities.
				AHS will provide individuals with information about their rights and
				responsibilities at the time of their application and subsequent reviews of
				eligibility.
(b) Right to
				nondiscrimination and equal treatment. AHS will not unlawfully discriminate on
				the basis of race, color, religion, national origin, disability, age, sex,
				gender identity, or sexual orientation in the administration of the Immigrant
				Health Insurance Plan.
(c) Right to
				confidentiality.
(1) AHS will not make any
				information regarding applicants and enrollees of the Immigrant Health
				Insurance Plan available to the United States government.
(2) All applications submitted and records
				received or created concerning any applicant for or enrollee of the Immigrant
				Health Insurance Plan:
(i) Are protected in
				accordance with federal and state laws regarding confidentiality, privacy,
				disclosure, and personally identifiable information, and
(ii) Will be made available only to persons
				authorized by AHS, by the State of Vermont, or by the United States government
				for purposes directly connected with the administration of the Immigrant Health
				Insurance Plan or as otherwise required by law.
(A) "Purposes directly connected with the
				administration of the Immigrant Health Insurance Plan" includes establishing
				eligibility, determining the amount of medical assistance, providing services
				to the individual, conducting or assisting with an investigation or
				prosecution, and civil or criminal proceedings, or audits, related to the
				administration of the Immigrant Health Insurance Plan.
(d) Right to timely
				eligibility decision on application. Applicants for the Immigrant Health
				Insurance Plan have the right to the timely decision on their application, as
				defined in subsection 7.02(h) of this rule.
(e) Right to information. Individuals who
				inquire about the Immigrant Health Insurance Plan have the right to receive
				information about eligibility, services, and the rights and responsibilities of
				program enrollees.
(f) Right to
				apply. 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 Immigrant Health Insurance Plan.
(g) Right to be assisted by others.
(1) The individual has the right to be:
(i) represented by a legal representative,
				and
(ii) accompanied and
				represented by an authorized representative during the eligibility or appeal
				processes.
(2) Upon
				request by the individual, copies of all eligibility notices and all documents
				related to the eligibility or appeal process will be provided to the
				individual's authorized or legal representative.
(h) Right to inspect the case file. An
				individual has the right to inspect information in their case file and contest
				the accuracy of the information.
(i) Right to appeal. An individual has right
				to appeal, as provided in Section 9.00 of this rule.
(j) Right to interpreter services.
				Individuals will be informed of the availability of interpreter services.
				Unless the individual chooses to provide their own interpreter services, AHS
				will provide telephonic or other interpreter services whenever:
(1) The individual who is seeking assistance
				has limited English proficiency or sensory impairment (for example, a seeing or
				hearing disability) and requests interpreter services, or
(2) AHS determines that such services are
				necessary.
(l) Right to
				information about Medicaid application. An individual who reports to AHS that
				they are pregnant has the right to be informed that, if they apply for and are
				determined eligible for Medicaid (including pursuant to HBEE § 17.02(d))
				their child will be deemed to have applied and been determined eligible for
				Medicaid effective as of the date of birth, provided the child's mother was
				eligible for and received covered services under Medicaid on that date
				(regardless of whether payment for services for the mother is limited to those
				defined in HBEE § 17.02(d)), and that the child will remain eligible for
				Medicaid until they reach age one regardless of changes in circumstances
				(except if the child dies or ceases to be resident of the state or the child's
				representative requests a voluntary termination of the child's
				eligibility).