Code of Vermont Rules › Agency 13 - AGENCY OF HUMAN SERVICES › Sub-Agency 170 - DEPARTMENT FOR CHILDREN AND FAMILIES (DCF) › Chapter 420 - MEDICAID, AGED, BLIND, AND DISABLED (4200) › Section 13 170 420 - MEDICAID, AGED, BLIND, AND DISABLED (4200)

Current through June, 2024
Section 4200
				Medicaid, Aged, Blind, and Disabled
Individuals who are aged, blind, or disabled (M211) are
				  eligible for Medicaid if they meet the financial and nonfinancial requirements
				  for participation in the Medicaid program. Financial requirements (M220-M223)
				  relate to the availability of resources (M230-M239) and income (M240-M249).
				  Nonfinancial requirements include general requirements for Medicaid
				  participation (M100-M199), the criteria for one of the coverage groups
				  identified in M200. 2-M200. 4, citizenship (M170, M212), Vermont residency
				  (M213), and living arrangement (M214). The coverage groups include the
				  categorically needy groups described beginning with rule M200.2, the medically
				  needy group described at rule M200.3, and the Medicare cost-sharing groups
				  described beginning with rule M200.4.
Section 4201 Definitions
This section defines terms used throughout M200-M299.
(a) Community Medicaid means Medicaid
				services other than long-term care.
(b) Community spouse (CS) means the spouse of
				an institutionalized individual who is not living in a medical institution or a
				nursing facility. A person is considered a community spouse even when receiving
				waiver services if that person is the spouse of an individual who is receiving
				long-term care.
(c) Coverage group
				refers to individuals who meet the specific financial and nonfinancial
				requirements of eligibility for Medicaid payment of particular medical
				services.
(d) Financial
				responsibility group means the people whose income and resources are considered
				when determining eligibility for a Medicaid group.
(e) Institutionalized individual means a
				person requesting Medicaid coverage for long-term care, whether the care is
				received at home in the community pursuant to a waiver or in a long-term care
				facility licensed by the Department of Disabilities, Aging and Independent
				Living.
(f) Institutionalized
				spouse (IS) means an institutionalized individual whose spouse qualifies as a
				community spouse.
(g) Long-term
				care means highest need and high need care, as determined by the licensing
				division of the Department of Disabilities, Aging and Independent Living
				received by people living in nursing facilities, rehabilitation centers,
				intermediate care facilities for the mentally retarded (ICF-MR), and other
				medical facilities for more than 30 consecutive days. It also includes waiver
				and hospice services.
(h) Medicaid
				group means one of two kinds of groups in SSI-related Medicaid: or spouses
				where at least one spouse is aged, blind or disabled, or an aged, blind or
				disabled individual with no spouse. 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.
(i) Medicaid services means medical services
				funded through Medicaid. They include Medicaid services (M500-M899), long-term
				care (M900-M999), and services defined in the Department for Disabilities,
				Aging and Independent Living Choices for Care regulations.
(j) SSI-related Medicaid means health care
				coverage available to members of the Medicaid group who are aged, blind, or
				disabled and pass financial and nonfinancial eligibility criteria for Medicaid.
				SSI-related Medicaid is based on 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).
(k) Waiver services means
				specialized medical services approved under an exception to standard Medicaid
				rules for a specific population.
It includes certain services administered by the Department
				  of Disabilities, Aging and Independent Living (DAIL):
. home-based and enhanced residential care services for the
				  aged and disabled (known as "Choices for Care"),
. traumatic brain injury services (TBI waiver), and
. home-and-community-based waiver services for the
				  developmentally disabled (DS waiver).
It also includes services administered by the Vermont
				  Department of Health's Division of Mental Health (VDH):
. children's mental health waiver services.
DCF determines financial and nonfinancial eligibility, other
				  than disability, for these services. DCF, through the disability determination
				  services unit determines whether individuals are blind or disabled according to
				  the criteria in rule M211. 2-M211.4, except as stated below.
(i) When DAIL administers the waiver
				services, it determines whether applicants need the level of care provided in a
				nursing facility, an intermediate care facility for the mentally retarded, or
				out-of-state rehabilitation facility qualified to serve persons with a
				traumatic brain injury. For the TBI and DS waivers, DAIL also determines
				whether applicants meet the disability criteria.
(ii) When VDH administers the waiver
				services, it determines whether, if waiver services were not available,
				children under age 22 need the level of care provided in an inpatient
				psychiatric facility for children.