Code of Vermont Rules › Agency 13 - AGENCY OF HUMAN SERVICES › Sub-Agency 001 - GENERAL; HEALTH BENEFITS ELIGIBILITY AND ENROLLMENT › Chapter 008 - PART EIGHT: STATE FAIR HEARINGS AND EXPEDITED ELIGIBILITY APPEALS › Section 13 001 008 - PART EIGHT: STATE FAIR HEARINGS AND EXPEDITED ELIGIBILITY APPEALS

Current through June, 2024
80.00 State Fair
				Hearings and Expedited Eligibility Appeals [1].
(01/01/2024, GCR 23-088)
80.01 Definitions [2]
(07/01/2019, GCR 18-126)
State fair hearing request.
A clear
				  expression, either orally or in writing, by an individual (applicant or
				  enrollee) to have any decision by AHS affecting the individual's eligibility or
				  level of benefits or services reviewed by the AHS Human Services Board.
State fair hearings entity.
The
				  Human Services Board, the body designated by law to hear State fair hearings of
				  eligibility determinations or redeterminations. AHS determines whether an
				  expedited eligibility appeal request meets the expedited appeal standard
				  pursuant to§
											80.07(b), and decides
				  expedited eligibility appeals for QHPs pursuant to §
											80.07(e).
80.02 Informing individuals of State fair
				hearing procedures [3]
(07/01/2019, GCR 18-126)
(a)
In
				general.
State fair hearings are processed in accordance
				with State fair hearing rules as promulgated by the Human Services Board
				pursuant to 3 VSA §
											3091 (b), and, in the case
				of an expedited State fair hearing, consistent with 3 VSA §
											3091(e)(3).
(b)
Requesting a State fair
				hearing.
An individual may submit a State 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 State fair hearing request. A State fair
				hearing request may be submitted by the individual, or, with the consent of the
				individual, their authorized representative as defined in §
											3.00, their legal counsel, a relative, a
				friend, or another spokesperson. The State fair hearing request process must
				comply with accessibility requirements in §
											5.01 (c). [4]
An individual, treating provider, or other person identified
				  at §
												80.02(b) may request an
				  expedited eligibility appeal by indicating that the time otherwise permitted
				  for a State fair hearing could jeopardize the individual's life or health or
				  ability to attain, maintain or regain maximum function. For the rule on
				  expedited eligibility appeals, see §
												80.07.
(c)
Notification of State
				fair hearing rights.
AHS will, at the times specified in
				§
											68.01(c), provide every
				individual in writing with an explanation of their State fair hearing rights as
				described in §
											68.01 (b)(2) and their
				right to request an expedited eligibility appeal pursuant to §
											80.07.
80.03 Right to a State fair hearing
(10/01/2021, GCR 20-005)
(a)
When a State fair
				hearing is required.
[5] AHS will grant an opportunity for
				a State fair 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 or decision by AHS has been taken
				erroneously. This includes, if applicable:
(1)
				A determination of the amount of medical expenses which must be incurred to
				establish Medicaid eligibility in accordance with §
												7.03(a)(8) or §
												8.06;
(2) A determination of income for the
				purposes of imposing Medicaid premiums and cost-sharing requirements;
(3) A determination for any month that an
				individual is ineligible for APTC because the individual is considered eligible
				for other MEC under §
												12.02(b) and §
												23.00. This includes, but is not limited
				to, determinations of affordability and minimum value for employer-sponsored
				plans;
(4) An initial determination
				of eligibility, including the amount of APTC, the Vermont Premium Reduction and
				level of federal or state CSR;
(5)
				A redetermination of eligibility, including the amount of APTC, the Vermont
				Premium Reduction and level of federal or state CSR;
(6) A failure by AHS to provide timely notice
				of a determination; and
(7) A
				determination of eligibility for a special enrollment period.
(b)
Exception:
				SSI enrollees.
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).
(c)
Exception: Mass
				changes.
There is no right to a State fair hearing or an
				expedited eligibility 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.
80.04 Request for a State fair
				hearing [6]
(07/01/2019, GCR 18-126)
(a)
Method for requesting a
				State fair hearing.
An individual, or an authorized
				representative on behalf of an individual, or a person identified at §
											80.02(b), may submit a
				State fair hearing request:
(1) By
				telephone;
(2) Via mail;
(3) In person;
(4) Through other commonly available
				electronic means; and
(5) Via the
				internet.
(b)
AHS's responsibilities related to a State fair hearing
				request.
[7] AHS will:
(1)
				Assist the individual making the State fair hearing request, if
				requested;
(2) Not limit or
				interfere with the individual's right to make a State fair hearing request;
				and
(3) Consider a State fair
				hearing request to be valid if it is submitted in accordance with §
												80.03 and paragraphs (a) and (c) of this
				subsection §
												80.04.
(4) Prior to referring an individual's
				request for a State fair hearing to the Human Services Board, AHS may take up
				to 15 days to review the individual's appeal, and if AHS determines that the
				individual is entitled to relief, AHS will grant the individual relief and will
				send the individual a new notice of decision if eligibility is
				redetermined.
(c)
Timely request.
An individual must
				request a fair hearing within 90 days from the date that notice of decision is
				sent by AHS (see §
											68.01).
(d)
Scope of State fair
				hearing request.
[8] 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.
80.05 AHS Secretary's decision and further
				appeal
(01/01/2024, GCR 23-088)
(a)
AHS Secretary's
				decision
[9]
(1) The
				Secretary of AHS will:
(i) Adopt the Human
				Services Board's decision or order, except that the Secretary may reverse or
				modify a decision or order of the Human Services Board if:
(A) The Human Services Board's findings of
				fact lack any support in the record; or
(B) The decision or order misinterprets or
				misapplies State or federal policy or rule.
(ii) Issue a written decision setting forth
				the legal, factual or policy basis for reversing or modifying a decision or
				order of the Human Services Board.
(2) An order of the Human Services Board will
				become the final and binding decision of AHS upon its approval by the
				Secretary. The Secretary will either approve, modify or reverse the Human
				Services Board's decision and order within 15 days of the date of the Human
				Services Board's decision and order. If the Secretary fails to issue a written
				decision within 15 days as required by this paragraph (a)(2), the Human
				Services Board's decision and order will be deemed to have been approved by the
				Secretary. The Secretary will approve, modify, or reverse a Human Services
				decision and order entered pursuant to §
												80.0 ?(f) within the timelines set forth in
				§
												80.07(f)(2).
(b)
Judicial review of AHS
				Secretary's decision.
[10]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.
(c)
HHS appeal
[11]
(1) An individual may make an appeal request
				to the HHS appeals entity within the time frame described in (2) of this
				paragraph (c) if the individual disagrees with the order of the Human Services
				Board or the AHS Secretary's reversal or modification, made pursuant to §
												80.05(a)(2), regarding:
(i) A determination for any month that an
				individual is ineligible for APTC because the individual is considered eligible
				for other MEC under §
													12.02(b) and §
													23.00. This includes, but is not limited
				to, determinations of affordability and minimum value for employer-sponsored
				plans;
(ii) An initial
				determination of eligibility, including the amount of APTC, the Vermont Premium
				Reduction and level of federal or state CSR;
(iii) A redetermination of eligibility,
				including the amount of APTC, the Vermont Premium Reduction and level of
				federal or state CSR; and
(iv) A
				failure by AHS to provide timely notice, as required by §
													68.02, in regard to the determinations
				described in (i) through (iii) above.
(2) An appeal request to the HHS appeals
				entity under (1) of this paragraph (c) must be made within 30 days of the date
				of the final and binding decision described in §
												80.05(a)(2). Such a
				request may be made at the same time or independent of judicial
				review.
(3) An individual who
				disagrees with the decision made by the HHS appeals entity may request review
				of the decision by the CMS Administrator. This administrative review process is
				described at 45 CFR §
													155.505(g).
80.06 Implementation of State fair hearing
				decisions [12]
(07/01/2019, GCR 18-126)
Upon receiving a final and binding decision as described in
				  §
											80.05(a)(2), AHS will
				  promptly implement the decision.
(a)
				In connection with a QHP decision:
(1)
				Implementation of the decision will be effective:
(i) Prospectively, on the first day of the
				month following the date of the notice, or consistent with §
													73.06 if applicable; or
(ii) Retroactively, to the coverage effective
				date the appellant did receive or would have received if the appellant had
				enrolled in coverage under the incorrect eligibility determination that is the
				subject of the appeal, at the option of the individual.
(2) AHS will redetermine the eligibility of
				household members who have not appealed their own eligibility determinations
				but whose eligibility may be affected by the State fair hearing
				decision.
(b) In
				connection with a Medicaid decision:
(1)
				Corrective payments. If the decision is favorable to the individual, corrective
				payments will be promptly made, retroactive to the date an incorrect action was
				taken; or
(2) If the decision is
				favorable to AHS:
(i) If the decision results
				in the individual's ineligibility, AHS will terminate continued coverage on the
				last day of the month in which AHS acts to implement the decision; or
(ii) If the decision results in a higher
				premium level, AHS will implement the higher premium level effective for the
				next monthly billing cycle following the decision.
80.07 Expedited
				eligibility appeals: expedited internal appeals and expedited State fair
				hearings [13]
(07/01/2019, GCR 18-126)
(a)
In
				general
(1)
Right to expedited eligibility appeal for health benefit
				applicants/enrollees.
Health benefit applicants and
				enrollees have a right to an expedited eligibility appeal, either through the
				internal appeal process (QHPs) or the State fair hearing process (Medicaid),
				when the individual has an immediate need for health services and taking the
				time otherwise permitted for a State fair hearing could jeopardize the
				individual's life or health or ability to attain, maintain or regain maximum
				function.
(i) QHPs. Individuals who request an
				expedited eligibility appeal related to a QHP through Vermont Health Connect
				have a right to an expedited internal appeal meeting, as described at §
													80.07(e).
(ii) Medicaid. Individuals who request an
				expedited eligibility appeal related to Medicaid have a right to an expedited
				State fair hearing, as described at §
													80.07(f).
(2)
Assistance.
AHS will assist the
				individual requesting the expedited eligibility appeal, if asked, and will not
				limit or interfere with the individual's right to appeal.
(3)
Independent
				Reviewer
(i) The person or
				persons deciding an individual's expedited eligibility appeal request on behalf
				of AHS will not have been involved with the unfavorable determination or other
				issue that is the subject of the appeal.
(ii) If it is determined that the expedited
				eligibility appeal request meets the criteria for such appeals, the person or
				persons hearing and deciding the expedited internal appeal or the expedited
				State fair hearing on behalf of AHS will not have been involved in the
				unfavorable determination or other issue that is the subject of the
				appeal.
(4)
Accessibility.
The processes set forth in
				this subsection will comply with the accessibility requirements in §
												5.01(c).
(b)
Requesting an expedited
				eligibility appeal
(1)
Who may request an expedited eligibility
				appeal.
An individual, and with the consent of the
				individual, the treating provider, or another person identified at §
												80.02(b) may request an
				expedited eligibility appeal.
(2)
How to request an expedited eligibility
				appeal.
A request for an expedited eligibility appeal may
				be made to AHS orally, in writing, or by any other method identified at §
												80.04(a).
(3)
When a State fair
				hearing request is considered an expedited eligibility appeal
				request.
AHS will consider a State fair hearing request as
				an expedited eligibility 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 State fair hearing could jeopardize the individual's life or health or
				ability to attain, maintain or regain maximum function.
(4)
Necessary
				information.
AHS wjll act promptly and in good faith to
				obtain the information necessary to resolve the expedited eligibility appeal
				request. "Necessary information" may include the opinion of the treating
				provider and the results of any face-to-face clinical evaluation or second
				opinion that may be required.
(5)
No punitive action.
AHS will not take any
				punitive action against a provider who requests an expedited eligibility appeal
				or supports an individual's request.
(c)
Denial of an expedited
				eligibility appeal request
(1)
Timing of notice of
				denial.
[14] If AHS denies a request for an expedited
				eligibility appeal because it does not meet the criteria at §
												80.07(a)(1), AHS will
				inform the individual as expeditiously as possible that the request does not
				meet the criteria for expedited eligibility appeals and that the appeal will be
				processed within the standard State fair hearing timeframe.
(2)
Telephonic
				notice.
AHS will promptly (as expeditiously as possible but
				not more than two (2) business days from the date of the individual's request
				for an expedited eligibility appeal made pursuant to §
												80.07(b)) provide
				telephonic notice of the denial of the request of the expedited eligibility
				appeal to the individual.
(3)
Written notice.
Telephonic notice to the
				individual will be followed with a written notice.
(4)
Content of denial
				notice.
[15]The denial notice will include:
(i) The reason for the denial;
(ii) An explanation that the appeal will
				continue to be processed within the standard fair hearing procedures and
				timeframe;
(iii) An explanation of
				the individual's rights under the State fair hearing process; and
(iv) Contact information for the Office of
				the Health Care Advocate.
(5)
No right to State fair
				hearing on denial.
A denial of a request for an expedited
				eligibility appeal is not an independent basis for review by the Human Services
				Board.
(d)
Approval of an expedited eligibility appeal
				request
(1)
Timing of notice of approval.
[16] If AHS
				determines that an individual's expedited eligibility appeal request meets the
				criteria for such appeals, AHS will inform the individual as expeditiously as
				possible that the request meets the criteria.
(i) Telephonic notice. AHS will promptly (as
				expeditiously as possible but not more than two (2) business days from the date
				of the individual's request for an expedited eligibility appeal) provide
				telephonic notice to the individual that AHS has approved the request for an
				expedited eligibility appeal.
(ii)
				Written notice. Telephonic notice to the individual will be followed with
				written notice. The notice is described at §
													80.07(e)(1)(i) and
				(f)(1)(i).
(e)
Expedited internal
				eligibility appeals (QHPs)
[17]
(1)
Procedures
(i) AHS will notify the individual of the
				following:
(A) The date and time of the
				meeting on the expedited eligibility appeal;
(B) The telephone number to call to
				participate in the meeting;
(C)
				Contact information for the Office of the Health Care Advocate; and
(D) The individual's rights during the
				expedited eligibility appeal process.
(ii) AHS will hold a meeting to decide the
				expedited eligibility appeal.
(iii)
				The individual will have the right to:
(A)
				Participate,
(B) Be accompanied and
				represented,
(C) Present oral and
				written evidence, and
(D) Present
				argument.
(iv) AHS will
				provide the individual with the opportunity to review the appeal record,
				including all documents and records considered by the decision-maker.
(v) AHS will consider the information used to
				determine the individual's eligibility as well as any additional relevant
				evidence presented during the course of the expedited appeal process, including
				at the appeal meeting.
(vi)
				Expedited eligibility appeals conducted under this subsection are not contested
				cases pursuant to 3 V.S.A. Chapter 25. The expedited internal appeal process,
				as described under this subsection, is not a fair hearing within the meaning of
				3 V.S.A. §
													3091. The decisions from expedited internal
				appeals have no precedential value.
(2)
Timeline for resolving
				expedited eligibility appeals
(i) AHS will hold a meeting and send notice
				of the written decision within seven (7) business days following the date the
				individual requests the expedited appeal.
(ii) AHS will send the written decision
				within the timeframes in 80.07(e)(2)(i) above except in unusual circumstances
				in which case AHS will send the written decision within no more than 21 days
				following the individual's expedited eligibility appeal request.
(A) Unusual circumstances mean AHS cannot
				reach a decision because the individual requests delay or fails to take a
				required action or there is administrative or other emergency beyond AHS's
				control. AHS must send the individual written notice of the reason for the
				delay.
(3)
Content of written notice of decision
(i) The written notice of decision will
				include:
(A) A statement of the decision,
				including a plain language description of the effect of the decision on the
				individual's eligibility;
(B) A
				summary of the facts relevant to the appeal;
(C) The legal basis, including the
				regulations, supporting the decision;
(D) The effective date of the
				decision;
(E) An explanation that
				the appeal will continue to be processed within the standard State fair hearing
				procedures and timeframe, unless the individual notifies the Human Services
				Board that the individual wishes to withdraw the request for a State fair
				hearing; and
(F) Contact
				information for the Office of the Health Care Advocate.
(f)
Expedited eligibility State fair hearings
				(Medicaid)
[18]
(1)
Procedures
(i) The Human Services Board will notify the
				individual of the following:
(A) The date and
				time of the hearing on the expedited eligibility appeal;
(B) The location of the hearing, if it will
				be held in person, or a description of how to participate by telephone, if the
				hearing will be held by phone;
(C)
				Contact information for the Office of the Health Care Advocate; and
(D) The individual's rights during the
				expedited eligibility appeal process, including the right: to review the appeal
				record, including all documents and records considered by the person deciding
				the expedited eligibility appeal; to participate in the hearing; to be
				accompanied or represented during the hearing; to present oral and written
				evidence; and to present argument.
(ii) The Human Services Board will conduct a
				hearing to decide the expedited eligibility appeal.
(A) The hearing will be recorded.
(B) The individual will have the right to:
(I) Participate,
(II) Be accompanied and
				represented,
(III) Present oral and
				written evidence, and
(IV) Present
				argument.
(iii)
				The individual will be provided an opportunity to review the appeal record,
				including all documents and records to be considered by the hearing officer, at
				a reasonable time before the date of the hearing and during the hearing.
				[19]
(iv) The Human Services Board
				will consider the information used to determine the individual's eligibility as
				well as any additional relevant evidence presented during the course of the
				appeal process, including at the hearing.
(2)
Timeline for resolving
				expedited eligibility appeals
(i) MCA: A final and binding decision or
				order will be sent to the individual as expeditiously as possible but not more
				than seven (7) business days following the date the individual requests the
				expedited eligibility appeal.
(ii)
				MABD and all long-term care Medicaid: A final and binding decision or order
				will be sent to the individual as expeditiously as possible following the date
				the individual requests the expedited eligibility appeal. [20]
(iii) A final and binding decision or order
				will be sent to the individual within the timeframes in §
													80.07(f)(2)(i) and (ii)
				above except in unusual circumstances.
(A)
				Unusual circumstances mean the Human Services Board cannot reach a decision
				because the individual requests delay or fails to take a required action or
				there is an administrative or other emergency beyond the Human Services Board's
				control. The Human Services Board must document the reason for delay in the
				individual's appeal record and send the individual written notice of the reason
				for the delay. [21]
(B) In no case
				will the Human Services Board send its decision to the individual more than 21
				days from the individual's request for an expedited State fair
				hearing.
(iv) If the U.S.
				Department of Health and Human Services (HHS) establishes a shorter timeframe
				for resolving expedited eligibility appeals, including the days available for
				extension, the Human Services Board will follow the timeframe established by
				HHS.
(3)
Content of written notice of decision
(i) The written notice will include:
(A) A statement of the decision, including a
				plain language description of the effect of the decision on the individual's
				eligibility;
(B) A summary of the
				facts relevant to the appeal;
(C)
				The legal basis, including the regulations, supporting the decision;
(D) The effective date of the decision;
				and
(E) Contact information for the
				Office of the Health Care Advocate.
(g)
Implementation of
				expedited internal appeal decisions and State fair hearing decisions or
				orders.
AHS will promptly implement expedited internal
				appeal decisions and expedited State fair hearing decisions or orders in
				accordance with the eligibility determination set forth in the decision or
				order.