Code of Vermont Rules › Agency 13 - AGENCY OF HUMAN SERVICES › Sub-Agency 170 - DEPARTMENT FOR CHILDREN AND FAMILIES (DCF) › Chapter 590 - PREMIUM ASSISTANCE (5900) › Section 13 170 590 - PREMIUM ASSISTANCE (5900)

Current through June, 2024
Section 5900 Premium Assistance
In 2006, the Vermont Legislature enacted Act 191, An Act
				  Relating to Health Care Affordability for Vermonters. Among other things, the
				  new law created four new health-care programs, designed to expand Vermonters'
				  access to quality, affordable health care. These programs are targeted at those
				  with incomes that exceed the traditional Medicaid limits. Eligibility is based
				  upon a variety of factors, including income, insurance status, the availability
				  of an approved employer-sponsored insurance (ESI) plan, and the relative cost
				  to the state of the individual's enrollment in the various programs. The
				  initiatives include:
Employer-Sponsored Insurance Premium-Assistance Program for
				  VHAP-Eligible Individuals (VHAP-ESIA). This is a premium-assistance program for
				  adults who are eligible for the Vermont Health Access Plan (VHAP) and who have
				  access to an approved ESI plan. VHAP-eligible individuals will be required to
				  participate in this program when the department determines that enrollment is
				  cost-effective to the state. VHAP-ESIA subsidizes the employee's premium
				  through a monthly payment. VHAP-ESIA also covers any required wraparound
				  services, and certain cost-sharing obligations. It provides the same coverage
				  that is available through VHAP, at the same cost to the beneficiary.
Employer-Sponsored Insurance Premium-Assistance Program for
				  Uninsured Individuals (Catamount-ESIA). This is a premium-assistance program
				  for adults who are uninsured and not eligible for VHAP and who have access to
				  an approved ESI plan. This program offers financial assistance through a
				  monthly payment for the purchase of ESI plans. It is available to uninsured
				  Vermont residents with incomes at or below 300 percent of the federal poverty
				  level (FPL) who are not eligible for VHAP-ESIA. In addition to a subsidy to
				  defray the employee's premium, Catamount-ESIA covers some chronic-care
				  cost-sharing.
Catamount Health Premium Assistance Program (CHAP). This is a
				  premium-assistance program for adults who are uninsured and not eligible for
				  VHAP and who do not have access to an approved ESI plan. This program offers
				  financial assistance for the purchase of a Catamount Health policy. Individuals
				  send their portion of the monthly premium to the state. The state then pays the
				  cost of the Catamount Health plan to the insurance company. CHAP is available
				  to Vermont residents with incomes at or below 300 percent of the FPL who are
				  uninsured and who are not eligible for a public insurance program.
Catamount Health (CH). A separate insurance pool, offering a
				  health-insurance product for uninsured Vermonters. Catamount policies provide
				  comprehensive benefit plans. They are modeled after a preferred-provider
				  organization plan with a $ 250 deductible. For those who are participating in a
				  chronic-care management program, cost sharing is not required for chronic-care
				  management and preventive services.
The department does not administer CH and these rules do not
				  address that program. However, in partnership with the Office of Vermont Health
				  Access (OVHA), the department determines eligibility for CHAP, as well as two
				  ESIA programs.
Section 5901
				Definitions
(a) Approved employer-sponsored
				insurance (ESI). An ESI plan that meets the coverage criteria established in
				subsection 4103.6 below.
(b)
				Available ESI plan. An ESI plan that the employee may enroll in within ninety
				days.
(c) "Chronic care" means
				health services provided by a health care professional for an established
				clinical condition that is expected to last a year or more and that requires
				ongoing clinical management attempting to restore the individual to highest
				function, minimize the negative effects of the condition, and prevent
				complications related to chronic conditions. Examples of chronic conditions
				include diabetes, hypertension, cardiovascular disease, cancer, asthma,
				pulmonary disease, substance abuse, mental illness, spinal cord injury, and
				hyperlipidemia. Chronic care includes any day-to-day monitoring, treatment, and
				therapy of chronic conditions. This includes consultations by any health-care
				professionals, medication, investigations (blood tests, radiology) etc.
				Excluded from chronic care is the treatment of acute complications related to
				chronic conditions unless such treatment is specified in the blueprint for
				health, as provided in 4106.2(c).
(d) Cost-effective. The program option that
				is the least costly to the state. The methodology for determining
				cost-effectiveness is described in subsection 4103.7 below.
(e) Cost sharing. Any health-care
				co-payments, deductibles, or co-insurance that an individual or family is
				required to pay, in addition to a premium.
(f) Employee. The applicant or a member of
				the applicant household who is eligible to enroll in ESI (irrespective of VHAP
				eligibility). "Employee" includes a retiree who is eligible to enroll in an ESI
				plan that is offered to the retiree by a former employer.
(g) Employee's share of the premium. The
				monthly portion of the ESI premium that is charged to the employee, before
				receipt of premium assistance.
(h)
				Employer-sponsored insurance (ESI). Health insurance or a group health plan
				offered to employees and retirees by an employer.
(i) Premium assistance. Financial assistance
				that is provided for the purchase of health insurance offered under an approved
				ESI plan or a CH plan.
(j) Premium
				balance. The monthly portion of the premium that the employee or individual is
				responsible for, after receipt of premium assistance.
(k) Resident. An individual who lives in
				Vermont with the intent to remain in the state permanently or for an indefinite
				period of time.
(l) Uninsured. An
				individual who does not qualify for Medicare, Medicaid, VHAP, or Dr. Dynasaur
				and had no private insurance or employer-sponsored coverage that includes both
				hospital and physician services within twelve months prior to the month of
				application, or lost private insurance or employer-sponsored coverage during
				the prior twelve months for any of the following reasons:
(1) The individual's private insurance or
				employer-sponsored coverage ended because of:
(i) Loss of employment, including a reduction
				in hours that results in ineligibility for employer-sponsored coverage, unless
				the employer has terminated its employees or reduced their hours for the
				primary purpose of discontinuing employer-sponsored coverage and establishing
				their eligibility for CH;
(ii)
				Death of the principal insurance policy holder;
(iii) Divorce or dissolution of a civil
				union;
(iv) No longer receiving
				coverage as a dependent under the plan of a parent or caretaker
				relative;
(v) No longer receiving
				COBRA, VIPER, or other state continuation coverage.
(2) College- or university-sponsored health
				insurance became unavailable to the individual because the individual
				graduated, took a leave of absence, decreased enrollment below a threshold set
				for continued coverage, or otherwise terminated studies.
(3)
(i) The
				individual lost health insurance as a result of domestic violence. The
				individual shall provide the agency of human services with satisfactory
				documentation of the domestic violence. The documentation may include a sworn
				statement from the individual attesting to the abuse, law enforcement or court
				records, or other documentation from an attorney or legal advisor, member of
				the clergy, or health care provider, as defined in section
				9402 of
				Title 18. Information relating to the domestic violence, including the
				individual's statement and corroborating evidence, provided to the agency shall
				not be disclosed by the agency unless the individual has signed a consent to
				disclose form. In the event the agency is legally required to release this
				information without consent of the individual, the agency shall notify the
				individual at the time the notice or request for release of information is
				received by the agency and prior to releasing the requested
				information.
(ii) Subdivision (i)
				of this subdivision (3) shall take effect upon issuance by the Centers for
				Medicare and Medicaid Services of approval of an amendment to the Global
				Commitment for Health Medicaid Section 1115 Waiver allowing for a domestic
				violence exception to the Catamount Health premium assistance waiting
				period.
(m)
				Wraparound services or coverage. Any health-care services not included in an
				approved ESI plan, or any cost sharing the ESI plan imposes, that the state is
				obligated to pay for. (See sub sections 4105.3 and 4106.2 below.)