Code of Vermont Rules › Agency 13 - AGENCY OF HUMAN SERVICES › Sub-Agency 170 - DEPARTMENT FOR CHILDREN AND FAMILIES (DCF) › Chapter 410 - MEDICAID PROGRAM (4100) › Section 13 170 410 - MEDICAID PROGRAM (4100)

Current through June, 2024
Section 4100 Medicaid Program
Medicaid is a federal-state program of financial help with
				  the cost of medical care. Vermont began participating in the Medicaid program
				  in 1967 to assist Vermont 's eligible low income individuals to gain access to
				  needed medical services. The federal funds come through Title XIX of the Social
				  Security Act. State funds are appropriated by the General Assembly. The
				  department determines eligibility for Medicaid in Vermont.
Medicaid covers most, but not all, medically necessary
				  medical care and services provided to eligible individuals (see sections
				  M500-M999 for covered services). In order to receive federal financial
				  participation in program expenditures, the state must provide coverage to
				  certain mandated categories of beneficiaries [
				  42 U.S.C. §
											1396 a(a)(10)(A) ] and offer specified
				  categories of medical services [
				  42 U.S.C. §
											1396 a(a)(10) ]. At state option, additional
				  categories of beneficiaries may be covered or services can be offered, for
				  which federal financial participation is also available. Services are provided
				  through fee-for-service and managed health care delivery systems as described
				  in section M103. The Vermont program covers all mandated categories of
				  beneficiaries. It also offers all mandatory services -- general hospital
				  inpatient; outpatient hospital and rural health clinics; other laboratory and
				  x-ray; nursing facility, EPSDT, and family planning services and supplies;
				  physician's services and medical and surgical services of a dentist; home
				  health services; and nurse-midwife and nurse practitioner services. Vermont
				  includes certain, but not all, optional categories of beneficiaries. Vermont
				  has also elected to cover certain, but not all, optional services for which
				  federal financial participation is available.
Vermont is authorized to establish reasonable standards,
				  consistent with the objectives of the Medicaid statute, for determining the
				  extent of coverage in the optional categories (
				  42 U.S.C. §
											1396 a(a)(17) ) based on such criteria as
				  medical necessity or utilization control (
				  42 C.F.R. §
											440.230(d) ). In
				  establishing such standards for coverage, Vermont must ensure that the amount,
				  duration, and scope of coverage are reasonably sufficient to achieve the
				  purpose of the service (
				  42 C.F.R. §
											440.230(b) ). Vermont may
				  not limit services based upon diagnosis, type or illness, or condition (
				  42 C.F.R. §
											440.230(c) ).
In order to obtain federal financial participation in the
				  Vermont program, a state plan must be filed with and approved by Health Care
				  Financing Administration (HCFA) (
				  42 U.S.C. §
											1396 a ). Among other things, the plan
				  describes the amount, duration and score of services included in the Vermont
				  program. Vermont is also required to have a state-wide management program to
				  control utilization and appropriateness of Medicaid services, based on such
				  criteria as medical necessity and the relative cost-effectiveness of covered
				  services [
				  42 U.S.C. §
											1396 a(a)(30)(A) ].
The scope of coverage for children under the Early Periodic
				  Screening, Diagnosis and Treatment (EPSDT) provisions or Title XIX is different
				  and more extensive than coverage for adults. The EPSDT provisions of Medicaid
				  law specify that services that are optional for adults are mandatory covered
				  services for all Medicaid-eligible children under age 21 when such services are
				  determined necessary as a result of an EPSDT screen. Specifically, Vermont is
				  required to provide
...such other necessary health care, diagnostic services,
				  treatment, and other measures described in subsection (a) of [1396d] to correct
				  or ameliorate defects and physical and mental illnesses and conditions
				  discovered by the screening services, whether or not such services are covered
				  under the State [Medicaid] plan.
				  42 U.S.C. §
											1396 d(r) (5).
A further definition of the scope of EPSDT services is found
				  in 42 C.F.R. § 1396 d(a)(13) which requires states to provide
other diagnostic, screening, preventive, and rehabilitative
				  services, including any medical or remedial services (provided in a facility,
				  home, or other setting) recommended by a physician or other licensed
				  professional of the healing arts within the scope of their practice under State
				  Law, for the maximum reduction of physical or mental disability and restoration
				  of an individual to the best functional level.
Medicaid is provided to pregnant women, individuals age 20 or
				  younger, parents or caretaker relatives of a dependent child, and aged, blind
				  or disabled individuals, as long as the individual meets general and financial
				  eligibility criteria and has, if required of him/her:
. assigned rights to any medical support and other payments
				  for medical care;
. cooperated with the department in establishing
				  paternity;
. enrolled in a group health plan if the department has
				  determined this would be cost-effective; and
. declared, under penalty of perjury, that he/she is a
				  citizen or national of the United States or a non-citizen qualified to
				  participate in the Medicaid program (see sections on Citizenship).
Most individuals who are eligible for and receiving
				  Supplemental Security Income (SSI/AABD) benefits or who meet the July 16, 1996.
				  ANFC rules are eligible for Medicaid as long as they meet the above
				  requirements, if applicable, and do not have a trust that places them over the
				  resource maximum.
Irrevocable trusts are not counted in the SSI program or
				  under the July 16, 1996. ANFC rules but must be counted in the Medicaid program
				  (see section on Trusts).
Individuals receiving essential person grants and the
				  essential persons for whom the state-funded AABD-EP benefits are paid are not
				  automatically eligible and must meet all eligibility criteria before being
				  granted Medicaid.
Section
				4101 Purpose - Medicaid Program
Medicaid was established as a result of amendments in 1965
				  that added Title XIX to the Social Security Act. It is a program administered
				  within a federal - state regulatory framework. The first statutory section of
				  Title XIX.
				  42 U.S.C. §
											1396. "Appropriation." states:
For the purpose of enabling each State, as far as
				  practicable, under the conditions in such State, to furnish (1) medical
				  assistance on behalf of families with dependent children and of aged, blind, or
				  disabled individuals, whose income and resources are insufficient to meet the
				  costs of necessary medical services, and (2) rehabilitation and other services
				  to help such families and beneficiaries attain or retain the capability for
				  independence and self-care, there is hereby authorized to be appropriated for
				  each fiscal year a sum sufficient to carry out the purposes of this subchapter.
				  The sums made available under this section shall be used for making payments to
				  States which have submitted, and had approved by the Secretary. State plans for
				  medical assistance.
Vermont 's State plan for medical assistance "must ...
				  include reasonable standards... for determining eligibility for and the extent
				  of medical assistance under the plan which ... are consistant with the
				  objectives" of Title XIX.
				  42 U.S.C. §
											1396 a(a)(17): Beal v. Doe. 432 U.S. 438. 444
				  (1977).
Section 4102
				Vermont Health Access Plan (VHAP)
The Vermont Health Access Plan (VHAP) operates as a Research
				  and Demonstration Project authorized under Section 1115(a) of the Social
				  Security Act. This program permits federal financial participation in health
				  benefit coverage to low-income, previously uninsured Vermont adults who do not
				  meet the Medicaid eligibility rules and pharmacy benefits to low-income elderly
				  or disabled adults who are eligible under the conditions of the waiver as
				  approved by HCFA. Under the terms of the waiver, coverage under this program is
				  not an entitlement in that the services covered are limited to those included
				  in the approved waiver program. VHAP beneficiaries do not have the same scope
				  of coverage as Medicaid beneficiaries as described in the state plan.
The department may, by rule, impose additional limitations on
				  coverage of services or items for expansion populations included in the waiver
				  for the effective and efficient administration of the program, consistent with
				  state and federal law and waiver terms and conditions.
Section 4103 VHAP Determination When Medicaid
				Closes
Individuals found no longer eligible for Medicaid shall have
				  their financial eligibility under the rules of the Vermont Health Access Plan
				  (VHAP) determined -before Medicaid is closed. An individual who meets the
				  financial eligibility criteria for VHAP shall be accepted in that program,
				  subject to program enrollment caps and shall have 30 days in which to pay any
				  required premium.
In areas where managed care is available, the individual
				  shall be contacted by the benefits counselor and enrolled in a managed health
				  care plan.
A delay in paying a required premium or in choosing a plan
				  could result in a gap between the date when Medicaid coverage ends and the date
				  when VHAP coverage begins.
Section
				4104 Quality Control Review
The main reason for quality control review is to be sure that
				  Medicaid rules are clear and consistently applied and that Medicaid applicants
				  and recipients can understand and give correct information for the eligibility
				  tests.
A random sample of active Medicaid recipients is chosen each
				  month for a full field review of their Medicaid eligibility. Each eligibility
				  factor must be verified with the recipient and collateral sources. If the
				  recipient refuses to cooperate in completing a quality control review, his or
				  her Medicaid benefits must be closed.
A similar sample of negative actions (denials, closures,
				  benefit decreases) is also chosen each month. These reviews do not usually
				  require a contact with the applicant or recipient, although the reviewer may
				  sometimes need to check facts with him or her.
When the quality control review shows different facts about
				  the individual's situation, the department must schedule an eligibility review
				  and take action to correct errors or review the effect of the changes.
Section 4105 Beneficiary Fraud
An individual who deliberately hides or omits information or
				  gives false information to get, or help another person to get, benefits he or
				  she would not otherwise be eligible for may be prosecuted under Vermont law for
				  recipient fraud. If convicted, the individual may be fined or imprisoned or
				  both. The department may also take action to recover the value of benefits paid
				  in error due to fraud.
When the department learns that fraud may have been
				  committed, it will investigate the case with respect for confidentiality and
				  the legal rights of the recipient. If appropriate, the case will be referred to
				  the State's Attorney, Attorney General, or United States Attorney for a
				  decision on whether to prosecute.
Section 4110 Eligibility and Enrollment
				Process
The eligibility and enrollment process includes the steps an
				  individual requesting health care assistance and the department must take to
				  determine an individual's eligibility for and enrollment in health care
				  assistance programs.
Eligible means the department has decided the individual
				  meets all the eligibility criteria specific to the coverage group such as age,
				  residency, and income level.
Enrolled means the department has received full payment of
				  required premiums for the individual who has been determined to meet all
				  eligibility criteria specific to the coverage group. Enrolled individuals are
				  health care assistance beneficiaries. Coverage begins the first day of the
				  month after receipt of any required premiums, unless retroactive coverage
				  provisions apply as in rule M113.
The person (or group) must:
. apply for health care assistance,
. give necessary facts about their (or their family's)
				  situation for the eligibility tests, and
. pay any required premium by the due date.
The department must:
. accept all health care assistance applications and premium
				  payments,
. compare the facts of the individual's situation to the
				  health care assistance eligibility rules,
. make decisions on initial and continuing eligibility for
				  health care assistance,
. notify the individual of its decisions, and
. keep records of decisions and the facts used to make
				  them.
Rules and time limits for these steps are given in
				  M110-M149.
Section 4111
				Premiums
Certain health care assistance groups are required to pay a
				  monthly premium as a condition of initial and continuing coverage. The amount
				  of the premium depends on the net income of the assistance group on the most
				  recent approved version of eligibility on the case record at the time the bill
				  is generated, and for some coverage groups, the existence of other insurance
				  that includes both hospital and physician coverage.
Failure to pay the full premium by the last day of the month
				  shall result in disenrollment.
The premium payment system is described in M150 through
				  M150.2.
Section 4112
				Authorized Representative
The parent, guardian or other caretaker responsible for a
				  minor child acts as the child's representative in the eligibility
				  process.
When a person cannot act for himself, because of his physical
				  or mental condition, one of the following people may act as his authorized
				  representative in the eligibility process.
A court appointed legal guardian or legal representative;
				  or
A relative, friend or other person who knows about or handles
				  his affairs; or
A person he names in a letter to the department to take his
				  place when he cannot come for a necessary interview because of an unexpected
				  emergency.
When a person dies before he can apply for retroactive
				  Medicaid coverage, the administrator or executor of his estate, a surviving
				  relative or other responsible person may act as his authorized
				  representative.
Section
				4113 Case Records
The Department keeps a permanent written record of facts and
				  actions concerning a person's (or group's) Medicaid eligibility for
				  administrative and accountability purposes. Information about each person or
				  group is kept in an individual case file in the district office responsible for
				  the town where the person or group lives. Information necessary to assure
				  prompt and correct payments of Medicaid benefits is also stored in computer
				  files.
Information which identifies a person or group as a Medicaid
				  applicant or recipient is only given out when it is necessary to furnish or pay
				  for Medicaid services. A recipient may permit the Department to give
				  information to another agency to help him get services from that agency.
Information about many applicants or recipients, which does
				  not identify persons or groups by name or other individual characteristics, may
				  be combined in the form of statistics or general descriptions for planning,
				  research and program administration.
Section 4120 Application
Any individual who wants Medicaid must file a Medicaid
				  application with the department except: An individual who has applied at a
				  Social Security Office for supplemental security income.
If an individual granted SSI/AABD also wants retroactive
				  Medicaid coverage before the start of the cash assistance grant, he/she must
				  file a separate application for retroactive Medicaid coverage and be found
				  eligible based on criteria other than receiving cash assistance.
Filing an application means taking or mailing a signed
				  Medicaid application form to a department office, preferably the district
				  office responsible for the town where the applicant lives. Department offices
				  give Medicaid application forms to any individual who asks for one. Medicaid
				  providers, referring agencies and other locations serving the public may also
				  keep supplies of application forms.
An application form must be signed by individuals applying
				  for Medicaid or by their authorized representative.
Section 4121 Reapplication and Reenrollment
Any individual who has applied before for Medicaid and is not
				  now eligible for coverage may reapply at any time.
To reapply, the individual (or group) must file a new
				  up-to-date signed application form with the department. An authorized
				  representative may act for the individual or group when needed.
When an individual has been disenrolled from coverage solely
				  for non-payment of a premium, if the department receives and processes the
				  payment on the next business day following the last day of the month the
				  premium was due, the coverage group will be automatically reenrolled without a
				  new application and without a break in benefits.
If the department receives and processes the payment after
				  the first business day after the month the premium was due, but within the
				  first month after closure, the coverage group will be automatically reenrolled
				  for the next month with a one month break in coverage. Beneficiaries must
				  submit a new application, however, if any change in a coverage group's
				  circumstances affects its eligibility or a review of the case is scheduled for
				  the current month or the following month.
Section 4122 Retroactive Application
Medicaid may be granted retroactively for up to three
				  calendar months before the month of application provided all eligibility
				  criteria were met during the retroactive period and any premiums required for
				  those months have been received by the department. A woman is not eligible for
				  the 60-day post-pregnancy period (i.e., when no other categorical criterion is
				  met) if she was granted retroactively after her pregnancy has ended.
An authorized representative may apply for retroactive
				  coverage on behalf of an individual who dies before he or she can apply for
				  Medicaid.
Payments for Medicare cost sharing for individuals who are
				  Qualified Medicare Beneficiaries (QMBs) and not otherwise eligible for Medicaid
				  are first made in the month following the month QMB eligibility is determined.
				  There is no retroactive QMB coverage.
Payments for Medicare cost sharing for the other Medicare
				  cost-sharing groups can be paid for allowed Medicare costs incurred prior to
				  the month of application provided all eligibility criteria were met during the
				  three month retroactive period.
Section
				4123 Date of Application
The date of application is the day on which a signed Medicaid
				  application form is received in a Department office, or the day on which an
				  application for Supplemental Security Income/Aid to the Aged, Blind or Disabled
				  (SSI/AABD) is filed with a Social Security office.
The application date sets the time limits for making a
				  decision on the application and the earliest date retroactive coverage may
				  begin.
Section 4124 Choice
				of Category
In order to be found eligible for Medicaid, an individual
				  must meet one of the following requirements:
(1) be found eligible for Medicaid as
				determined by the Department of Social Welfare's application of
				SSI/AABD-related Medicaid rules (M200 Section); or
(2) be found eligible for Medicaid as
				determined by the Department of Social Welfare's application of ANFC-related
				Medicaid rules (M300 Section).
Any individual seeking Medicaid coverage has the right to
				  select which of the two sets of rules listed above, he or she wishes to have
				  applied to his or her eligibility determination. In order to assist applicants
				  in making this decision, the Department of Social Welfare is responsible for
				  providing the following information:
(1) the requirements specific to
				SSI/AABD-related Medicaid eligibility. In order to be SSI/AABD-related, an
				applicant must be either:
- 65 years of age or older, or
- blind, or
- disabled
(2) the requirements specific to ANFC-related
				Medicaid eligibility. In order to be ANFC-related, an applicant must be:
- 20 years of age or younger, or
- a pregnant woman, or
- a parent or caretaker relative of a child who meets the
				  ANFC age criteria for a child and is deprived of parental care and support in
				  accordance with the rules of the ANFC-related Medicaid program.
In some instances an applicant may meet the non-financial
				  requirements applicable to both ANFC- and SSI/AABD-related Medicaid
				  eligibility. In these cases, the Department of Social Welfare is responsible
				  for providing the following information regarding the financial requirements of
				  both programs.
(1) The
				SSI/AABD rules usually allow more extensive exclusions of income and resources.
				In addition, a larger portion of earned income may be disregarded than is
				allowed by the ANFC-related rules. If the applicant who meets the non-financial
				requirements of both programs is the only member of the family in need of
				Medicaid enrollment, it may be more advantageous for him or her to apply under
				the SSI/AABD-related rules than under the ANFC-related rules.
(2) When an individual(s) who has a choice of
				category and other members of his/her family apply for Medicaid at the same
				time, the individual(s) having a choice of category may choose to apply on the
				basis of the rules of the program for which the rest of the family is not
				eligible. In this situation, the individual(s) with the choice must be included
				in the other family members' Medicaid group when determining their financial
				eligibility for Medicaid provided that the inclusion of the individual(s)
				having the choice of category is required by the rules of the program under
				which the other family members are applying and his/her inclusion does not
				result in prohibited deeming.
If one or more members of the family are already enrolled in
				  Medicaid, the worker must determine if any change in the family's circumstances
				  has occurred since the most recent eligibility determination which would
				  require a redetermination of his/her (their) Medicaid eligibility. If
				  circumstances relevant to his/her (their) Medicaid eligibility have changed the
				  Medicaid eligibility of the members of the family who are already enrolled in
				  Medicaid must be redetermined prior to completing the determination of Medicaid
				  eligibility for those family members who are not currently enrolled in
				  Medicaid. If circumstances relevant to Medicaid eligibility have not changed,
				  no redetermination of Medicaid eligibility should be completed at this
				  time.
When one or more family members are already enrolled in and
				  remain eligible for Medicaid, the determination of the other family members'
				  financial eligibility for Medicaid will exclude from consideration:
All of their (i.e. the Medicaid recipients' or recipient's)
				  benefits which are based on financial need; and
Those portions of their (i.e. the Medicaid recipients' or
				  recipient's) income used to determine their benefits with the following
				  exception. The exclusion of income does not apply to individuals found eligible
				  due to total countable income which does not exceed one of the special income
				  tests but does exceed the applicable Protected Income Level; and
Resources owned solely or jointly by the Medicaid
				  recipient(s) with the following exception. A resource cannot be excluded if it
				  was an excluded resource for the family member(s) already enrolled in Medicaid
				  solely because the joint-owner member(s) of the subsequent applicant group
				  refused to make the resource accessible to the family member(s) already
				  enrolled in Medicaid.