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 February, 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:
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:
- 65 years of age or older, or
- blind, or
- disabled
- 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.
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.
Section 4130 Application Decisions
A decision must be made to grant or deny any Medicaid application filed with a Department Office.
Medicaid is granted when a person's situation passes all necessary eligibility tests. When a family group applies together, some members may pass the tests and be granted Medicaid while other members do not and must be denied. A Medicaid grant begins on the first day that all eligibility tests are passed. This may be the first of a month during which all the tests are passed at anytime during that month, except when an income spend-down test is necessary (see Section M423).
Medicaid is denied when a persons situation does not pass any one or more of the eligibility tests. A Medicaid denial takes effect on the day the decision is made.
An application decision may grant Medicaid for a part of the period applied for and deny it for another part (such as the retroactive period) because the person did not pass all the tests for the full time.
When an applicant fails to do his part, an application may be denied if a decision cannot be made within the time limit, for example:
An applicant fails to give necessary information or proofs asked for or takes longer than expected without explaining the delay; or
An applicant fails to have necessary medical examinations asked for.
When an applicant has done everything he was asked to do, the application will not be denied even though a decision cannot be made before the time limit.
Section 4131 Decision Time Limits
A decision on a Medicaid application must be made as soon as possible, but no later than:
90 days after the application date, if the application is based on a person's disability; or
30 days after the application date for any other Medicaid application.
The decision is not completed until a written notice of the decision has been given or mailed to the applicant.
Decisions may take longer in unusual situations, such as:
An examining physician delays sending a necessary report; or
An unexpected emergency or administrative problem beyond Department control delays action on applications.
Section 4132 Application Forms
An applicant's signed application form(s) is the main source of information used to make a decision on the applicant's application.
The application form(s) provides the applicant's written record of the facts about his/her situation as related to Medicaid eligibility tests. A relative, friend or other interested person may help the applicant to fill out the statement. If the applicant has no one to help, he/she may ask for help at a Department Office.
The applicant, or his/her authorized representative (see Authorized Representative), who signs the form(s) is held responsible for the truth of the information on the form. When no interview is necessary, the Department will make the application decision from the information on the form(s) and any necessary proofs. It may be necessary to write or telephone the applicant for more information or explanation of entries on the form(s).
Section 4133 Interview
An interview is a face-to-face meeting between the applicant, or his/her authorized representative (see Authorized Representative), and a Department employee to review the applicant's application form(s) and resolve any problems or questions about the applicant's situation in relation to the Medicaid eligibility tests.
An interview must be held when:
The Medicaid application includes a patient living in a long-term care living arrangement unless it is clear that no additional information will be gained from an interview (see below); or
The application form(s) does not give enough clear and consistent information about the applicant's situation to make a decision on his/her application.
An interview may be desirable, but not necessary, to work out complex eligibility test problems, or to help an applicant who has trouble understanding eligibility rules or in giving written information.
Interviews are private. One representative chosen by the applicant may be present to help explain the applicant's situation. Interviews are held at the District Office or at the long-term care facility where the applicant is living. An interview at home, or some other location convenient for both, may be arranged if unusual health or transportation problems make an office visit impossible for the applicant or his/her representative.
A face-to-face interview is not required if no additional information will be gained. If the client is unable to respond to questions, consider a telephone interview with the individual(s) acting on behalf of the client to obtain additional information.
Section 4134 Social Security Numbers
The Department will notify applicants or recipients that Social Security numbers will be used in the administration of the Medicaid program.
Refusal to furnish a Social Security number, refusal to verify a Social Security number, or refusal to apply for a Social Security number for any applicant or recipient shall make that individual ineligible for assistance. However, refusal to furnish a Social Security number shall not affect eligibility if the individual is a member of a religious organization that objects to this practice.
The Department will advise applicants how to apply for Social Security numbers and will not delay, deny or discontinue assistance during the issuance and verification of such numbers.
Section 4135 Verification
Verification means proof of an applicant's statements by written records or documents shown to the Department's employee or agent, or by statements of another person who adds to or supports the applicant's statements.
Proof of the following is required:
All applicants' and recipients' Social Security numbers. Verification of application for such numbers is an acceptable substitute until such time as the Social Security numbers are received and verified; and
A medical decision, based on professional examination and judgment, on blindness, disability or incapacity; and
All countable income;
All resources, when the total is within $ 200 of the resource maximum; and
Proof of citizenship or alienage status and identity (M170).
Proof may also be necessary when the statement form and interview, if one is held, do not give enough clear and consistent information to make a decision on any other eligibility test.
Proof documents are returned to the applicant as soon as necessary information is recorded. Proof documents may be brought to the interview if one is held. Added proofs asked for after review of the applicant's statement may be sent or brought to the office.
When an applicant refuses to give necessary proofs, the application may be denied.
Section 4136 Collateral Sources
Contact with sources other than the applicant may be made concerning his eligibility for aid or benefits. These contacts are limited to interviews, telephone calls, or correspondence necessary to obtain information required to make a decision on eligibility. Information requested from collateral sources is limited to the specific eligibility factors in question.
Common collateral sources are relatives, landlords, employers, town officials, Town Service Officers, public records, doctors, medical facilities, etc. Other agencies which have worked with the client are generally the best source of collateral information.
When information given by the client is either insufficient or questionable, contact with a collateral source may be made without the client's consent. Information requested from collateral sources is limited to eligibility requirements.
Section 4137 Potential Unearned Income
As a condition of eligibility, the Department of Social Welfare requires an applicant or recipient to take all necessary steps to obtain any annuities, pensions, retirement, or disability benefits to which he or she may be entitled, unless he or she can show good cause for not doing so. Annuities, pensions, retirement and disability benefits include, but are not limited to, veterans' compensation and pensions, Old-Age, Survivors, and Disability Insurance (OASDI) benefits, railroad retirement benefits, and unemployment compensation. Application for these benefits, when appropriate, must be verified prior to granting or continuing Medicaid.
Individuals are not required to apply for cash assistance programs such as SSI/AABD or ANFC as a condition of eligibility for Medicaid.
Section 4138 Other Potential Income
As a condition of initial and continuing eligibility, all Medicaid applicants and beneficiaries must meet the requirements related to the pursuit of medical support, third-party payments and the requirement to enroll or remain enrolled in a group health insurance plan, as detailed in M129.1-M129.3 below.
Medicaid applicants and beneficiaries with the legal authority to do so must assign their rights to medical support and third-party payments for medical care to the department, with the exceptions noted below. If they have the legal authority to do so, they must also assign the rights of any other Medicaid applicants and beneficiaries to such support and payments to the department.
No assignment is required for Medicare payments or cash payments from the Department of Veterans Affairs for aid and attendance.
Medicaid applicants and beneficiaries must cooperate with the department in obtaining medical support and third-party payments for medical care unless the department has granted them a good cause waiver for not cooperating (M129.21). To meet this requirement, the department may require an individual to:
provide information or evidence relevant and essential to obtain such support or payments; appear as a witness in court or at another proceeding;
provide information or attest to lack of information under penalty of perjury; or
take any other reasonable steps necessary for establishing parentage or securing medical support or third-party payments.
The department shall exempt an unmarried pregnant woman with income under 200 percent of the federal poverty level from the requirement to cooperate in establishing paternity or obtaining medical support and payments from, or derived from, the father of the child she expects to deliver or from the father of any of her children born out-of-wedlock. She shall remain exempt through the end of the calendar month in which the 60-day period beginning with the date of her delivery ends.
Medicaid applicants and beneficiaries may request a waiver of the cooperation requirement from the department. Those to whom the department has granted a good cause waiver for noncooperation are eligible for Medicaid, provided that all other program requirements are met. The department shall grant such waivers when either of the following circumstances has been substantiated to the department's satisfaction:
. conceived as a result of incest or rape from the father of that child;
. for whom adoption proceedings are pending; or
. for whom adoptive placement is under active consideration.
Individuals requesting waivers of the cooperation requirement bear the primary responsibility for providing the documentation the department deems necessary to substantiate their claims of good cause. The department shall consider an individual who has requested a good cause waiver and submitted the required documentation to be eligible for Medicaid while a decision on the request is pending.
The department may require a Medicaid applicant or beneficiary to enroll or remain enrolled in a group health insurance plan for which the department pays the premiums. Payment of group health insurance premiums shall be made only under the conditions specified in this section and in M158.1 and remain entirely at the department's discretion. Such payment of premiums shall not be considered an entitlement for any individual.
As a condition of continuing eligibility, the department may require beneficiaries to remain enrolled in individual health insurance plans, provided that they are enrolled in plans for which the department has been paying the premiums on a continuous basis since July 2000.
For the purposes of this section and M158.1, a group health insurance plan is a plan that meets the definition of a group health insurance plan specified in 8 V.S.A. § 4079. An individual health insurance plan is a plan that does not meet that definition.
Section 4140 Eligibility Review
Once granted, Medicaid coverage continues until a decision is made to end it because the person (or group) no longer passes all the eligibility tests or the recipient chooses not to continue Medicaid coverage although still eligible. Eligibility must be reviewed to take into account any changes in the facts of the recipient's situation from the facts on which the grant decision was based.
Each Medicaid recipient is responsible for reporting to the Department any change in his situation that is related to the Medicaid eligibility tests (such as changes in income, resources, disability, living arrangement, Medicaid group membership, etc.). He must report any change within ten days after he learns of it.
Every recipient's Medicaid eligibility must be reviewed in full every so often, whether or not his situation changes. The frequency of full reviews depends on how likely the recipient's situation is to change.
Eligibility reviews are carried out under the same rules as initial eligibility investigations (see Sections M123-M126). New up-to-date forms must be filed and proofs given. Interviews are not, however, required, but may be used to clear up incomplete or inconsistent information. Collateral sources may also be used, as needed.
The Department reminds recipients when eligibility must be reviewed by sending necessary forms and directions far enough ahead to complete the review within the time limit. If the recipient fails to do his part, Medicaid coverage may be ended.
Section 4141 Review Frequency
Individuals receiving cash assistance through Supplemental Security Income/Aid to the Aged, Blind or Disabled (SSI/AABD) or state Aid to the Aged, Blind or Disabled (AABD) do not need a separate Medicaid eligibility review by the department. Their Medicaid eligibility is reviewed by the Social Security Administration at the same time as their cash assistance eligibility.
When a recipient's situation is known to change frequently, schedule more frequent reviews. If the Medicaid group meets more than one of the following criteria, schedule a review at the earliest required time.
A full eligibility review must be completed within 12 months after the initial eligibility date, or the date of last full eligibility review, for:
. individuals whose Medicaid group has stable countable income under one of the following levels applicable to their Medicaid eligibility determination: the ANFC payment level in effect as of July 16, 1996, the SSI/AABD payment level, or the protected income level (PIL);
. individuals living in long-term care whose gross income does not exceed the Institutional Income Standard or whose monthly cost of long-term care exceeds their monthly spend-down requirement;
. children whose Medicaid group has stable countable income under one of the special income levels and who will not become ineligible for the special income level due to age in the 12-month period;
. children living in Vermont for whom an adoption assistance agreement is in effect or foster care maintenance payments are being made under title IV-E of the Social Security Act;
. children committed by a Vermont court to the care and custody of Social and Rehabilitation Services; and
. women determined eligible for the breast and cervical cancer treatment group.
A full eligibility review must be completed within six months after the initial eligibility date, or the date of last full eligibility review, for:
. individuals voluntarily placed in the care of Social and Rehabilitation Services, and
. individuals living in long-term care who have gross income over the Institutional Income Standard, have excess income over the cost of long-term care, and must spend-down this excess income on other medical expenses. A review of income eligibility must be completed every month.
. persons determined eligible as working disabled.
A full eligibility review must be completed by the end of the six-month accounting period for:
. individuals living in the community who were not eligible for Medicaid until their Medicaid group incurred medical expenses equal to their spend-down amount (i.e., the group met their six-month spend-down requirement).
A full eligibility review must be completed (at the stated time) for:
. an individual granted Medicaid because he/she meets the ANFC age criteria whose eligibility based on age is ending (review month is the month prior to the month of the child's birthday),
. a woman granted Medicaid because she was pregnant whose Medicaid eligibility under that provision is ending (review month is the month in which the 60th day, beginning with the last day of the pregnancy, falls),
. a child who has been granted Medicaid based on the special income level whose eligibility for the special income level is ending (review month is the month prior to the month of the child's birthday),
. a family found eligible for the 12-month (or 36-month) transitional Medicaid extension whose eligibility under this coverage provision is ending must be redetermined (before Medicaid is terminated), and
. individuals who lose SSI/AABD for a reason other than a final determination by the Social Security Administration that the individual is no longer blind or disabled. Medicaid is reviewed when cash benefits under SSI/AABD are ended and before Medicaid is terminated.
Section 4142 Review Decisions
Section 4150 Notice of Decision and Appeal
Each Medicaid applicant/recipient must be given written notice of the decision on his or her application or review of eligibility. A group notice must include notice of the decisions about each member of the group.
All notice letters must contain:
A statement of what action the Department intends to take;
When it intends to take the action;
The reasons for the intended action;
The policy citation(s) that supports the action;
An explanation of the individual's right to appeal the decision and the circumstances under which a hearing will be granted; and
Note: The Department need not grant a hearing if the sole issue is a Federal or State law requiring a mandated change adversely affecting some or all recipients.
An explanation of the circumstances under which Medicaid is continued if a hearing is requested.
When an eligibility review decision will end or reduce the amount of Medicaid coverage an individual has been receiving, the notice of decision must be mailed at least ten (10) days before the closure or change will take effect, except when:
The Department has facts confirming the death of a Medicaid recipient;
The Department has facts confirming that the recipient has been granted Medicaid in another State;
The recipient has been admitted or committed to an institution where he or she is ineligible for further services;
The Department receives a clear written statement signed by a recipient that:
The recipient's whereabouts are unknown and the post office returns agency mail directed to him or her indicating no forwarding address; or
A change in the level of medical care is prescribed by the recipient's physician.
Section 4151 Right to Appeal
Any Medicaid applicant or beneficiary has a right to appeal any decision about his or her Medicaid eligibility or amount of coverage, and to request a fair hearing before the Human Services Board (see Section M144) with the following exception: An applicant for or recipient of Supplemental Security Income (SSI/AABD) benefits who is denied SSI/AABD benefits or has his/her SSI/AABD benefits terminated because the Social Security Administration (SSA) or its agent found him/her 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 below).
Note: an applicant or beneficiary found to be not disabled by the SSA prior to 4/1/90 may appeal the resulting denial or termination to the Human Services Board as long as the appeal is filed within ninety (90) days of the date the notice of denial or termination was mailed. A person may also appeal if he or she thinks the Department is taking too long to make a decision. The right to appeal and procedures for making an appeal must be explained in Department forms and publications used by Medicaid applicants and beneficiaries and by Department employees during eligibility determination and review contacts.
Regarding eligibility issues, complaints or misunderstandings about decisions may be discussed with the employee who made the decision or his or her supervisor. If this review does not satisfy the applicant or beneficiary, he or she still has the right to request a fair hearing. A request for a fair hearing must be made within ninety (90) days of the date the notice of the decision being appealed was mailed. A request for a hearing is defined as a clear expression, oral or written, that the Medicaid applicant or beneficiary wishes to appeal a decision or that he/she wants an opportunity to present his/her case to a higher authority.
Regarding issues of coverage, a beneficiary may utilize the internal MCO appeal process (see M181) while a fair hearing is pending or before a fair hearing is requested (see M182). Fair hearings or MCO appeals must be filed within 90 days of the date the notice of action was mailed by the MCO, or if no mailing, within 90 days after the action occurred. A request for a fair hearing challenging an MCO appeal decision must be made within ninety (90) days of the date the original notice of the MCO decision being appealed was made, or within thirty (30) days of the date the notice of the MCO decision being appealed was mailed.
Medicaid beneficiaries also have the right to file grievances using the provisions of the Global Commitment for Health 1115 waiver internal grievance process. Beneficiaries (or duly appointed representatives) may file grievances orally or in writing. The grievance provisions are found at M184.
Section 4152 Disability Determination Appeal
- a final SSA disability determination is binding on the Department for 12 months or, if earlier, until the determination is changed by SSA and may not be appealed through the Department's appeal process. However, when an individual who has been found "not disabled" by the SSA meets the requirements specified in M211.4, he or she, though not entitled to an appeal of the SSA determination through the Department's appeal process, is entitled to a separate state determination of disability for the purposes of determining his or her eligibility for Medicaid.
- the Department must refer all applicants who do not meet the requirements specified in M211.4 for a separate state determination of disability and who allege new information or evidence affecting previous SSA determinations of ineligibility based upon disability, to SSA for reconsideration or reopening of the determination.
Section 4153 Continued Benefits Pending Appeal
When beneficiaries appeal a decision to end or reduce Medicaid coverage, they have the right, under certain conditions, to have benefits continue without change until the appeal is decided or the fair hearing is resolved provided the beneficiary requests an appeal or fair hearing before the effective date of the adverse action and has paid in full any required premiums (see M181.3). If the last day before the adverse action date is on a weekend or holiday, the beneficiary has until the end of the first subsequent working day to request the appeal or fair hearing. Beneficiaries appealing the amount of their premiums shall pay at the billed amount in order for coverage to continue until the dispute is resolved. Beneficiaries who are successful on an appeal concerning the amount of their premium will be reimbursed by the Department for any premium amounts overpaid.
Continuation of benefits without change does not apply when the appeal or fair hearing is based solely on a reduction or elimination of a benefit required by federal or state law affecting some or all beneficiaries, or when the decision does not require the minimum advance notice (see Notice of Decision at M141).
Beneficiaries may waive their right to continued benefits. If they do so and are successful on an appeal, benefits will be paid retroactively.
The OVHA may recover from the beneficiary the value of any continued benefits paid during the appeal and fair hearing period when the beneficiary withdraws the appeal or fair hearing before the relevant MCO or fair hearing decision is made, or following a final disposition of the matter in favor of the MCO. Beneficiary liability will occur only if an MCO appeal, fair hearing decision, Secretary's reversal and/or judicial opinion upholds the adverse determination, and the MCO also determines that the beneficiary should be held liable for service costs.
When SSI/AABD beneficiaries are determined "not disabled" by the Social Security Administration (SSA) and appeal this determination, their Medicaid coverage continues as long as their SSI/AABD benefits are continued (or could have been continued but the client chose not to receive them during the appeal period) pending a SSA decision on the appeal. When eligibility for SSI/AABD benefits is terminated following a determination of "not disabled", Medicaid coverage ends unless they apply and are found eligible for Medicaid on the basis of a categorical factor other than disability.
When Medicaid beneficiaries apply for SSI/AABD and are determined "not disabled" by the Social Security Administration (SSA) and file a timely appeal of this determination with the SSA, their Medicaid coverage continues until a final decision is made on the appeal provided the SSA's determination of "not disabled" is the only basis on which they might be found ineligible for Medicaid. If they continue to appeal unfavorable decisions by SSA, the "final decision" is made by the SSA Appeals Council.
Section 4154 MCO Appeal and Fair Hearing Rules
Medicaid coverage appeals are processed in accordance with applicable MCO Appeals Rules, at M181, and fair hearing rules, as promulgated separately by the Human Services Board pursuant to 3 V.S.A. § 3091(d). A copy of the Human Services Board fair hearing rules is in the All Programs Procedures Manual.
Section 4160 Payment System
The Vermont legislature instituted a premium-based payment system for most health care assistance programs with the 2004 Appropriations Act, Act 66 of 2003. This legislation also unified the method of billing and the premium collection system for all coverage groups.
Section 4161 Cost Sharing
This section describes the general premium rules and process. Additional rules applicable to the specific coverage groups subject to these premium rules vary, and are described in the following sections: Dr. Dynasaur (4312.6 and 4312.7), VHAP (5300), VHAP-Pharmacy (5500), and VScript (5600).
The department will:
When households with more than one coverage group make a partial payment of a bill that includes more than one premium, the payment will be applied as payment of one or more premiums in full rather than as a partial payment of all of the billed premiums. Beneficiaries who want to choose which premium to pay must call the Member Services number on the bill to record that designation on the case record.
In the event the beneficiary has not made the designation, the department will apply the partial payment to the following coverage groups in the following order:
In the event of an overpayment, the department will retain and reflect it as a credit on the next premium bill. When coverage ends, to expedite a possible reinstatement if requested, the department will wait 30 days before reimbursing a beneficiary any credit remaining on the account. If coverage remains closed for 30 days, DCF will issue a refund within 10 business days thereafter. If it will be a financial hardship to apply an overpayment in this way, beneficiaries may request that the department reimburse the overpayment within 30 days.
In addition to premiums, health care beneficiaries may also be responsible for copayments for some services, which are described below.
Copayments from some beneficiaries are required for certain services. Copayments will be deducted from the Medicaid payment for each service subject to copayment. Section 1916(c) of the Social Security Act requires that "no provider participating under the State (Medicaid) plan may deny care of services to an individual eligible for (Medicaid) ... on account of such individual's inability to pay (the copayment)." This subsection further provides, however, that these requirements "shall not extinguish the liability of the individual to whom the care or services were furnished for the payment of (the copayment)."
Section 4162 Obligation of the Department
The department will assure that mechanisms exist for the payment of reimbursable expenses.
Section 4163 Eligibility Expenses
The department will pay the reasonable charge for any professional examination and report necessary to make a decision, or appeal a decision, on medical factors of blindness, disability or incapacity.
To receive payment, the examiner must submit the required report and an itemized bill for services necessary to complete the report.
Section 4164 Recipient Identification
The Department must give each recipient a permanent identification document which can be used by a provider to determine eligibility for Medicaid at the time of service. Documents, including temporary identification as a Medicaid recipient, will be mailed to new recipients as soon as possible after Medicaid is granted. Temporary identification will also be given to the individual by the District Office when services are needed immediately.
Information the provider needs to claim payment from other available resources, such as health insurance, and to prepare his/her Medicaid claim, and information about restrictions, if any, imposed on the recipient's use of Medicaid Services due to utilization abuse (see also Section M157) are provided when eligibility is confirmed by the provider.
Additional prior authorization to claim Medicaid payment may be required for certain types of Medicaid services. such as long-term care. (See also Sections M500-M599).
Section 4170 Citizenship
(05/01/2010, 10-02)
Section 4171 U.S. Citizen
The state may undertake to document citizenship or identity through one or more data-system cross matches that may be available for such purposes. If the state obtains the needed documentation, the individual need not provide additional proof in this regard. However, if the state does not secure such documentation, it will notify the individual as to the extent of the requirement that remains outstanding. The individual will then be responsible for securing acceptable documentation (M170.22) and providing it to the department.
(05/01/2010, 10-02)
Evidence is "available" if it exists and can be obtained within the period of time specified in paragraph (b) of this section.
The Department of State issues this. A U.S. passport need not be currently valid to be accepted as evidence of U.S. citizenship, as long as it was originally issued without limitation. However, a passport that was issued with limitation and is not currently valid may be used as proof of identity.
Department of Homeland Security issues this.
Department of Homeland Security issues certificates of citizenship to individuals who derive citizenship through a parent.
A document issued by a federally recognized Indian tribe evidencing membership or enrollment, or affiliation with, such tribe (such as a tribal enrollment card or certificate of Indian blood.) The Secretary of Health and Human Services will issue regulations concerning tribes located in states with international borders whose members include individuals who are not citizens of the United States. The regulations will authorize the presentation of such other forms of identification that the Secretary determines to be satisfactory evidence of citizenship or nationality.
If primary evidence from the list in paragraph (c) of this section is unavailable and the person claims a U.S. place of birth, the person should provide satisfactory documentary evidence from paragraph (g) of this section to establish identity, and satisfactory documentary evidence of citizenship from the list below:
The Department of State issues a DS-1350 to U.S. citizens in the U.S. who were born outside the U.S. and acquired U.S. citizenship at birth, based on the information shown on the FS-240. When the birth was recorded as a Consular Report of Birth (FS-240), certified copies of the Certification of Report of Birth Abroad (DS-1350) can be issued by the Department of State in Washington, D.C. The DS-1350 contains the same information as that on the current version of Consular Report of Birth FS-240. The DS-1350 is not issued outside the U.S.
The Department of State consular office prepares and issues this. A Consular Report of Birth can be prepared only at an American consular office overseas while the child is under the age of 18. Children born outside the U.S. to U.S. military personnel usually have one of these.
Before November 1, 1990, Department of State consulates also issued Form FS-545 along with the prior version of the FS-240. In 1990, U.S. consulates ceased to issue Form FS-545. Treat an FS-545 the same as the DS-1350.
(This form was issued as Form I-197 until the 1980s by INS. Although no longer issued, holders of this document may still use it consistent with the provisions of section 1903(x) of the Act. Note that section 1903(x) of the Act incorrectly refers to the same document as an I-97). INS issued the I-179 from 1960 until 1973. It revised the form and renumbered it as Form I- 197. INS issued the I-197 from 1973 until April 7, 1983. INS issued Form I-179 and I-197 to naturalized U.S. citizens living near the Canadian or Mexican border who needed it for frequent border crossings. Although neither form is currently issued, either form that was previously issued is still valid.
(Issued by the DHS to a collectively naturalized citizen of the United States who was born in the Northern Mariana Islands before November 4, 1986.) The former Immigration and Naturalization Service (INS) issued the I-873 to a collectively naturalized citizen of the U.S. who was born in the NMI before November 4, 1986. The card is no longer issued, but those previously issued are still valid.
The adoption decree must show the child's name and U.S. place of birth. In situations where an adoption is not finalized and the state in which the child was born will not release a birth certificate prior to final adoption, a statement from a state-approved adoption agency that shows the child's name and U.S. place of birth is acceptable. The adoption agency must state in the certification that the source of the place of birth information is an original birth certificate.
The document must show employment by the U.S. government before June 1, 1976. Individuals employed by the U.S. Civil Service prior to June 1, 1976 had to be U.S. citizens.
The document must show a U.S. place of birth (for example a DD-214 or similar official document showing a U.S. place of birth.)
If evidence from the lists in paragraphs (c) and (d) of this section is unavailable and the person claims a U.S. place of birth, the person should provide satisfactory documentary evidence from paragraph (g) of this section to establish identity, and satisfactory documentary evidence of citizenship from the list below:
The record must have been established at the time of the person's birth and created 5 years before the initial application date. (For children under 16 the document must have been created near the time of birth or 5 years before the date of application.) A souvenir "birth certificate" issued by a hospital does not satisfy this requirement.
The record must have been created at least 5 years before the initial application date.
If evidence from the lists in paragraphs (c), (d), and (e) of this section is unavailable and the person claims a U.S. place of birth, the person should provide satisfactory documentary evidence from paragraph (g) of this section to establish identity, and satisfactory documentary evidence of citizenship from the list below:
The census record must also show the applicant's age.
The record must have been created at least 5 years before the initial application date. (For children under 16 the document must have been created near the time of birth or 5 years before the date of application.) An immunization record is not considered a medical record for purposes of establishing U.S. citizenship.
Declarations should only be used in rare circumstances. If the documentation requirement needs to be met through declarations, the following rules apply:
The card must have a photograph of the individual.
The card must have the same information that is required for driver's licenses.
The document must have a photograph or other personal identifying information relating to the individual.
For children under 16, if none of the documents in paragraph (g) are available, a Declaration of Identity (ESD Form No. 201ID) may be used to prove the identity of the child. A Declaration of Identity is only acceptable if it is signed under penalty of perjury by a parent or guardian stating the date and place of the birth of the child and cannot be used if declarations were used to establish citizenship.
ESD shall assist individuals to secure satisfactory documentary evidence of citizenship and identity when, because of incapacity of mind or body, the individual would be unable to comply with the requirement to present satisfactory documentary evidence of citizenship or identity in a timely manner and the individual lacks a representative to assist him or her.
Section 4172 Qualified Alien
Refugees usually change to Lawful Permanent Resident status after 12 months in the United States, but for the purposes of Medicaid eligibility are still considered refugees. They are identified by Form I-551 with codes RE-6, RE-7, RE-8, or RE-9.
Section 4173 Five-Year Bar for Qualified Aliens
Section 4174 Non-qualified Aliens
Aliens who do not meet qualified alien status are considered non-qualified aliens. Non-qualified aliens who otherwise meet the Medicaid eligibility criteria of a categorical assistance program are eligible for the treatment of emergency medical conditions only. (M170.8). These aliens do not have to make a declaration of immigration status. Immigration status does not have to be verified. Such aliens do have to provide their Social Security Number if one is available or apply for one if the person does not have one. Non-qualified aliens include illegal and undocumented aliens.
These aliens were never legally admitted to the U.S. for any period of time, or were admitted for a limited time and did not leave the U.S. when the time expired. These individuals are not issued Social Security Numbers. Therefore, they do not have to provide one.
Aliens who do not have any type of BCIS documentation are undocumented aliens.
Section 4175 Ineligible Aliens and Non-immigrants
Section 4176 Confirmation of Immigration Via SAVE
A qualified alien's immigration status must be confirmed through the Systematic Alien Verification for Entitlement (SAVE) Program, regardless of documentation presented by the alien.
Section 4177 Emergency Medical Services
