Code of Vermont Rules
Agency 13 - AGENCY OF HUMAN SERVICES
Sub-Agency 170 - DEPARTMENT FOR CHILDREN AND FAMILIES (DCF)
Chapter 550 - VHAP - PHARMACY (5500)
Section 13 170 550 - VHAP - PHARMACY (5500)
Current through February, 2024
Section 5500 VHAP-Pharmacy
Legislative Act 14, authorizing and supporting the Vermont Health Access Plan, was adopted by the Vermont General Assembly and signed into law by the Governor on April 12, 1995. The Vermont Health Access Plan extends a pharmacy benefit and vision care services to low-income disabled and elderly Vermonters to assist them to purchase the prescription medicines that maintain their health and prevent unnecessary health problems. Vision care services do not include eyewear.
The policies which follow describe this coverage group called VHAP-Pharmacy.
Section 5501 Beneficiary Fraud
A person, who knowingly gives false or misleading information or holds back needed information in order to obtain VHAP-Pharmacy benefits may be prosecuted for fraud under Vermont law or federal law or both. If convicted, the individual may be fined or imprisoned or both.
When ESD learns that fraud may have been committed, it will investigate the case with respect for confidentiality and the legal rights of the beneficiary. If appropriate, the case will be referred to the State's Attorney or Attorney General for a decision on whether or not to prosecute.
Section 5510 Eligibility
An individual must meet all of the following requirements (3301.1 - 3301.74) to be found eligible for this program.
Section 5511 Age
An individual qualifying on the basis of age must be at least 65 years of age on the date the application is filed.
Section 5512 Disability
An individual qualifying on the basis of disability must be receiving disability benefits from Social Security (OASDI) to be considered disabled.
Section 5513 Uninsured
Individuals meet the uninsured requirement if they do not have any plan, including VHAP-Limited and Medicare, which pays or reimburses, either in whole or in part, with the exception of VScript, or Healthy Vermonters, their prescription drug expenses.
Section 5514 Citizenship and Identity
The rules for citizenship and identity are in section M170.
Section 5515 Residence
An individual is a state resident if he/she has lived in Vermont during the entire 12-month period immediately preceding application for the VHAP-Pharmacy program and is living in Vermont at the time of such application:
Temporary absences from Vermont for any of the following purposes does not interrupt or end Vermont residence: visiting, obtaining necessary medical care, or obtaining education or training under a program of vocational rehabilitation or higher education.
Section 5516 Living Arrangement
An individual meets the living arrangement requirement unless he/she is living in a correctional facility including a juvenile facility.
An individual living in a psychiatric facility, an alcohol treatment facility, or a drug treatment facility is eligible for VHAP-Pharmacy.
Section 5520 Financial Need
An individual must be a member of a VHAP-Pharmacy group with countable income under the applicable income test to meet this requirement.
A VHAP-Pharmacy group includes all of the following individuals if living in the same home:
The VHAP-Pharmacy group shall not include any individual eligible for and receiving SSI/AABD benefits. In addition, the income of all SSI/AABD recipients living in the household shall not be considered in determining whether the VHAP-Pharmacy group passes the income test for VHAP-Pharmacy.
The VHAP-Pharmacy group shall not include any individual eligible for and receiving ANFC benefits. In addition, the income (including the ANFC assistance payment) of all ANFC recipients living in the household shall not be considered in determining whether the VHAP-Pharmacy group passes the income test for VHAP-Pharmacy.
Section 5521 Countable Income
Countable income is all earned and unearned income, defined in this section, less all allowed deductions. Income in the month of application (or review) and future months is estimated based on income in the calendar month prior to the month of application (or review) unless changes have occurred or are expected to occur and this income does not accurately reflect ongoing income. If changes are expected to occur, an estimate of income based on current information should be used.
To determine countable monthly income, average weekly income is multiplied by 4.3 and average bi-weekly income is multiplied by 2.15.
Lump sum benefits that would have been counted as income if received on time, such as Social Security benefits and Unemployment Compensation, shall be added to all other countable income received or expected by an applicant for or recipient of VHAP-Pharmacy and counted only in the month of receipt.
Windfall lump sums, such as insurance payments and money received from the sale of a resource, are not counted.
An insurance payment or similar third party payment which is received for a specific purpose, for example, the payment of medical bills or funeral costs, and is used for the stated purpose is excluded. Payments not used for the stated purpose are counted as income in the month received.
Unearned income includes, but is not limited to, the following:
Income from benefit and pension programs, such as Social Security, Railroad Retirement, veterans' pensions or compensation, unemployment compensation and employer or individual private pension plans or annuities.
Interest and dividends.
Child support payments (see 3301.72 #23 for the exclusion of the first $ 50) and alimony payments.
Income from capital investments in which the individual is not actively engaged in managerial effort.
Time payments on mortgages or notes resulting from a casual sale [i.e., a sale not related to self-employment] of real (stationary or fixed property) or personal property.
Voluntary contributions from others.
Unearned income does not include the following:
Infrequent or irregular voluntary cash contributions or gifts received from friends or relatives.
In-kind income that is unearned.
Five percent of a VA monthly award that is retained by a guardian.
Earned income includes all salary, wages, commissions or profit from activities in which an individual is engaged as an employee or a self-employed person, including but not limited to active management of capital investments (e.g., rental property).
Earned income is defined as income prior to any deductions for income taxes, FICA, insurance or any other deductions voluntary or involuntary except that in determining earned income for self-employed individuals, business expense are deducted first.
Earnings over a period of time, for which settlement is made at one given time, are also included; i.e., sale of farm crops, livestock, poultry, etc. Monthly income is determined by dividing the settlement by the number of months in which it was earned.
Earned income does not include in-kind income that is earned.
The following items are deducted from gross earned income in the sequence listed:
Business expenses (self-employment only)
Standard employment expense deduction
Dependent care expenses
Business expenses, which are deducted from gross receipts to determine adjusted gross unearned income, are limited to operating costs necessary to produce cash receipts, such as:
Items such as personal business and entertainment expenses, personal transportation, purchase of capital equipment, depreciation and payment on the principal of loans for capital assets or durable goods are not allowable business expenses.
Tax returns and business records are considered appropriate sources of accurate figures for farm and business receipts and expenses.
The income of a VHAP-Pharmacy group owning or operating a commercial boarding house shall be treated as any other business income. A commercial boarding house is defined as an establishment licensed as a commercial enterprise that offers meals and lodging for compensation. In areas without licensing requirements, a commercial boarding house shall be defined as a commercial establishment that offers meals and lodging with the intention of making a profit.
No computation is required for foster homes furnishing boarding care to children in custody of and placed by the Department of Social and Rehabilitation Services. Department board rates are established to cover expenses only with no profit available; therefore, no earned income is considered available from this source.
For a VHAP-Pharmacy group that is not a commercial boarding house, the business expense of furnishing room and board, alone or as part of custodial care, shall be allowed provided that the amount shall not exceed the payment the VHAP-Pharmacy group receives from the roomer/boarder for lodging/meals. (See the Procedures Manual for the table of standard business expense deductions for homes providing room or board on a non-commercial basis.)
The standard employment expense deduction is the first $ 90.00 earned per month after deduction of business expenses, where applicable.
The standard employment expense deduction is applied separately to the gross earned income of each individual in the VHAP-Pharmacy group (see 3301.7) who is employed or self-employed.
Dependent care expenses necessary to enable the individual to retain his or her employment will be deducted up to a maximum of $ 175.00 per month for the care of each member of the VHAP-Pharmacy group who is an incapacitated adult or a child age two years or older, and up to a maximum of $ 200 per month for the care of each child under two years of age who is a member of the VHAP-Pharmacy group.
Dependent care expenses for the care of a child are not deducted unless the child requiring care is a member of the VHAP-Pharmacy group or is not a member of the VHAP-Pharmacy group solely because he/she is a SSI/AABD or an ANFC recipient and is:
Dependent care expenses will be allowed as paid up to the maximum. If a recipient's dependent care expenses are below the maximum, transportation to and from the dependent care facility may be deducted as part of the expense up to the maximum for both dependent care and transportation.
Payments for dependent care provided by a member of the same VHAP-Pharmacy group, by the child's parent (biological, adoptive, or stepparent) or legal guardian, or by the incapacitated adult's spouse do not qualify as necessary dependent care expenses under this policy.
The provider of care must be at least 16 years of age. A deduction for dependent care expenses for care of a child can be allowed only when neither parent is available and able to provide necessary care. A deduction for dependent care expenses for care of an incapacitated adult can only be allowed when the incapacitated adult's spouse (where applicable) is either unavailable or available but unable to provide the necessary care because he or she is incapacitated. A spouse shall be considered unavailable if he/she is employed during the time care is required. Incapacity shall be determined in accordance with the process used to determine whether a parent applying for or receiving ANFC is incapacitated (see WAM 2332.1). This process shall give appropriate consideration to the treating physician's opinion.
If dependent care is required for reasons other than employment (e.g., protective services child care or care for training purposes), the client shall be referred to SRS.
Section 5522 Excluded Income
Examples of excludable income sources are: Basic Educational Opportunity Grants, Vermont Student Assistance Corporation grants or loans, Senatorial Scholarships, Supplemental Educational Opportunity Grants (SEOG), and College Work-Study Programs (CWSP).
That portion of any Veterans Administration Educational Assistance Program payment that is for the student and is actually used for tuition, books, fees, child care services or other expenses necessary for enrollment is also excluded.
Examples of programs in Title IV of the Higher Education Act include:
This income cannot be disregarded for adults.
The $ 10 per day allowance given to individuals in JTPA training is also always disregarded as income for both children and adults.
Section 5523 Determining Countable Income
Complete the following steps to determine countable income:
All otherwise eligible individuals in a VHAP-Pharmacy group who pass the income test are income-eligible for the VHAP-Pharmacy program.
Individuals potentially eligible for traditional Medicaid, such as pregnant women or children, have their eligibility determined under those rules but are considered members of the VHAP-Pharmacy group for purposes of determining the VHAP-Pharmacy group size and countable income.
Section 5524 Income Test
The income test, which is based on a percentage of the federal poverty line (FPL), is anticipated to follow the schedule below. However, enrollment may be suspended without further rule-making if this is required to remain within the state appropriation.
|
Date |
* Income Test |
|
05/15/96 |
less then 100% FPL |
|
07/01/97 |
less than 125% FPL |
|
07/01/98 |
less than 150% FPL |
|
* Current poverty lines are in the Procedure Manual at P-2420. |
|
The income maximums (P-2420) are updated annually on January 1 using a methodology similar to the one employed by the federal government in setting the FPLs. In years when the actual FPL exceeds PATH's income maximum, PATH will issue a second increase on April 1.
Section 5530 Application
An application submitted through the Vermont state income tax process within the usual January 1 to June 15 application period shall be considered a valid application for VHAP-Pharmacy. Applicants determined eligible for VHAP-Pharmacy shall be offered enrollment..
Individuals who did not file through the state income tax process must file an application for VHAP-Pharmacy with the Vermont Health Access Eligibility Unit or a Department of Social Welfare district office and provide information about his/her situation relevant to the tests for eligibility ( Section 3301 ). Applications are date-stamped to assure that earlier applications are acted upon first.
An applicant must furnish his/her social security number or apply for a social security number unless he/she substantiates he/she is a member of a religious organization that objects to the use of a social security number. An applicant who substantiates membership in such an organization shall be given an alternate identification number.
Verification of the information provided is not generally required of the applicant or recipient unless it is questionable, verification is outstanding for another benefit program, or the applicant or recipient has refused to provide a social security number because of a religious objection. Social security numbers are used to verify information through tape matches. Clients are notified on the application form of the verification actions the department may take, including the use of verification obtained for other department programs, randomly selected quality control reviews, and the penalties for fraudulent reporting of their situation.
Individuals who are found eligible for VHAP-Pharmacy and subsequently become ineligible for that program, due to a change in their circumstances or other program changes, shall be considered for eligibility in the VScript or Healthy Vermonter's program.
Section 5531 Application Decision
An eligibility decision must be made within 30 days of the date the application is received by PATH. An applicant with countable income over the income test shall be denied and may reapply at any time.
An applicant will be sent a notice regarding the action being taken on his/her application. An applicant who is denied will be sent a denial notice that includes the reason for the denial and the applicant's appeal rights.
Individuals offered VHAP-Pharmacy coverage may apply for any other health care assistance offered by the department at any time.
Section 5532 Eligibility Period and Enrollment
Eligibility criteria are described in rules 3301.1 - 3301.74.
If VHAP-Pharmacy eligibility begins on or after July 1 but no later than December 31, eligibility continues through June 30 of the next year. If VHAP-Pharmacy eligibility begins on or after January 1 but no later than June 30, eligibility continues through June 30 of the following year.
A review of eligibility will be completed before the end of each certification period to assure uninterrupted coverage if the individual remains eligible, pays all required premiums, and complies in a timely manner with the review requirements. An individual who fails to pay required premiums or fails to comply in a timely manner with review requirements shall receive a termination notice mailed at least 11 days before termination date.
Once eligibility for VHAP-Pharmacy is determined and required premiums are received by the department, according to the rules specified at M150-M150. 2, beneficiaries are enrolled beginning on the first day of the month following receipt of full premium payment through June 30 unless they are disenrolled at the end of the month following a notice mailed at least 11 days before the disenrollement date. Disenrollment shall occur whenever beneficiaries:
. fail to pay the required premium;
. are incarcerated;
. become eligible for another plan of assistance or insurance that provides any payment or reimbursement of prescription costs;
. move out-os state;
. voluntarily withdraw;
. are found to have been ineligible on the date coverage began;
. are no longer in contact with the Department and has no known address;
. die.
Individuals are required to report any of the above changes, as applicable, and any change of address within 10 days of the change.
If beneficiary's coverage is terminated solely because of nonpayment of the premium, and the reason is medical incapacity, as specified in section M150.1(A)(1), the beneficiary or their representative may request coverage for the period between the day coverage ended and the last day of the month in which they request coverage. The department will provide this coverage if it has received verification of medical incapacity and all premiums due for the period of non-coverage. The beneficiary is responsible for all bills incurred during the period of non-coverage until the department receives the required verification and premium amounts due.
If the health condition related to this medical incapacity is expected to continue or recur, the department will encourage beneficiaries to designate an authorized representative to receive and pay future bills for as long as the anticipated duration of the condition.
Section 5533 Identification Document
Each individual in the household enrolled in VHAP-Pharmacy is provided with an identification card which includes the name and identification number.
Section 5534 Application for Other Benefits
Individuals who wish to apply for traditional Medicaid or other benefits available through PATH must file an application as required under those programs.
Section 5540 Right to Appeal
The Department shall provide individuals with notice whenever they are found ineligible for the VHAP-Pharmacy program or when the services they may receive under the VHAP-Pharmacy program are denied, reduced or discontinued. The notice shall include a statement of the intended action, the reason for the action and an explanation of the individual's right to request an internal managed care organization ("MCO") appeal and a fair hearing before the Human Services Board.
Regarding eligibility issues, 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 individual 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.
When beneficiaries appeal a decision to end or reduce VHAP-Pharmacy coverage, they have the right, under certain conditions, to have benefits continue without change until the appeal or fair hearing is decided provided the beneficiary has requested an appeal before the effective date of the change and has paid in full any required premiums (see M181.3). 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 appeal the amount of their premium and win will be reimbursed by ESD for any premium amounts overpaid.
Continuation of benefits without change does not apply when the appeal 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 who waive their right to continued benefits will be reimbursed for out-of-pocket expenses for covered services provided during the appeal period in any case in which the MCO or Human Services Board reverses the decision.
VHAP-Pharmacy 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 5550 Cost-Sharing
The department requires all beneficiaries to pay a monthly premium of $ 17.00 to enroll in the VHAP-Pharmacy program. The premium payment system applicable to VHAP-Pharmacy is described in M150 through M150.2.
Section 5551 Payments for Prescribed Drugs
Payment for prescribed drugs, whether legend or over-the-counter items, will be made at the lower of the price for ingredients (see 3303.3) plus the dispensing fee on file or the provider's actual amount charged, which shall be the usual and customary charge to the general public.
Section 5552 Price for Ingredients
Payment for the ingredients in covered prescriptions is made for two groups of drugs; multiple-source (i.e., therapeutically equivalent or generic drugs) and "other" drugs (i.e., single-source drugs [brand name] or drugs "other" than multiple-source).
The exact payment methodology can be found in Attachment 4.19-B of the Vermont Medicaid State Plan.
When a physician certifies in his or her own handwriting that a specific brand of a multiple-source drug is medically necessary for a particular beneficiary, the price for ingredients will be calculated as for "other" drugs. The physician's handwritten phrase "brand necessary" or "brand medically necessary" must appear on the face of the prescription.
Section 5553 Compounded Prescriptions
Payment for compounded prescriptions is made at the lower of the actual amount charged or the price for ingredients plus the dispensing fee plus the compounding fee on file for each minute directly expended in compounding.
Section 5554 Participating Pharmacy
"Pharmacy" means a retail or institutional drug outlet licensed by the Vermont State Board of Pharmacy pursuant to chapter 36 of Title 26, or by an equivalent board in another state, in which prescription drugs are sold at retail and which has entered into a written agreement with the state to dispense drugs.
A provider must:
satisfactorily complete and submit to the Office of Vermont Health Access the standard enrollment form;
conform to the standards of the Vermont State Board of Pharmacy and other federal and state statutes and regulations applicable to the dispensing of prescription drugs to the general public;
agree to provide reasonable access to records necessary to comply with the provisions for program review set forth in the Provider Agreement;
never deny services to, or otherwise discriminate against on the basis of race, color, sex, age, religious preference, national origin, handicap or sexual orientation;
take appropriate steps to prevent the wrong utilization of prescription drugs, with special concern for the potentially dangerous interaction of two or more prescription drugs from different prescribers.
Section 5555 Co-payments
A beneficiary shall contribute a co-payment of $ 1.00 for prescriptions costing less than $ 30.00, and a co-payment of $ 2.00 for prescriptions costing $ 30.00 or more.
A pharmacy may not refuse to dispense a prescription to a beneficiary who does not provide the co-payment.
Section 5560 Prescribed Drugs
Pharmaceutical items include drugs that are obtained through appropriately licensed pharmacies. Payment for prescribed drugs is limited to:
[bullet] Registered Vermont pharmacies, including hospital pharmacies; or
[bullet] Pharmacies appropriately licensed in another state; or
[bullet] A physician, serving in areas without regular pharmacy services, who has been granted special approval to bill these items direct.
Payment is limited to covered items furnished on written prescription from a duly licensed medical professional licensed by the state of Vermont to prescribe within the scope of his or her practice and enrolled in Vermont Medicaid, or on telephoned prescription from a prescriber as previously described and enrolled in Vermont Medicaid processed in compliance with applicable federal and state statutes and regulations.
"Maintenance drug" means a drug approved by the FDA for continuous use and prescribed to treat a chronic condition for a prolonged period of time of 30 days or longer, and includes insulin, an insulin syringe and an insulin needle.
Apart from the select drugs used for maintenance treatment described below, all other maintenance drugs must be prescribed and dispensed for not less than 30 days and not more than 90 days. Excluded from this requirement are drugs which the beneficiary takes or uses on an "as needed" basis or generally used to treat acute conditions. If there are extenuating circumstances in an individual case which, in the judgment of the prescriber, dictate a shorter prescribing period for these drugs, the supply may be for less than 30 days as long as the prescriber prepares in sufficient written detail a justification for the shorter period. The extenuating circumstance must be related to the health and/or safety of the beneficiary and not for convenience reasons. It is the responsibility of the pharmacy to maintain in the beneficiary's record the prescriber's justification of extenuating circumstances.
Select drugs used for maintenance treatment must be prescribed and dispensed in increments of 90-day supplies. The drug utilization review board shall make recommendations to the director on the drugs to be selected. This limit shall not apply when the beneficiary initially fills the prescription in order to provide an opportunity for the beneficiary to try the medication and for the prescriber to determine that it is appropriate for the beneficiary's medical needs. If there are extenuating circumstances in an individual case which, in the judgment of the prescriber, dictate a shorter prescribing period, an exception form that identifies the individual and the reason for the exception may be filed with the Office of Vermont Health Access.
Up to five refills are permitted if allowed by state or federal law.
The pharmacist shall not fill a prescription in a quantity different from that prescribed by the physician if payment is to be made by VHAP-Pharmacy, except in an individual case when the quantity has been changed in consultation with the physician.
Payment may be made for any preparation, except those unfavorably evaluated, either included or approved for inclusion in the latest edition of official drug compendia: American Hospital Formulary Service Drug Information; United States Pharmacopeia-Drug Information (or its successor publications); the DRUGDEX Information System; and the peer-reviewed medical literature. These consist of "legend" drugs for which a prescription is required by State or Federal law.
Physicians and pharmacists are required to conform to Act 127 (18-VSA-Chapter 91), otherwise known as the Generic Drug Bill. In those cases where the Generic Drug Bill permits substitution, only the lowest priced equivalent shall be considered medically necessary. If, in accordance with Act 127, the beneficiary does not wish to accept substitution, VHAP-Pharmacy will not pay for the prescription.
