Code of Vermont Rules
Agency 13 - AGENCY OF HUMAN SERVICES
Sub-Agency 170 - DEPARTMENT FOR CHILDREN AND FAMILIES (DCF)
Chapter 580 - HIV/AIDS (5800)
Section 13 170 580 - HIV/AIDS (5800)
Current through February, 2024
Section 5800 Introduction
The General Assembly of the State of Vermont, in its 1992 passage of H.937, directed the Department of Social Welfare to develop an "HIV/AIDS Health Insurance Assistance Program." Specifically, Section 124 of H. 937 directs that:
Expenditures shall not exceed the funds appropriated annually by the General Assembly for this program.
The policies with follow implement this program.
Section 5810 Eligibility
An individual must meet the following requirements to be found eligible for this program.
Section 5811 Residence
An individual must be living in (i.e. a resident of) Vermont to meet the State Resident requirement. Temporary absences to visit or obtain necessary medical care do not end Vermont residence.
Section 5812 Member of Covered Group
An individual must meet the following criteria to be a member of the covered group:
- be too ill with an HIV-related illness to continue to work a sufficient number of hours to afford individual or group health insurance (see Income Level);
- have been enrolled, prior to the reduction or termination of hours of employment, in a health insurance plan the continuation of which is determined by the Department to be less costly to the state than other alternatives.
Section 5820 Financial Need
An individual must be a member of a household with total income and resources under the following limits to meet this requirement
Section 5821 Definition of Household
The household includes the individual with an HIV-related illness and all of the following persons living in his/her household: his/her spouse, his/her unmarried and unemancipated children (biological and adopted) and stepchildren who are under the age of twenty-one, and the mother(s)/father(s) (biological or adoptive) of the included children and stepchildren.
Section 5822 Income Level
The total gross income of the household must not exceed 200 percent of the federal poverty guideline for the same size household to meet this requirement. (Gross income means that no deductions are allowed for employment expenses such as FICA, taxes withheld, union dues, transportation, dependent care expenses, etc.) Only unreimbursed medical expenses and health insurance premiums are deducted in determining gross income.
The total gross income from self employment is the adjusted gross income after business expenses including depreciation, have been deducted.
Section 5823 Resource Limit
The total countable resources of the household must not exceed $ 10,000.00. The following resources are not counted:
- the individual's primary residence;
- the value of vehicles owned by members of the household;
- the value of life insurance; or
- the value of personal belongings.
Section 5830 Coverage
Individuals found eligible for this program are eligible for:
- payment of their health insurance premium including payment for family coverage if that is what the individual had prior to reducing/terminating employment;
- until the funds appropriated by the Vermont General Assembly are exhausted.
The program will not pay:
- premiums for new insurance (i.e. it will not purchase insurance for individuals who do not have an existing individual or group health plan); and
- deductibles or coinsurance.
Section 5840 Application
An individual or his/her representative may file an application and must provide the applicant's Social Security number.
An application may be filed by mailing a signed HIV/AIDS application form to the Medicaid Division, Department of Social Welfare, 103 So. Main Street, Waterbury, VT 05671-1201.
The following documents, if they apply to any persons in the applicant's household, must be provided to the Department:
Physician's Certification
The individual must provide written certification from his/her physician that due to HIV-related illness, he/she is, or will be within 3 months, unable to continue working or has had, or will have, to reduce his/her hours of employment.
Verification of Income
Verification of income must be provided at the time of application or review. Acceptable forms of verification include but are not limited to:
- paystubs
- income tax forms
- written employer statements
- self employment business records
- award letters (i.e. Social Security, VA)
Verification of Resources
Verification of resources must be provided at the time of application or review. Acceptable forms of verification include but are not limited to:
- bank books and/or statements
- stock/bond certificates
- deeds
- property tax records
In addition to the above, it is the applicant's responsibility to provide all necessary information relative to his/her health insurance, including company name and address, employer name and address, premium amount verification and any other information which may be required.
The applicant/recipient is responsible for reporting any changes in his/her residence, income, resources, medical condition, or other circumstances affecting eligibility to the Medicaid Division within 10 days of the change.
Section 5841 Application Decision
Applications will be processed by the Medicaid Division of the Department of Social Welfare within 30 days of receipt of a completed application form and required verification/documentation.
Individuals will be notified in writing of all decisions made pertaining to their eligibility.
Section 5842 Period of Eligibility
Individuals who meet the eligibility criteria will be accepted into the program as long as the projected expenditures of individuals already enrolled in the program are not expected to exhaust the funds appropriated for the fiscal year.
Eligibility will be reviewed annually for each participant, or sooner, if changes occur which affect ongoing eligibility.
Payment of premiums under this program will continue until the earliest of the following occurs:
If eligibility for this program ends, a notice will be sent to the individual at least 10 days before the effective date of the adverse action.
Section 5843 Payment Methodology
Premium payment will be made on behalf of eligible recipients to:
Section 5845 Right to Appeal
Any applicant/recipient has the right to appeal any decision of the Department relating to their HIV/AIDS Health Insurance Assistance Program eligibility, and to request a fair hearing before the Human Services Board. A request for a fair hearing must be made within ninety (90) days of the date the notice of the decision being appealed was made. A request for a hearing is defined as a clear expression, oral or written, that the applicant/recipient wishes to appeal a decision. A recipient will continue to have the premiums paid pending the outcome of the appeal.
