Current through February, 2024
Section 5900 Premium Assistance
In 2006, the Vermont Legislature enacted Act 191, An Act
Relating to Health Care Affordability for Vermonters. Among other things, the
new law created four new health-care programs, designed to expand Vermonters'
access to quality, affordable health care. These programs are targeted at those
with incomes that exceed the traditional Medicaid limits. Eligibility is based
upon a variety of factors, including income, insurance status, the availability
of an approved employer-sponsored insurance (ESI) plan, and the relative cost
to the state of the individual's enrollment in the various programs. The
initiatives include:
Employer-Sponsored Insurance Premium-Assistance Program for
VHAP-Eligible Individuals (VHAP-ESIA). This is a premium-assistance program for
adults who are eligible for the Vermont Health Access Plan (VHAP) and who have
access to an approved ESI plan. VHAP-eligible individuals will be required to
participate in this program when the department determines that enrollment is
cost-effective to the state. VHAP-ESIA subsidizes the employee's premium
through a monthly payment. VHAP-ESIA also covers any required wraparound
services, and certain cost-sharing obligations. It provides the same coverage
that is available through VHAP, at the same cost to the beneficiary.
Employer-Sponsored Insurance Premium-Assistance Program for
Uninsured Individuals (Catamount-ESIA). This is a premium-assistance program
for adults who are uninsured and not eligible for VHAP and who have access to
an approved ESI plan. This program offers financial assistance through a
monthly payment for the purchase of ESI plans. It is available to uninsured
Vermont residents with incomes at or below 300 percent of the federal poverty
level (FPL) who are not eligible for VHAP-ESIA. In addition to a subsidy to
defray the employee's premium, Catamount-ESIA covers some chronic-care
cost-sharing.
Catamount Health Premium Assistance Program (CHAP). This is a
premium-assistance program for adults who are uninsured and not eligible for
VHAP and who do not have access to an approved ESI plan. This program offers
financial assistance for the purchase of a Catamount Health policy. Individuals
send their portion of the monthly premium to the state. The state then pays the
cost of the Catamount Health plan to the insurance company. CHAP is available
to Vermont residents with incomes at or below 300 percent of the FPL who are
uninsured and who are not eligible for a public insurance program.
Catamount Health (CH). A separate insurance pool, offering a
health-insurance product for uninsured Vermonters. Catamount policies provide
comprehensive benefit plans. They are modeled after a preferred-provider
organization plan with a $ 250 deductible. For those who are participating in a
chronic-care management program, cost sharing is not required for chronic-care
management and preventive services.
The department does not administer CH and these rules do not
address that program. However, in partnership with the Office of Vermont Health
Access (OVHA), the department determines eligibility for CHAP, as well as two
ESIA programs.
Section 5901
Definitions
(a) Approved employer-sponsored
insurance (ESI). An ESI plan that meets the coverage criteria established in
subsection 4103.6 below.
(b)
Available ESI plan. An ESI plan that the employee may enroll in within ninety
days.
(c) "Chronic care" means
health services provided by a health care professional for an established
clinical condition that is expected to last a year or more and that requires
ongoing clinical management attempting to restore the individual to highest
function, minimize the negative effects of the condition, and prevent
complications related to chronic conditions. Examples of chronic conditions
include diabetes, hypertension, cardiovascular disease, cancer, asthma,
pulmonary disease, substance abuse, mental illness, spinal cord injury, and
hyperlipidemia. Chronic care includes any day-to-day monitoring, treatment, and
therapy of chronic conditions. This includes consultations by any health-care
professionals, medication, investigations (blood tests, radiology) etc.
Excluded from chronic care is the treatment of acute complications related to
chronic conditions unless such treatment is specified in the blueprint for
health, as provided in 4106.2(c).
(d) Cost-effective. The program option that
is the least costly to the state. The methodology for determining
cost-effectiveness is described in subsection 4103.7 below.
(e) Cost sharing. Any health-care
co-payments, deductibles, or co-insurance that an individual or family is
required to pay, in addition to a premium.
(f) Employee. The applicant or a member of
the applicant household who is eligible to enroll in ESI (irrespective of VHAP
eligibility). "Employee" includes a retiree who is eligible to enroll in an ESI
plan that is offered to the retiree by a former employer.
(g) Employee's share of the premium. The
monthly portion of the ESI premium that is charged to the employee, before
receipt of premium assistance.
(h)
Employer-sponsored insurance (ESI). Health insurance or a group health plan
offered to employees and retirees by an employer.
(i) Premium assistance. Financial assistance
that is provided for the purchase of health insurance offered under an approved
ESI plan or a CH plan.
(j) Premium
balance. The monthly portion of the premium that the employee or individual is
responsible for, after receipt of premium assistance.
(k) Resident. An individual who lives in
Vermont with the intent to remain in the state permanently or for an indefinite
period of time.
(l) Uninsured. An
individual who does not qualify for Medicare, Medicaid, VHAP, or Dr. Dynasaur
and had no private insurance or employer-sponsored coverage that includes both
hospital and physician services within twelve months prior to the month of
application, or lost private insurance or employer-sponsored coverage during
the prior twelve months for any of the following reasons:
(1) The individual's private insurance or
employer-sponsored coverage ended because of:
(i) Loss of employment, including a reduction
in hours that results in ineligibility for employer-sponsored coverage, unless
the employer has terminated its employees or reduced their hours for the
primary purpose of discontinuing employer-sponsored coverage and establishing
their eligibility for CH;
(ii)
Death of the principal insurance policy holder;
(iii) Divorce or dissolution of a civil
union;
(iv) No longer receiving
coverage as a dependent under the plan of a parent or caretaker
relative;
(v) No longer receiving
COBRA, VIPER, or other state continuation coverage.
(2) College- or university-sponsored health
insurance became unavailable to the individual because the individual
graduated, took a leave of absence, decreased enrollment below a threshold set
for continued coverage, or otherwise terminated studies.
(3)
(i) The
individual lost health insurance as a result of domestic violence. The
individual shall provide the agency of human services with satisfactory
documentation of the domestic violence. The documentation may include a sworn
statement from the individual attesting to the abuse, law enforcement or court
records, or other documentation from an attorney or legal advisor, member of
the clergy, or health care provider, as defined in section
9402 of
Title 18. Information relating to the domestic violence, including the
individual's statement and corroborating evidence, provided to the agency shall
not be disclosed by the agency unless the individual has signed a consent to
disclose form. In the event the agency is legally required to release this
information without consent of the individual, the agency shall notify the
individual at the time the notice or request for release of information is
received by the agency and prior to releasing the requested
information.
(ii) Subdivision (i)
of this subdivision (3) shall take effect upon issuance by the Centers for
Medicare and Medicaid Services of approval of an amendment to the Global
Commitment for Health Medicaid Section 1115 Waiver allowing for a domestic
violence exception to the Catamount Health premium assistance waiting
period.
(m)
Wraparound services or coverage. Any health-care services not included in an
approved ESI plan, or any cost sharing the ESI plan imposes, that the state is
obligated to pay for. (See sub sections 4105.3 and 4106.2 below.)
Section 5910 Eligibility
Individuals are eligible for premium assistance if they meet
the financial and nonfinancial requirements set forth in this rule. Except for
M108, the provisions of Medicaid Rules M100-M199 are generally incorporated
into this rule. However, if there is a conflict between a provision in the
Medicaid rules and in this rule, the provision in this rule shall apply.
Section 5911 VHAP-ESIA
Employer-Sponsored Insurance Premium-Assistance Program for
VHAP-Eligible Individuals (VHAP-ESIA). This is a premium-assistance program for
adults who are eligible for the Vermont Health Access Plan (VHAP) and who have
access to an approved ESI plan. VHAP-eligible individuals will be required to
participate in this program when the department determines that enrollment is
cost-effective to the state. VHAP-ESIA subsidizes the employee's premium
through a monthly payment. VHAP-ESIA also covers any required wraparound
services, and certain cost-sharing obligations. It provides the same coverage
that is available through VHAP, at the same cost to the beneficiary.
To be eligible for VHAP-ESIA, an individual must meet all of
the VHAP eligibility rules (4000.1-4000.92) and the eligibility rules in
Medicaid Rules M100-M199 and have access to an approved, cost-effective ESI
plan. If eligible, an individual is granted VHAP while an ESIA determination is
being made.
5911.1 VHAP-ESIA
Enrollment.
(a) Enrollment in an ESI plan
with VHAP-ESIA is a condition of eligibility for VHAP if the plan is approved
and available, and enrollment is determined to be cost-effective. If the
employee in the household is a spouse or civil-union partner, the employee is
responsible for enrolling the VHAP-eligible spouse in the ESI plan.
(b) Except as provided in paragraph (c) of
this subsection, failure to meet this requirement shall result in both of the
following:
(1) Termination of VHAP
eligibility; and
(2)
Disqualification from participation in any premium-assistance program for the
period in which the individual remains unenrolled in a required ESI plan. The
individual may, at any time, requalify by reapplying for premium assistance;
enrolling in an approved, available, and cost-effective ESI plan; and otherwise
satisfying program requirements.
(c) An individual shall not be required to
enroll in a spouse or civil-union partner's ESI plan pursuant to this
subsection if a complaint for divorce, legal separation, dissolution, or
petition for relief from abuse has been filed by one spouse or partner against
the other.
Section
5912 Catamount-ESIA
Employer-Sponsored Insurance Premium-Assistance Program for
Uninsured Individuals (Catamount-ESIA). This is a premium-assistance program
for adults who are uninsured and not eligible for VHAP and who have access to
an approved ESI plan. This program offers financial assistance through a
monthly payment for the purchase of ESI plans. It is available to uninsured
Vermont residents with incomes at or below 300 percent of the federal poverty
level (FPL) who are not eligible for VHAP-ESIA. In addition to a subsidy to
defray the employee's premium, Catamount-ESIA covers some chronic-care
cost-sharing.
(a) An individual is
eligible for Catamount-ESIA if the individual:
(a) Is uninsured (see, paragraph (1) of
section
4101
);
(b) Is a Vermont
resident;
(c) Has income at or
below 300 percent of the FPL;
(d)
Is age eighteen or older and is not claimed on a tax return as a dependent of a
resident of another state; and
(e)
Meets the other eligibility requirements in Medicaid Rules M100-M199;
(f) Has access to an approved,
cost-effective, ESI plan.
Section 5913 CHAP
Catamount Health Premium Assistance Program (CHAP). This is a
premium-assistance program for adults who are uninsured and not eligible for
VHAP and who do not have access to an approved ESI plan. This program offers
financial assistance for the purchase of a Catamount Health policy. Individuals
send their portion of the monthly premium to the state. The state then pays the
cost of the Catamount Health plan to the insurance company. CHAP is available
to Vermont residents with incomes at or below 300 percent of the FPL who are
uninsured and who are not eligible for a public insurance program.
Except as provided in paragraph (b), an individual is
eligible for CHAP if the individual:
(a) Is uninsured (see, paragraph (1) of
section
4101
);
(b) Is a Vermont
resident;
(c) Has income at or
below 300 percent of the FPL;
(d)
Is eighteen or older and is not claimed on a tax return as a dependent of a
resident of another state;
(e)
Meets the other eligibility requirements in Medicaid Rules M100-M199;
and
(f) Does not have access to an
approved, cost-effective, ESI plan.
Section 5914 Prior Loss of Insurance
(a) An individual is ineligible for premium
assistance for the twelve-month period following loss of private insurance or
ESI without premium assistance unless coverage ends for a reason set forth in
4101(l)(1) or (2).
(b) No waiting
period is imposed because of the loss of:
(1)
Medicaid;
(2) VHAP;
(3) Dr. Dynasaur;
(4) VHAP-ESIA;
(5) Catamount-ESIA;
(6) CH with or without premium assistance,
or
(7) Any other health-benefit
plan authorized under Title XIX or Title XX of the Social Security
Act.
(c) Notwithstanding
any other provision of law, when an individual is enrolled in Catamount Health
solely under the high-deductible standard outlined in
8 V.S.A. §
4080f(a)(9), the individual
shall not be eligible for VHAP or premium assistance for the 12-month period
following the date of enrollment in Catamount Health.
Section 5915 Medicare
An individual who qualifies for Medicare, regardless of
actual enrollment, shall not be eligible for premium assistance.
Section 5916 Income Determinations
A household's income shall be calculated in accordance with
VHAP rule (5320) 4001.8.
Section
5917 ESI Available to Ineligible Member
When an ineligible employee has access to an approved,
cost-effective ESI plan, the ESI plan shall only be available to an eligible
household member if the employee is enrolled in the ESI plan.
Section 5920 Eligibility Process
Section 5921 Application
(a) Forms. Individuals must apply for premium
assistance on an application form that the department provides for this
purpose. Applications must be filed with the Health Access Eligibility Unit or
a district office of the Economic Services Division (ESD) of the Department for
Children and Families (DCF). Applications are acted upon in the order they are
received.
(b) Social Security
Number. An applicant must furnish a social security number or apply for a
social security number unless the individual 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. Social security numbers are used to verify
information through electronic data matches.
(c) Verification. Except as is specifically
required, the applicant or beneficiary is not generally required to provide
verification of the information provided. However, the department may require
verification if: the information is questionable, verification is outstanding
for another ESD benefit program, or the applicant or beneficiary has refused to
provide a social security number because of a religious objection. Individuals
are notified on the application form of the verification actions the department
may take.
Section 5922
Cooperation Requirements
(a) In addition to
any other cooperation requirements that the individual may be subject to, all
VHAP and premium-assistance applicants and beneficiaries must cooperate as
follows:
(1) All applicants and beneficiaries
must:
(i) Provide information regarding other
health coverage and access to ESI. The required information includes:
(A) The names of any spouse or civil-union
partner in the household currently covered by or with access to ESI;
(B) The name of the employee and the employer
offering the plan; and
(C) Any
requested information regarding the plan.
(ii) Report to the department any changes in
enrollment status, employee's premium share, household composition, employment,
income, residence, and access to ESI within ten days from the date the change
occurs.
(iii) Timely comply with
all program requirements.
(2) To receive CHAP, applicants and
beneficiaries must:
(i) Enroll in, and remain
enrolled in, CH;
(ii) Submit
verification of CH enrollment; and
(iii) Timely pay required premiums to the
state.
(3) To receive
Catamount-ESIA or VHAP-ESIA, applicants and beneficiaries must:
(i) Enroll in, and remain enrolled in, an
approved, available, and cost-effective ESI plan, as provided in subsection
4103.9;
(ii) Submit verification of
plan enrollment; and
(iii) Timely
pay employee's share of the premium or premium balance.
(b) Failure to cooperate as
specified in this rule, will result in denial of premium assistance and
termination of any VHAP, VHAP-ESIA, Catamount-ESIA, or CHAP benefits that the
individual may have been receiving.
(c) If an individual:
(1) Fails to timely complete and return a
required Plan Information Sign-Up Letter (PIRL) (4103.4) 5924 or Plan Sign-Up
Letter (PSL) (4103.9) 5924.5;
(2)
Subsequently reapplies for benefits within twelve months; and
(3) Is again required to complete and return
a PIRL or PSL, the individual will not be enrolled in any health-care program
until after the required forms are timely completed and returned.
Section 5923 Screening;
Initial Eligibility
(a) Upon receipt of a
health-care application, and based upon the information provided, the
department shall screen the applicant for eligibility for all of Vermont's
health-care programs. If it appears that the individual may be eligible for
Medicaid, the individual will be notified of the option to apply for that
benefit.
(b) VHAP-Eligible
Applicants.
(1) If the department initially
determines that the individual is eligible for VHAP, it shall enroll the
individual in that program.
(2) The
department shall also assess whether the individual may have access to an ESI
plan. This assessment may be made upon information including, but not limited
to:
(i) The individual's
statements;
(ii) Information known
to the department regarding insurance offerings of household members'
employers; and
(iii) Household job
income suggesting hours of employment sufficient to qualify the individual for
participation in an ESI plan.
(3) If it appears that the VHAP-eligible
individual may have access to an ESI plan, the VHAP eligibility notice shall
include a statement indicating that continued eligibility is subject to a
determination of whether enrollment in an ESI plan with VHAP-ESIA is
required.
(4) For as long as the
individual remains eligible for VHAP, the individual will continue to receive
VHAP benefits. However, as is provided in subsection 4103.11 below, if it is
subsequently determined that the individual is eligible for VHAP-ESIA, the
individual must enroll in the ESI plan at the earliest time permitted by the
employer.
(c)
VHAP-Ineligible Applicants.
(1) If the
department initially determines that an individual is not eligible for VHAP but
is eligible for premium assistance, it shall then assess whether the individual
may have access to an ESI plan. This assessment may be made as is provided in
subparagraph (b)(2) of this subsection.
(2) If it does not appear that the individual
has access to an ESI plan, the individual shall be offered the opportunity to
purchase a CH policy with CHAP. (See 4103.8.)
(d) If it appears that the individual may
have access to an ESI plan, OVHA shall determine whether the plan is an
approved plan. If so, OVHA will determine if:
(1) The plan is available; and
(2) It would be cost-effective to the state
to require the individual to enroll in the plan with premium
assistance.
Section
5924 Plan Information Request Letter
(a) The Plan Information Request Letter
(PIRL) solicits information pertinent to OVHA's determinations of whether an
ESI plan is approved, available, and cost-effective. (See 4103.2(a)(1)). The
PIRL shall indicate that the completed form is to be returned to
OVHA.
(b) A PIRL may be sent:
(1) After eligibility for premium assistance
is initially determined;
(2) When
eligibility is redetermined;
(3)
When it appears that the availability of an ESI plan may have changed;
or
(4) When it appears that the
individual's ESI-plan coverage or cost may have changed.
(c) The individual shall have an initial
period of at least ten days to respond to the PIRL. If the response is not
submitted within the time period prescribed in the initial PIRL, the department
shall send a second request, affording at least ten additional days for a
response.
(d) The time limit for
responding to a PIRL shall be extended if the individual has, in good faith,
tried to respond to the request, but has been unable to do so within the
prescribed period of time. For example, an extension will be granted if the
individual's inability to respond is due to an employer's delay in responding
to the individual's request for plan information.
(e) If the individual fails to respond to the
PIRL within the time period provided, the department will deny VHAP, VHAP-ESIA,
Catamount-ESIA, or CHAP, or terminate any of these healthcare benefits that the
individual had been receiving.
5924.1 Enrollment Determination
(a) Upon timely receipt of a PIRL response,
OVHA shall review it for completeness. If the form is incomplete, OVHA may
either:
(1) Return the PIRL to the
individual, with an indication of the additional information required,
or
(2) Attempt to gather the
missing information directly from the individual's employer.
(b) If OVHA returns an incomplete
PIRL, it shall provide the individual with a period of at least ten days to
provide the requested information. If the individual fails to provide the
requested information within the time period provided, the department will deny
VHAP, VHAP-ESIA, Catamount-ESIA, or CHAP, or terminate any benefits that the
individual had been receiving.
(c)
If, after receipt of a complete PIRL response, OVHA determines that it needs
additional information to complete its enrollment determination, it may request
it from the individual, the employee, and, where appropriate and necessary, the
employer or insurance carrier.
(d)
OVHA shall determine whether an approved ESI plan is available to the
individual, and if so, whether the individual's enrollment in the plan will be
cost-effective. This determination shall be made within ten days of the date
that OVHA receives all of the information requested for this purpose.
5924.2 Approval of ESI Plans
(a) VHAP-ESIA or Catamount-ESIA will only be
extended to subsidize the cost of plans that OVHA approves as comprehensive and
affordable.
(b) An ESI plan will be
approved if it conforms to the following standards:
(1) The plan includes coverage for:
(i) Physician visits;
(ii) Inpatient care;
(iii) Outpatient services, including:
(A) Diagnostics;
(B) Physical therapy, and
(C) Surgery;
(iv) Prescription drugs;
(v) Emergency room services;
(vi) Ambulance services;
(vii) Mental health and substance abuse
treatment;
(viii) Medical equipment
and supplies; and
(ix) Maternity
care.
(2) Once statewide
participation in the Vermont blueprint for health is achieved, the plan
includes appropriate coverage of chronic conditions as specified in the
blueprint and in accordance with the standards established in section
702
of Title 18.
(3) The plan's
in-network deductible for health-care services is not in excess of: $ 500 for
an individual and $ 1,000 for two people or a family.
5924.3 Determining
Cost-Effectiveness
(a) OVHA shall base
determinations of cost-effectiveness on information gathered from the following
sources:
(1) Information submitted by the
individual in the application for benefits and in response to a PIRL.
(2) Information contained within the OVHA
database. (OVHA collects data about approved ESI plans from a variety of
sources, including other beneficiaries, employers, and insurance
carriers.)
(3) OVHA
records.
(4) Additional information
OVHA may request from the individual, the employee, and, where appropriate and
necessary, the employer or insurance carrier.
(b) OVHA will use the information about the
ESI plan to compare the cost of premium assistance with the expense the state
is likely to incur if the state elects to enroll the individual in an
alternative program (i.e., VHAP, for VHAP-eligible individuals or CHAP, for
those who are ineligible for VHAP).
(c) For VHAP-eligible individuals, enrollment
in an ESI plan is deemed cost-effective when the premium assistance plus the
projected cost of wraparound coverage is less than the projected cost of
covering the individual through VHAP.
(d) For VHAP-ineligible individuals,
enrollment in an ESI plan is deemed cost-effective when the premium assistance
plus the projected cost of wraparound coverage is less than the cost of the CH
premium assistance the state will pay if the individual purchases a CH plan
with premium assistance.
5924.4 No Cost-Effective or Available ESI
(a) If OVHA determines that an approved ESI
plan is not available or that the individual's enrollment in an available plan
would not be cost-effective, the department shall act as follows:
(1) If the individual is otherwise eligible
for VHAP, the department shall send the individual a notice advising that VHAP
coverage shall continue.
(2) If the
individual is not eligible for VHAP, but has household income at or below 300
percent of the federal poverty level, the department shall send the individual:
(i) Notices shall include:
(A) Apprisal of the availability of
CHAP.
(B) An explanation that
enrollment in a CH plan is voluntary, but that premium assistance is only
available to those who enroll in a CH plan;
(C) Referral to plan enrollment
information;
(D) Notice that, if
the CHAP option is chosen, the individual must return a completed CHAP Plan
Sign-Up Letter (PSL) to OVHA and send payment of the first month's premium
balance. Failure to return a completed PSL within the specified time period
will result in denial of CHAP;
(E)
Notice that the individual must pay a monthly premium to the state before CHAP
can begin and must timely pay a monthly premium to the state for CHAP to
continue. Failure to pay the premium within the specified time period will
result in the denial of CHAP or program termination.
(F) Notice that, if CHAP is elected, the
individual will be required to enroll in ESI, if the department subsequently
determines that an approved, cost-effective plan is available.
(ii) Premium bill. An initial
premium bill. The bill shall indicate that payment is owed, only if the
individual elects to participate in CHAP.
(iii) CHAP Plan Sign-Up Letter. After the
initial premium payment is received, the individual will receive a CHAP PSL
requesting information regarding the specifics of any CH plan that the
individual elects to enroll in.
(b) Premium due date. The individual will
have thirty days to pay the premium. Eligibility for CHAP will be terminated if
the premium is not received by the premium due date.
(c) CHAP PSL time frame. The individual will
have thirty days to return the completed CHAP PSL. If the individual does not
return the PSL by the due date, the department will deny CHAP, even if the
premium payment is timely received.
(d) If the CHAP PSL and premium payment are
timely received, OVHA will initiate payment of CHAP, coverage begins on the
start date indicated on the PSL.
5924.5 Cost-Effective ESI Available
(a) If OVHA determines that it will be
cost-effective for the individual to enroll in an available ESI plan with ESIA,
the individual will receive an ESI Plan Sign-Up Letter (PSL). The PSL shall
include:
(1) An instruction, directing
enrollment in the ESI plan at the earliest time permitted by the
employer;
(2) A request for
additional information from the individual regarding the specifics of the ESI
plan; and
(3) Notice that failure
to return a completed PSL, failure to enroll in the ESI plan, or disenrollment
from the plan while the plan remains available will render the individual
ineligible for premium assistance and result in the termination of any VHAP
benefit that may have been granted.
(b) The individual shall be provided with a
period of at least ten days to return the completed PSL to OVHA.
(c) Upon receipt of a completed PSL, OVHA
will initiate payment of premium assistance to the individual, as provided in
subsection 4106.1.
(d) If the
individual fails to return the completed PSL within the time period provided or
fails to enroll in the ESI plan, the department will deny the application and
terminate any VHAP benefit that may have been granted.
Section 5925 Eligibility Period
and Enrollment
Eligibility for all premium-assistance programs is subject to
annual review. Eligibility review will be completed before the end of each
certification period to assure uninterrupted coverage if the individual remains
eligible, complies in a timely manner with review requirements, and pays any
required premium by the due date. An individual who fails to timely comply with
review and premium requirements shall receive a termination notice mailed at
least eleven days before the termination date. A failure to timely comply may
result in a gap in coverage.
5925.1
New Access to ESI
(a) Decisions about whether
a VHAP or CHAP applicant or beneficiary will be required to enroll in an
approved ESI plan may be made in conjunction with:
(1) Initial determinations of
eligibility;
(2) Periodic
redeterminations of eligibility;
(3) Eligibility redeterminations resulting
from changes in access to ESI (e.g., work status, residency, income, household
composition, etc.); and
(4) The
department's receipt of information indicating that an individual applying for
or receiving VHAP or CHAP has access to and is eligible to enroll in an
approved ESI plan.
(b) A
VHAP or CHAP beneficiary who becomes eligible for an ESI plan must notify the
department of that change and cooperate with the department as provided in this
rule.
(c) If the department
determines that the plan is an available, approved ESI plan and that it would
be cost-effective for the individual to enroll in the plan, the individual will
be notified of the determination and informed that plan enrollment with ESIA is
a condition of retaining program eligibility. The individual must enroll in the
plan at the earliest time permitted by the employer.
(d) During the period of review, and pending
enrollment in the ESI plan, the individual shall continue to be enrolled in
VHAP or CHAP.
5925.2
Plan Disenrollment
(a) If the employee
disenrolls from an ESI plan because the plan is no longer available, the
individual shall be enrolled in VHAP or CHAP.
(b) If the employee disenrolls in an ESI plan
while the plan remains available, premium assistance and VHAP shall terminate.
The individual may, at any time, requalify by reapplying for premium
assistance, enrolling in an approved, available and cost-effective ESI plan,
and otherwise satisfying program requirements.
5925.3 ESI No Longer Approved or
Cost-Effective
Premium assistance will terminate if OVHA withdraws its
approval of an ESI plan or determines that an individual's continued enrollment
in a plan is no longer cost-effective. If premium assistance is terminated in
this manner, VHAP-ESIA participants will return to the VHAP program and
Catamount-ESIA participants will be offered the opportunity to purchase a CH
policy with CHAP.
Section
5930 Notice-and-Appeal Rights
(a) Premium-assistance applicants and
beneficiaries shall receive timely notification of department eligibility and
enrollment determinations.
(b)
Notices will be in writing and sent by first-class mail to the most current
address on file for the individual.
(c) Notices shall:
(1) State the reason for any adverse
decisions; and
(2) Explain the
individual's right to request a fair hearing before the Human Services
Board.
(d) A notice of
termination must be sent at least eleven days prior to disenrollment.
(e) A VHAP or premium-assistance applicant or
beneficiary has a right to appeal eligibility and enrollment decisions and to
request a fair hearing before the Human Services Board.
(f) A request for a fair hearing must be made
within ninety days of the date the notice of the decision being appealed was
mailed.
(g) Except as provided in
paragraph (h) below, enrollment shall continue without change pending
resolution of an appeal if:
(1) The appeal
challenges a decision to terminate a benefit;
(2) The beneficiary requests a hearing before
the effective date of the termination; and
(3) The beneficiary has fully paid any
required premiums.
(h)
Enrollment will not continue pending appeal if:
(1) The appeal is based solely on a benefit
reduction or elimination which is required by federal or state law affecting
some or all beneficiaries,
(2) The
challenged decision does not require the minimum advance notice (see Notice of
Decision at M141), or
(3) The
appeal is based solely upon termination of interim seamless coverage provided
pursuant to 4108 below.
(i) Beneficiaries appealing the amount of
their premium balances or premium assistance must pay at the billed amount
until the dispute is resolved in order for coverage to continue. If the
fair-hearing process is concluded in favor of the beneficiary, the beneficiary
will be reimbursed for any premium amounts overpaid.
(j) VHAP beneficiaries who request a hearing
after the effective date of termination will not receive continued benefits. In
such a case, however, if the fair-hearing process is concluded in favor of the
beneficiary, the department will pay the costs incurred in securing what would
have been covered services during the appeal period. Payment will be made to
the beneficiary if the beneficiary actually paid out of pocket to the provider.
Otherwise, payment will be made to the provider.
(k) Premium-assistance beneficiaries who
request a hearing after the effective date of termination will not receive
premium assistance pending resolution. If the fair-hearing process is concluded
in favor of the beneficiary, the beneficiary's remedy will be reinstatement and
reimbursement for the amount of premium assistance and wraparound coverage that
would have been provided, had the benefit remained in effect.
(l) Beneficiaries may waive their right to
continued benefits. If they do so and are successful on an appeal, benefits
will be paid retroactively.
(m) For
grievances and appeals regarding services for which the state is a payor,
Medicaid Rules M180 and M181 apply.
Section 5940 Premium-Assistance Amounts
(a) In general, the premium-assistance amount
depends on the net income of the household on the most recent approved version
of eligibility on the case record at the time the bill or premium-assistance
payment is generated.
(b) No
premium assistance shall be paid for any month in which the assistance amount
is less than $ 5.00.
Section
5950 VHAP-ESIA Benefits
Section
5951 Premium Balances and Assistance Amounts
(a) The VHAP-ESIA premium balance is equal to
the amount of the VHAP premium that would have been paid, had the individual
only been enrolled in VHAP. The VHAP premium amounts are set forth in VHAP rule
4001.91.
(b) The VHAP-ESIA
premium-assistance amount is the difference between the employee's share of the
premium and the premium balance. For example, if the employee's share of the
premium is $ 120 and the premium balance is $ 33, the monthly VHAP-ESIA premium
assistance owing to the individual would be $ 120 minus $ 33 or $ 87, which is
paid to the individual.
(c) If the
employer offers more than one approved ESI plan, the individual may enroll in
the plan of choice, provided that ESI enrollment remains cost-effective. The
premium-assistance amount will be calculated as provided in paragraph (b),
regardless of any differences in plan costs.
(d) At the beginning of the month that the
employee's premium share is due, the household shall receive the
premium-assistance benefit. Monthly payments may be made either by mailing a
check or electronically transferring payment to the designated account. If the
household has a bank or credit-union account, direct deposit to the account is
the required payment method.
(e) In
cases where the employee's share of the premium is paid before the commencement
of premium assistance (e.g., when plan enrollment occurs on a day other than
the first of the month), the department shall reimburse the household for the
prorated premium-assistance amount due for the period in issue.
Section 5952 VHAP-ESIA Wraparound
Coverage
(a) VHAP-ESIA wraparound coverage
includes:
(1) VHAP-covered health-care
services not included in the approved ESI plan, and
(2) Cost sharing incurred under the ESI plan
for VHAP-covered services that exceeds the cost-sharing requirements for VHAP
enrollees. (See, 4001.91 and 4001.92).
(b) To qualify for wraparound coverage,
VHAP-ESIA enrollees must be served by a Medicaid-participating provider within
the ESI network who agrees to bill the state for the wraparound services and
cost sharing up to the Medicaid-allowed amount.
(c) VHAP-ESIA enrollees will receive an ID
card. This card, together with the individual's ESI group-health card is
presented to health-care providers at the point of service to signify the
department's responsibility for any VHAP-ESIA wraparound coverage. Payments for
wraparound coverage will be made at the Medicaid rate.
(d) The individual shall be fully responsible
for the cost of any service that is not included in the ESI plan or
VHAP.
Section 5960
Catamount-ESIA Benefits
Section
5961 Premium Balances and Premium-Assistance Amounts
(a) Pursuant to
33 V.S.A. §
1974(c)(3), the department
set the initial Catamount-ESIA premium balances at amounts equal to the premium
balances established in statute for CHAP. To ensure future program parity, once
each year the Catamount-ESIA premium balances shall be adjusted to equal the
CHAP premium balances in effect at that time. Catamount-ESIA premium balances
are published in P-2420 A of the department's Medicaid Procedures.
(b) The Catamount-ESIA premium-assistance
amount is the difference between the employee's share of the premium and the
premium balance. Thus, for example, if the employee's share of the premium is $
130.00 per month and the household's income is at 195 percent of the FPL, the
monthly ESIA premium-assistance would be $ 130.00 minus $ 65.00 or $
65.00.
(c) If the employer offers
more than one approved ESI plan, the individual may enroll in the plan of
choice, provided that ESI enrollment remains cost-effective. The premium
assistance will be calculated as provided in paragraph (a), regardless of any
differences in plan costs.
(d) At
the beginning of the month that the employee's premium share is due, the
household shall receive the premium-assistance benefit.. Monthly payments may
either be made by mailing a check or electronically transferring payment to the
designated bank. If the household has a bank or credit-union account, direct
deposit to the account is the required payment method.
(e) In cases where the employee's share of
the premium is paid before the commencement of subsidy payments (e.g., when
plan enrollment occurs on a day other than the first of the month), the
department shall reimburse the household for the prorated premium-assistance
amount due for the period in issue.
Section 5962 Chronic-Care Wraparound Coverage
(a) Until January 1, 2009, or statewide
participation in the Vermont blueprint for health is achieved, the
Catamount-ESIA program shall provide wraparound coverage for the cost sharing
incurred under the ESI plan for VHAP-covered chronic care, as defined in
paragraph (c).
(b) To qualify for
wraparound coverage, Catamount-ESIA enrollees must be served by a
Medicaid-participating provider within the ESI network who agrees to bill the
state for the wraparound cost sharing up to the Medicaid-allowed
amount.
(c) The services subject to
wraparound coverage under this subsection are the chronic-care health services
covered by the Vermont Health Access Plan to treat the chronic conditions
specified in the blueprint for health in section
702
of Title 18. Annually, after consultation with the director of the blueprint
for health, OVHA shall establish in procedure the codes that are associated
with treatments for chronic conditions that are eligible for the assistance
provided for in this paragraph.
(d)
Catamount-ESIA enrollees will receive an ID card. This card, together with the
individual's ESI group health card, is to be presented to health-care providers
at the point of service to signify the department's responsibility for any
Catamount-ESIA wraparound coverage.
(e) The individual shall be fully responsible
for the cost of any service that is not covered by the ESI plan or
VHAP.
Section 5963
Premium Balances and Premium-Assistance Amounts
(a) Premium Balances are published in P-2420
A of the department's Medicaid Procedures.
(b) Initial CHAP premium balances were
established in statute. (
33 V.S.A. §
1984(b) ). That provision
directs the department to index premium balances to the overall growth in
spending per enrollee in Catamount Health. The following methodology shall be
used for this purpose:
(1) Premium balances
established in statute are the "base premium balances."
(2) One to four times each year, the CH
carriers will review product premiums and set new rates. Following the first
premium changes, the department will proportionately adjust the base premium
balances, rounding to the nearest whole dollar. The new premium balances become
the "adjusted-base" premium balances. The department shall likewise readjust
adjusted-base premium balances following the carriers' every subsequent premium
change.
(3) If new base premium
balances are established in statute, the department shall subsequently adjust
the new base premium balances in the same manner provided above.
(4) New applicants shall pay the premium
balance in effect on the date of enrollment.
(5) Premium balances charged to enrolled
beneficiaries are subject to change on enrollment anniversary dates. The new
premium balances will correspond to the premium balances in effect on the
enrollment anniversary date.
(6)
This methodology is illustrated as follows:
|
Date
|
Premium
|
% Increase Over Prior Dec.
Premium
|
Premium Balance 200-225% FPL
|
|
Dec. 31, 2008
|
$ 393.00
|
$ 110.00
|
|
July, 2009
|
$ 432.00
|
10%
|
$ 121.00
|
|
January, 2010
|
$ 441.00
|
2%
|
$ 123.00
|
|
July, 2010
|
$ 454.00
|
3%
|
$ 127.00
|
In this example, in July of 2009, the CH premium increases by
10%. Therefore, the premium balance is likewise increased by 10% (from $ 110.00
to $ 121.00). In January of 2010, the CH premium increases from $ 432 to $ 441
an increase of 2%. Therefore, the premium balance for those applying on or
after January 1 (or having an anniversary date that falls on or after January)
is $ 123.00 (2% more than $ 121.00). The following July, the premium balance
will be increased to $ 127.00 (3% more than $ 123.00). The beneficiary premium
balance will be $ 127 for those applying on or after July 1; the premium
balance for beneficiaries will increase when the beneficiaries reach their
anniversary dates, beginning with the July anniversary date.
(c) The premium-assistance amount
for the lowest-cost CH plan is the difference between the full CH premium and
the CHAP premium balance. For example, if the lowest-cost CH premium is $ 350
per month and the household's income is at 230 percent of the FPL, the
individual's premium balance would be $ 135 and the monthly CHAP premium
assistance would be $ 350 minus $ 135 or $ 215.
(d) For CH plans other than the lowest cost
plan, the individual's premium balance shall be the sum of the premium balance
as set out in paragraph (a) and the difference between the premium for the
lowest cost plan and the premium for the plan in which the individual is
enrolled. Thus, if in the example above, the individual chooses a CH plan with
a monthly premium of $ 400, the individual's premium assistance remains $ 215.
The premium balance would be: $ 135 plus $ 50 ($ 400 minus $ 350), or $
185.
(e) CHAP program participants
pay their premium balances to the department, as provided in section 4108
below. The department is responsible for transmitting the full CH premium
amount (the premium balance plus the CHAP premium assistance) directly to the
CH carrier.
Section 5970
Seamless Coverage
From time to time, a beneficiary's changed circumstances may
require a change from one health-care program to another. For example, a
childless adult who is enrolled in VHAP will lose eligibility for that program
when income rises above 150% FPL and become eligible for CHAP. This rule
ensures that individuals retain coverage during program transitions brought
about by changed circumstances.
5970.1
Transitions between VHAP and VHAP-ESIA
Coverage during transitions between VHAP and VHAP-ESIA is
provided for in sub sections 4103.3(b)(4) and (5925.1) 4103.11(d) above.
5970.2 Transitions from Medicaid,
Dr. Dynasaur, VHAP, or VHAP-ESIA
Beneficiaries who become ineligible for Medicaid, Dr.
Dynasaur, VHAP, or VHAP-ESIA due to changed circumstances shall retain coverage
pending enrollment in an alternative premium-assistance program, if
they:
(a) Remain eligible for an
alternative premium-assistance program and
(b) Timely comply with the eligibility
requirements pertaining to the alternative premium- assistance
program.
Section
5971 Premium Payments
Every month that the department receives a premium-balance
payment from a CHAP beneficiary, it shall forward that sum, along with the
premium assistance amount, to the beneficiary's CH provider.
Section 5972 Payment Adjustments
5972.1 Underpayments
(a) Department errors that result in
underpayment of premium assistance shall be promptly corrected retroactively
under the following conditions:
(1) When the
information was available to the department at the time the error occurred to
enable authorization of the correct amount.
(2) Retroactive corrected payment shall be
authorized only for the twelve months preceding - the month in which the
underpayment is discovered. Payments shall be authorized irrespective of
current receipt of, or eligibility for, benefits.
(3) The retroactive corrective payments shall
not be considered as income in the month paid or in the following
month.
(b) Corrective
payments shall be retroactive to the effective date of the incorrect action,
not subject to the above limitations, when:
(1) Ordered as a result of a fair hearing or
court decision.
(2) Authorized by
the Commissioner as the result of a department decision rendered on a formal
appeal prior to hearing.
(c) Retroactive corrective payments will be
applied first to any outstanding unrecovered overpayment. The amount of
corrective payment remaining, if any, shall be paid to the
beneficiary.
5972.2
Overpayments
(a) Overpayments of premium
assistance, whether resulting from administrative error, beneficiary error, or
payments made pending a fair hearing which is subsequently determined in favor
of the department, shall be subject to recovery. Recovery of an overpayment can
be made through beneficiary repayment or by a reduction in the amount of any
current or future premium-assistance payment the household may
receive.
(b) No recovery shall be
attempted if the overpayment took place more than twelve months prior to the
date of discovery unless the overpayment was caused by the individual's willful
withholding of information which affected the amount of payment. In such cases,
recovery of overpayments which took place within a three-year period prior to
the date of discovery can be attempted.
(c) The beneficiary may elect to repay an
overpayment through a lump-sum cash payment or, with the agreement of the
department, installment payments. If the installment method elected, the
monthly payment amount must be at least ten percent of the current monthly
health-care benefit or $ 10.00 per month, whichever is more. Installment terms
must be recorded in a written document, signed by the beneficiary and an
authorized representative of the department. If the beneficiary fails to submit
a payment in accordance with the terms of an agreed-upon repayment schedule,
the claim becomes delinquent and subject to collection through reduction in
premium-assistance benefits or as otherwise provided for by law. If the
beneficiary fails to elect a recovery method, recovery will be made by a
reduction in the amount of any current or future premium-assistance payment the
household may receive. The monthly reduction shall equal ten percent of the
monthly benefit or $ 10.00, whichever is more.
