Code of Vermont Rules
Agency 13 - AGENCY OF HUMAN SERVICES
Sub-Agency 170 - DEPARTMENT FOR CHILDREN AND FAMILIES (DCF)
Chapter 710 - MEDICAID BENEFIT DELIVERY (7100)
Section 13 170 710 - MEDICAID BENEFIT DELIVERY (7100)
Current through February, 2024
Section 7101 Medicaid Benefit Delivery
(06/01/2018, GCR 17-090)
The following includes steps the department, the eligible Medicaid beneficiary and the medical care provider must take for the provider to receive payment for services given to the beneficiary.
Managed health care plans must notify the affected member, or his or her designated representative, in writing, of a plan-initiated request for disenrollment. Only the department may disenroll a member from a managed health care plan.
The primary care case management (PCCM) program is a managed health care service delivery system that requires a beneficiary to choose a primary care provider (PCP) and to access specified medical care through this provider. The primary care provider (PCP) will provide and coordinate medical care for the beneficiary through direct service delivery or by making appropriate referrals to other providers for necessary services.
Under this system a payment is made to the primary care provider (PCP) each month for case management services provided to each beneficiary enrolled with the PCP. Family practitioners, general internists, pediatricians, or doctors of general medicine, that are enrolled with Vermont Medicaid may become a PCP in the PCCM program. Specialists may become a PCP only under the conditions described below. The PCP selected by a beneficiary shall coordinate needed medical services. PCPs will be responsible for providing beneficiaries with referrals to specialists when in their judgement it is considered medically necessary; for coordinating all ancillary, outpatient and inpatient services; and for preventing the duplication of services.
If a beneficiary has either a life-threatening condition or disease, or a degenerative or disabling condition or disease, that requires specialized medical care over a prolonged period of time, a specialist with expertise in treating the condition or disease may act as the beneficiary's PCP. If a specialist agrees to act as the PCP, the specialist shall provide and coordinate medical care for the beneficiary through direct service delivery or by making appropriate referrals to other providers for necessary services. The DVHA Medical Director must review and approve of such arrangements before a specialist may become the PCP. If the request is denied by DVHA, the beneficiary has the right to appeal DVHA's decision and to request a fair hearing.
Enrollees may change their primary care provider (PCP) for any reason every 30 days. Primary care provider changes will become effective on the first day of the following month, if all required actions have been completed by the fifteenth of the prior month. Otherwise, the change shall become effective the first of the second month after all required actions are completed.
If a beneficiary has to change PCP as a result of his or her PCP restricting or terminating participation in the PCCM program, the DVHA will assist the beneficiary in selecting another PCP in order to assure continuity of care.
Written confirmation of the determination will be sent to the provider within twenty-four (24) hours of the telephone notification.
The DVHA will not require any beneficiary to be assigned to the PCCM program unless covered health care services, including referrals to participating specialty physicians, are accessible to members on a timely basis, as follows. The DVHA will make a good faith effort to attract sufficient numbers and types of providers to ensure that all covered health care services will be provided without unreasonable delay.
The DVHA shall take the appropriate steps necessary to ensure that information gathered by it in its quality assurance activities shall be confidential and privileged.
The DVHA shall supply to each beneficiary upon enrollment and upon major revision thereafter the following information consistent with 42 CFR § 438.10(g). The information shall be in handbook form and in twelve-point type, and shall be in plain language. This requirement may be satisfied by giving a copy of the handbook to each household, rather than to each beneficiary. The DVHA shall make available to any beneficiary, upon request, a listing by specialty of the name, telephone number and address of all health care providers and health care facilities enrolled in PCCM and Medicaid (including, in the case of physicians, information as to board certification). This list shall be updated (by addendum or otherwise) at least once every six months, and shall indicate which primary care providers are accepting new patients. In addition, the handbook shall include:
* has not been effective in treating the patient's medical condition; or
* causes or is reasonably expected to cause adverse or harmful reactions in the beneficiary.
Section 7102 Prior Authorization
Prior authorization is a process used by the department to assure the appropriate use of health care services. The goal of prior authorization is to assure that the proposed health service [n1] is medically needed; that all appropriate, less-expensive alternatives have been given consideration; and that the proposed service conforms to generally accepted practice parameters recognized by health care providers in the same or similar general specialty who typically treat or manage the diagnosis or condition. It involves a request for approval of each health service that is designated as requiring prior approval before the service is rendered. The department shall notify each patient and provider of its decision, which is arrived at by applying the criteria set forth in M106.3.
[n1 "Health services" as used in these rules include services, items or procedures.]
The complete and current list of all services and items including procedure codes that require prior authorization is set out in the Provider Manual. The list is updated periodically. Additions and deletions to the list are also published in advance in the provider advisory newsletter and other communications to providers.
The department is responsible for determining questions of coverage and medical necessity under the Vermont Medicaid program. The department may contract with external organizations to help make these determinations; however, the final decision rests with the department.
Supporting information for a prior authorization request must include a completed claim and a completed medical necessity form. Additional information that may be required includes:
* the patient's complete medical record;
* the patient's plan of care;
* a statement of long-term and short-term treatment goals;
* a response to clinical questions posed by the department;
* a second opinion or an evaluation by another practitioner, at Medicaid expense;
* the practitioner's detailed and reasoned opinion in support of medical necessity;
* a statement of the alternatives considered and the provider's reasons for rejecting them; and,
* a statement of the practitioner's evaluation of alternatives suggested by the department and the providers reasons for rejecting them.
If any of this additional information is required, the department will notify the provider promptly. Once the necessary information has been received, the beneficiary will be sent a notice of decision that may be appealed. See M142.
* The service was required to treat an emergency medical condition.
* The service was provided prior to the determination of Medicaid eligibility and within the retroactive coverage period.
Section 7103 Medical Necessity for Covered Services Exceptions
(07/01/20, GCR 19-060)
Section 7104 Requesting Coverage Exceptions
Any beneficiary may request that the department cover a service or item that is not already included on a list of covered services and items. The request should be sent to the Director of the Office of Vermont Health Access (OVHA). The director will review the request and supporting documentation and make a good faith effort to obtain any additional information quickly to allow the commissioner to make a decision within thirty days. In no case will a request for a service or item be approved for coverage unless it is medically necessary.
Each decision shall result in one of four outcomes. The four possible outcomes are:
If the commissioner's decision is to add the service or item to a pre-approved list of covered services, a PP&D memorandum will be issued delineating the addition. All such PP&D memoranda will be incorporated into the rule as soon as practical. An adverse decision from the commissioner may be appealed through the fair hearing process. An adverse decision may not be renewed by the same beneficiary until twelve months have elapsed since the previous final decision or until new documentation of the individual's condition, a change in the individual's condition, new medical evidence, or a change in technology has been demonstrated.
The Office of Vermont Health Access shall, semiannually, issue a PP&D memorandum updating the listing of all affirmative coverage decisions made under this procedure that do not result in the service or item that is authorized being added to a list of pre-approved services or items. This list shall include the commissioner's coverage decisions, plus negotiated settlements and Human Services Board and Vermont Supreme Court decisions. Because this list shall be available for public inspection, it shall be composed in a manner that protects beneficiaries' right to confidentiality. The department will ensure that all Medicaid beneficiaries who are similarly situated to the individual who has obtained coverage will be treated similarly with respect to coverage of the same service or item.
If, under this section, an individual requests that a service or item be covered, the following criteria will be considered, in combination, in determining whether to cover the service or item for the individual and/or to add it to a list of pre-approved services or items, with the following exception. If the service or item is subject to FDA approval and has not been approved (criterion #9 below), the request for coverage of the service or item will be denied.
Section 7105 Medical Service Payment
The department pays providers for Medicaid Services through a fiscal agent. To receive payment, the provider must send a claim to the fiscal agent subject to the limitations and conditions specified in Sections M154-M159.
The department will reimburse a Medicaid recipient for his/her out-of-pocket expense for covered medical services under the following conditions only:
* The recipient applied for benefits after February 15, 1973, and was denied; and
* The recipient was later granted Medicaid as a result of any review of the initial denial which resulted in its reversal (e.g. quality control review, supervisory review, SSI appeal, appeal and reversal by the Human Services Board, or any other identification of an error in the original determination which results in its reversal).
Reimbursement is for 100 percent of the out-of-pocket expenditures made by a recipient or a member of his/her Medicaid group or a financially responsible relative who is not a member of the group, for Medicaid-covered services provided between the date of eligibility (which may be as early as the first day of the third month before the month of application) and the date the recipient's first Medicaid ID was made available to him/her (when this date cannot be determined otherwise, use the second mail delivery day following the date the first Medicaid ID was mailed). No copayment is due.
Payment cannot otherwise be made direct to a Medicaid recipient, even if he/she has already paid the provider for a covered service. When Medicaid coverage is granted after bills have been paid (for example, through application for retroactive coverage), the recipient may ask the provider to bill Medicaid and refund the recipient's payment. If the provider agrees to do so, he/she must accept the Medicaid allowance and refund the full amount of the recipient's payment (see also Provider Responsibility).
The fiscal agent sends a notice of Medicaid benefits paid to a sample of recipients who receive a service each month. The recipient must report any disagreement with the notice to the department.
The beneficiary was present in the U.S. when the emergency arose, or was traveling to Alaska by the most direct route without delay, and
The foreign hospital is closer to, or more accessible from the site of the emergency than the nearest U.S. hospital equipped to deal with and available to treat the individual's illness or injury.
Payment for covered services under Medicaid is limited to those services certified as medically necessary in the judgment of a qualified physician for the proper management, control, or treatment of an individual's medical problem and provided under the physician's direction and supervision.
Providers agree to keep necessary records as required by Medicaid regulations and make them available to authorized State and Federal officials upon request.
Medicaid payment rates are established for covered services. For certain services, a recipient co-payment may be required for a portion of the Medicaid rate (see Obligation of Recipients).
A provider must accept as payment in full the amounts paid in accordance with the rate schedule established for Medicaid. For example, a physician performing a particular surgical procedure may not request or receive any additional payment from the recipient, or anyone acting on the recipient's behalf, for the same surgical procedure, although in medical expenses spend-down cases, as specified by the Department, the recipient may be held responsible for a portion of the amount specified in the fee schedule_ (see Sections M400-M499).
No Medicaid payment will be made for claims received either by the Department or its fiscal agent later than six months following the date the service was provided, except when the delay has been caused by extenuating circumstances and authorization has been granted by the Medicaid Division.
When the recipient has other medical insurance, the benefits available must be applied prior to payment by Medicaid. In instances where other insurance companies have been billed, but not paid, claims may be submitted up to 12 months from the date of service.
In no case will payment be made when more than 24 months have elapsed since the date of service. A provider must, as well, meet other commonly accepted standards of professional practice, including compliance with State and Federal anti-discrimination regulations.
In all joint Medicare-Medicaid cases the provider of services must accept assignment of Medicare payment in order to receive payment from Medicaid of amounts not covered by Medicare.
Claims and claims documentation as required must be submitted in a form acceptable to the Medicaid Division or its designee.
With respect to physicians, dentists, or other individual practitioners payment may be made:
To the employer, if the practitioner is required as a condition of his employment to turn over his fees to his employer; or
To the facility in which the care or service was provided, if there is a contractual arrangement between the practitioner and that facility whereby the facility submits the claims for reimbursement; or
To a foundation, plan, health maintenance or similar organization, which furnishes health care through an organized health care delivery system if there is a contractual arrangement between the organization and the person furnishing the service under which the organization bills or receives payments for such person's services.
Payment will not be made to or through a factor, making claim by virtue of a power of attorney, sale, assignment or other transfer given by the provider to the factor. In this context a "factor" is an organization, collection agency, service bureau, or an individual that receives an added fee or a deduction of a portion of the face value of the accounts receivable in return for advancing money to a provider for his accounts receivable.
Section 7106 Violations of Provider Responsibility
Information from any source indicating that a provider is violating any of the policies set forth above shall be transmitted to the department. The following describes the administrative actions and sanctions that the department may take with regard to any provider participating in the Vermont Medicaid program. Taking these actions, however, does not preclude subsequent or simultaneous civil or criminal court action.
"Person" means any natural person, company, firm, association, corporation or other legal entity.
"Affiliates" means persons having an overt or covert relationship such that any one of them directly or indirectly controls or has the power to control another.
"Administrative Agent" means an organization that processes and pays provider claims on behalf of the department.
"Review Methods" means the methods by which the department or its administrative agent determines whether payment errors have been made.
"Exclusion from participation" means termination of a provider's participation in the Vermont Medicaid Program, with the probability that it is permanent.
"Suspension from participation" means temporary expulsion from participation in the Vermont Medicaid Program for a specified period of time or until specified conditions are met.
"Deferment of payments" means the withholding of payments due a provider pending resolution of a specified problem. It may be taken or continued as a sanction or imposed as an administrative precaution upon discovery of a provider discrepancy.
"Offsetting of payments" means a reduction or other adjustment of the amounts paid to a provider on deferred, pending, or future bills for purposes of recovering over payments previously made to the provider.
"Closed-end Medicaid provider agreement" means an agreement that is for a specified period of time not to exceed twelve months.
"Open-end Medicaid provider agreement" means an agreement that has no specific termination date and continues in force as long as it is agreeable to both parties.
* exclusion from participation in the Medicaid program;
* suspension from participation in the Medicaid program;
* deferment or offsetting of payments to a provider;
* transfer to a closed-end provider agreement not to exceed 12 months;
* mandatory attendance at provider information sessions;
* required prior authorization of service;
* 100 percent review of the provider's claims prior to payment; or
* recovery of overpayment by offset or civil action, including recovery of reasonable interest and costs.
* the nature of the discrepancy or inconsistency;
* the dollar value, if any, of such discrepancy or inconsistency;
* the method of computing such dollar values;
* that one or more sanctions may be taken;
* that the provider may, within 20 days from receipt of written notice, request a meeting with the Director of the OVHA to negotiate an amicable settlement of the discrepancy or request a commissioner's conference to be heard in the matter;
* that the provider may bring evidence, witnesses and representation of choice to either the meeting or conference as desired, or may submit a written statement to the Director or Commissioner for consideration in the decision to impose sanction; and
* that if a meeting or conference is not requested within the 20-day period, the decision regarding imposition of sanctions will be made based upon information at hand.
Simultaneous with taking action to advise the provider as above, the department may defer payments on pending and future claims pending resolution of the discrepancy and shall so advise the provider if this action has been taken.
If a mutually agreeable settlement is negotiated with the Director of the OVHA, formal sanction action is discontinued at this point. If not, at any point in the negotiation, at the discretion of either party, a commissioner's conference may be requested to resolve the issue.
If the provider prefers to bypass negotiation with the director and, within 20 days from receipt of written notice, does request a commissioner's conference in the matter at dispute, or negotiations are unsuccessful and a conference is requested, a date shall be set, with notice sent to all parties, and the conference conducted within 20 days from the date of request. The purpose of the conference shall be to assure that the commissioner has all pertinent information at hand prior to making a decision regarding imposition of sanctions. The provider may utilize any records, witnesses, or other information which will be helpful in achieving this purpose and may utilize legal or other representation in the presentation. The conference will be recorded and pertinent records retained by the department at least until the end of the appeal period, and if subsequent imposition of sanction is appealed, shall be made available to all parties as potential evidence in the conduct of the appeal hearing. If, after written notice as provided above, there has been no request from the provider for either a director's meeting or commissioner's conference at the end of 10 days, this shall be noted and the commissioner shall proceed, on the basis of information at hand, to imposition of sanctions as outlined in following sections.
The decision as to discretionary sanctions to be imposed shall be made by the commissioner.
The following factors shall be considered in determining discretionary sanctions to be imposed:
* seriousness of the offense,
* extent of the violations,
* history of prior violations,
* prior imposition of sanctions,
* prior provision of provider information and training,
* provider willingness to adhere to program rules,
* agreement to make restitution,
* actions taken or recommended by peer groups or Licensing Boards, and
* whether a lessor sanction will be sufficient remedy.
The following mandatory sanctions shall be applied by the commissioner effective as of the date of action requiring the sanction.
* When a provider has been suspended or terminated from the Medicare program, imposition of the same sanction as that imposed by Medicare is mandatory upon the commissioner by federal regulation. The only appeal is to the Medicare sanctioning authority.
* When a provider has been convicted of a violation under 33 VSA Chapter 26, Subchapter 5 or under any Vermont statute of general applicability, and said conviction arises from or is directly related to the Medicaid program (33 VSA Ch 36), that provider will be suspended from further participation in the Medicaid program for a period of four years unless such suspension is specifically waived or reduced by the Secretary of Human Services.
* When a provider has failed to retain licensure, certification or registration which is required by state or federal law for participation in the Medicaid program, suspension from participation shall be imposed.
A sanction may be applied to all known affiliates of a provider, provided that each decision to include an affiliate is made on a case by case basis after giving due regard to all relevant facts and circumstances. The violation, failure or inadequacy of performance may be imputed to a person with whom the provider is affiliated where such conduct was accomplished within the course of his or her official duty or was effectuated by him or her with the knowledge or approval of such person.
Suspension or exclusion from participation of any provider shall preclude such provider from submitting claims for payment, either personally or through claim submitted by any clinic, group, corporation or other association to the department or its fiscal agent for any services or supplies provided under the Medicaid program except for those services or supplies provided prior to the effective date of the suspension or exclusion.
No clinic, group, corporation or other organization which is a provider of services shall submit claims for payment to the department or its administrative agent for any services or supplies provided by a person within such organization who has been suspended or excluded from participation in the Medicaid program except for those services and supplies provided prior to the effective date of the suspension or termination.
When any provision of Section M155.2, above is violated by a provider of services which is a clinic, group, corporation or other organization, the department may suspend or terminate such organization or any individual within said organization who is responsible for such violation.
When a provider has been sanctioned, the commissioner or the commissioner's designee shall notify the provider in writing of the sanction imposed. The letter will also notify the provider of his right of appeal. The provider shall also be notified when a decision is made to take no sanctions.
When a provider has been sanctioned, the commissioner shall notify as appropriate, the applicable professional society, Board of Registration or Licensure, and federal or state agencies of the findings made and the sanctions imposed.
When a provider's participation in the Medicaid program has been suspended or terminated, the commissioner may notify the beneficiaries for whom the provider has submitted claims for services, that such provider has been suspended or terminated.
Provider Information Programs may include instructions relating to:
* claim form completion,
* use and format of provider manuals,
* use of appropriate procedure codes,
* key provisions of the Medicaid program,
* reimbursement rates and billing charges, and
* how to inquire about coding or billing problems.
A provider may appeal a discretionary sanction within 10 days after notice of such sanction by requesting a hearing of the Secretary of the Agency of Human Services. Unless a timely request for hearing is received by the Secretary , the sanctions shall be considered final and binding. The sanctions imposed shall be suspended pending the outcome of the hearing; however, if payment on pending and future claims has been deferred pending resolution of the discrepancy, such deferment shall be continued.
A hearing on the appeal shall be conducted within 30 days of the request, by the Secretary or a hearing officer appointed by the Secretary , under the same rules of conduct as in current use for hearings before the Human Services Board.
The department shall send notice of its decision to withhold program payments, within five days of taking such action. The notice must set forth the general allegations that form the basis of the withholding action. The notice shall also:
* state that payments are being withheld in accordance with this provision;
* state that the withholding is for a temporary period as stated in this section, and cite the circumstances under which withholding will be terminated;
* specify which Medicaid claims are affected by the withholding action; and
* inform the provider of the right to submit to the commissioner written evidence contradicting the allegations which formed the basis for the withholding action.
Within ten days, the commissioner shall review the evidence submitted by the provider and determine whether the withholding of payments by the department under this section is warranted.
All withholding of payment actions under this section will be temporary and will not continue after:
* the department and the Medicaid Fraud Control Unit of the Vermont Attorney General's Office determine that there is insufficient evidence of fraud or willful misrepresentation by the provider; or
* legal proceedings related to the provider's alleged fraud or willful misrepresentation are completed.
The procedures relating to sanctions under the Medicaid program as delineated in M155.4 through M155.6 shall not apply during the period of any withholding action under this section.
Section 7107 Utilization Control
The Department in accordance with 1902(a)(30) of the Social Security Act, has implemented a statewide utilization control program to safeguard against unnecessary or inappropriate utilization of services available under Medicaid. Excessive or inappropriate use of service is identified through the utilization review process and characterized as recipient abuse, provider abuse, or a combination thereof. Reports of suspected abuse generated by Department staff, the medical community or the general public should be referred to the Medicaid Division.
Obtaining an inordinate supply of a prescription drug, especially those which are potentially addictive; or
Consistently requesting care at a hospital emergency facility for non-emergency ailments; or
Obtaining concurrent service from two or more practitioners for the same condition without medical referral, on an ongoing basis or for purpose of obtaining prescriptions necessary for the implementation of (i) above. This is not to preclude reasonable access to a "second opinion" of a diagnostic nature or taking action on such opinion.
Inducing, furnishing or otherwise causing a recipient to receive service not required for the recipient's care; or
Submission of incorrect claims; or
Excessive prescribing or dispensing of drugs, especially those which are potentially addictive or which are essentially irrelevant to the patient's care other than for their placebo effect.
Section 7108 Third-Party Liability
Medicaid is the payer of last resort, after all third party medical resources have been applied. A third party is defined as one having an obligation to meet all or any portion of the medical expense incurred by the beneficiary for the time such service was delivered. Such obligation is not discharged by virtue of being undiscovered or undeveloped at the time a Medicaid claim is paid; it then becomes an issue of recovery (see Section M159). Medicaid beneficiaries are required to follow all rules of their third party insurance. Medicaid will not pay claims that have been denied by the third party insurer for failure to follow their rules. Some examples of third party medical resources are:
Medicare;
Health insurance, including health and accident but not that portion specifically designated for "income protection" which has been considered in determining beneficiary eligibility to participate in the Medicaid program;
Medical coverage included in conjunction with other benefit or compensation programs such as military and veteran programs, and worker's compensation; and
Liability for medical expenses as agreed or ordered in negligence suits, support settlements, trust funds, etc.
Once an individual has met this requirement by enrolling or remaining enrolled in a health insurance plan, Medicaid will cover the full array of Medicaid services and items, provided that the rules of their health insurance plan have been followed.
The department may:
Providers may be required to enter a claim against any subsequently discovered health insurance resources previously unknown or overlooked and submit an adjusted Medicaid claim upon collection, with reimbursement as appropriate.
The department will file a claim with the probate court as a creditor of the estate to recover its expenditures for long-term care services only after the death of an individual's surviving spouse, if any, and when the individual has no surviving child who is under age 21, or blind, or permanently and totally disabled as defined by the Social Security Administration.
The department exempts the following assets from estate adjustment or recovery when an heir requests an exemption in writing no later than four months after the publication of notice to creditors of the estate.
The department normally recovers for long-term care Medicaid costs incurred after January 1, 1994. Individuals with homes in revocable trusts who received Medicaid payment of long-term care services before December 1, 1997, however, are exempt from recovery until after May 1, 1998, or, if later, the effective date of the first Medicaid eligibility review completed after December 1, 1997.
The department will not seek adjustment or recovery from assets when that adjustment or recovery would present an undue hardship to the decedent's family members, as specified below and in subsection M159.21.
Undue hardship exists when adjustment or recovery from an income-producing asset can be made only if the asset, alone or in combination with other related assets, is sold and either or both of the following conditions are met:
The department will not seek recovery where the estate inventory filed with the probate court consists only of personal property that does not exceed $ 2,000 in value, such as home furnishings, apparel, personal effects, and household goods.
The department will not seek to recover assets for which the department has imposed a penalty period of ineligibility for Medicaid coverage of long-term care services related to the transfer of those assets.
At any time before closure of the probate estate, an heir may assert that adjustment or recovery against the home-stead would be an undue hardship and that the homestead should be exempt from adjustment or recovery for the costs of Medicaid long-term care services. The department shall exempt a decedent's home from estate adjustment or recovery based on undue hardship when one or more of the following three conditions have been established to the department's satisfaction.
|
Type of Heir |
Family Members, If Living in the |
|
Adult 18 years or older; or person younger than 18 and emancipated |
Heir's Household Heir Heir's spouse or civil union partner Heir's biological or adoptive child or stepchild |
|
Person younger than 18 and not emancipated |
Heir Heir's parent Heir's stepparent Heir's biological or adoptive sibling, stepsibling, or half sibling, if younger than 18 and not emancipated |
To meet condition (B), the services or financial support must fall into one or both of the following two categories:
* medically necessary;
* provided directly by the heir or the heir's spouse without compensation, or purchased with the heir's funds; and
* provided while the deceased person required medical care and services consistent with the level of care standard for level III residential care homes at a frequency averaging no fewer than three times per week or, if provided less frequently, constituting the equivalent expenditure of time or money.
The department shall not verify the level of care unless it has a reasonable basis for questioning that the level III standard was met.
When there are two or more heirs, the full value of the homestead is exempt from Medicaid estate adjustment or recovery only if each heir meets conditions (1), (2), and (3) above. When one or more heirs do not meet conditions (1), (2), and (3), the percentage of the value of the homestead corresponding to their share is subject to Medicaid estate adjustment or recovery.
An estate includes all real and personal property and other assets listed on an inventory filed in the probate court. The probate court oversees the distribution of assets to heirs and the payment of the decedent's outstanding debts, which requires creditors to submit proof of their claims to the court.
The probate court judge compares the total value of claims filed by creditors to the total value of available assets in the estate. The court determines which assets are available to pay debts.
When any heir meets the department's undue hardship criteria as specified in M159.2, some or all of these available assets may be exempt from adjustment or recovery by the department under these rules. Nonexempt assets are those subject to the department's claim because an heir has not met the undue hardship criteria. Creditors other than the department are not subject to these exemptions.
When the total available assets are insufficient to pay all claims, the probate court prioritizes the debts and prorates each claim according to law. Each creditor collects the resulting percentage of its claim.
If there are sufficient nonexempt assets to allow the department to collect its full percentage, it does so. If the nonexempt assets allow the department to collect only a partial amount of its share after the court's proration, it collects that amount. The department shall maintain its original claim so it can be prorated along with all other creditor's claims according to law. The department notifies the court of its decision on the homestead exemption. If the department grants a homestead exemption, it shall inform the court of the maximum payment it will accept against its claim. The department determines the maximum payment it will accept by subtracting the amount of the exemption from the amount of the department's claim.
The undue hardship exemption applicable to homesteads shall be effective for any probate estate opened after June 30, 1999. Heirs seeking the exemption from July 1, 1999, through the effective date of this policy must submit their claim to the department's Third Party Liability Unit in the Office of Vermont Health Access within 60 days following receipt of proper notice from the department. In the sole discretion of the commissioner, the department may make exceptions to the 60-day rule when an heir establishes undue hardship due to lack of notice, a medical need, or natural disaster. Heirs seeking an exemption from the 60-day submission requirement must sign an affidavit describing the condition that prevented them from complying with the 60-day submission requirement and submit the affidavit along with supporting documentation to the commissioner.
The department will exempt assets or resources pursuant to Rule M232.22 in an amount equal to the insurance benefit payments that are made to or on behalf of an individual who is a beneficiary under a qualified State long-term care insurance partnership policy whether or not an heir requests an exemption.
Section 7109 Health Care Trust Fund
In accordance with 33 VSA § 1956, a Health Care Trust Fund is established in which proceeds from health care provider taxes shall be deposited. The proceeds of other taxes designated by law and donations may also be deposited in the fund.
Health care provider taxes shall be assessed upon hospitals, nursing homes and intermediate care facilities for the mentally retarded (ICF/MRs) licensed in Vermont, pursuant to 33 VSA § 1953, § 1954, and § 1955, in an amount established by statute.
For each fiscal year in which health care provider taxes are due, the Department of Social Welfare shall notify each provider of the amount of its assessment. The notification shall include the appeals provisions set forth in 33 VSA § 1958 and shall establish an assessment payment schedule for each provider.
Payment in full of each installment must be sent to the Department of Social Welfare, post marked no later than the date specified for each payment by the Commissioner in the assessment notification. Late payments will be subject to a late fee assessment of eight percent or $ 1,000, whichever is less. The filing of a request for reconsideration, pursuant to 33 VSA § 1958, does not relieve a provider from its obligation to make timely payments.
For hospital fiscal years ending after June 30, 1993, hospitals are required to identify gross inpatient revenues as a separate footnote in their audited financial statements.
Section 7110 Repealed
STATUTORY AUTHORITY:
33 V.S.A. §§ 105, 1901
