Section 1.00 General Provisions.
The Agency of Human Services (AHS) is the adopting authority
for the Immigrant Health Insurance Plan administrative rule. The Immigrant
Health Insurance Plan was enacted by the Vermont General Assembly in Act 48 of
2021 and is codified in state statute at 33 V.S.A. chapter 19, subchapter
9.
The Immigrant Health Insurance Plan was created to establish
Dr. Dynasaur-like coverage for certain Vermont residents (children under 19
years of age and pregnant individuals) who have an immigration status for which
Medicaid coverage is not available, including migrant workers who are employed
in seasonal occupations in Vermont, and who are otherwise uninsured.
This Immigrant Health Insurance Plan rule refers to other
Agency of Human Services' administrative rules in some sections to best align
the Immigrant Health Insurance Plan with the Dr. Dynasaur program. There are
two bodies of rules referenced:
Health Benefits Eligibility and Enrollment (HBEE) Rules - The
HBEE rules provide the eligibility standards for Medicaid and other health care
programs in Vermont.
Health Care Administrative Rules (HCAR) - HCAR is the
collection of regulations adopted by the Agency of Human Services that govern
the administration of Vermont Medicaid, including general provisions,
eligibility, benefit delivery, covered services, reimbursement, specialized
services, beneficiary rights, and provider responsibilities.
Current HCAR and HBEE adopted rules can be found on the
Agency of Human Services' website.
Section 2.00 Definitions.
As used in this rule, the following terms are used as defined
below:
Alternate reporter means a person who is authorized to
receive original notices or copies of notices on behalf on an
individual.
Applicant means an individual seeking eligibility for
Immigrant Health Insurance Plan health benefits for themselves through an
application submission.
Application means a non-Medicaid application for Immigrant
Health Insurance Plan health benefits, submitted by or on behalf of an
applicant to determine eligibility, or, for an individual who applies for the
Immigrant Health Insurance Plan by completing an application for Vermont
Medicaid and being approved for Medicaid coverage of emergency medical
conditions only (pursuant to HBEE § 17.02(d)), it means the Vermont
Medicaid application.
Application date means the day the application is received by
AHS, if it is received on a business day; or the first business day after the
application is received, if it is received on a day other than a business
day.
Assister Program means the professionals who are trained and
certified by the Department of Vermont Health Access to help Vermont residents
enroll and maintain health coverage through Vermont's state- based health
insurance marketplace, Medicaid, or other state health care programs.
Authorized representative means a person or entity designated
by an individual to act responsibly in assisting the individual with their
application, renewal of eligibility and other ongoing communications.
Case record means the permanent collection of documents and
information required to process eligibility.
Categorical eligibility criteria means the age or pregnancy
status that an individual must have to be eligible for the Immigrant Health
Insurance Plan.
Child means an individual under 19 years of age.
Electronic account means an electronic file that includes all
information collected and generated regarding each individual's health benefit
eligibility, including all required documents and information collected or
generated as part of the State fair hearing process conducted with regard to
health benefits eligibility and enrollment.
Eligibility decision or determination means an approval,
denial, or termination of eligibility.
Eligible means the status of an individual determined to meet
all financial, nonfinancial, and categorical requirements for a health benefits
program.
Enrollee means an individual who has been approved for
benefits under the Immigrant Health Insurance Plan.
Federal poverty level (FPL) means the poverty guidelines most
recently published in the Federal Register by the Secretary of HHS under the
authority of
42
USC §
9902(2), as in
effect for the applicable period of time used to determine an individual's
income eligibility for health benefits.
Human Services Board means AHS's fair hearings entity for
Immigrant Health Insurance Plan appeals.
In an institution refers to an individual who is admitted to
live in an institution and receive treatment or services provided there.
Individual means an applicant or enrollee for Immigrant
Health Insurance Plan health benefits.
Institution means, for purposes of Section 5.00 of this rule,
the same as the definition of institution and medical institution in
42 CFR §
435.1010. For purposes of an out of state
placement in an institution, the term also includes foster care homes, as set
forth in
45
CFR §
1355.20, that provide food,
shelter and supportive services to one or more persons unrelated to the
proprietor. For purposes of subsection 6.03 of this rule, institution means an
establishment that furnishes food, shelter, and some treatment or services to
four or more individuals unrelated to the proprietor.
Interpreter means a person who orally translates for an
individual who has limited English proficiency or an impairment.
Limited English proficiency means an ineffective ability to
communicate in the English language for individuals who do not speak English as
their primary language and may be entitled to language assistance with respect
to a particular type of service, benefit or encounter.
Long-term services and supports means services and supports
provided to individuals of all ages who have functional limitations and/or
chronic illnesses that have the primary purpose of supporting the ability of
the individual to live or work in the setting of their choice, which may
include the individual's home, a worksite, a provider-owned or controlled
residential setting, a nursing facility, or other institutional setting,
including medically complex nursing care or assistance with activities of daily
living (such as eating, bathing, dressing, preparing meals, and managing
medication).
Medicaid means the medical assistance provided under the
State Plan approved under Title XIX of the Social Security Act, and the terms
and conditions of the Global Commitment to Health Waiver, as approved by the
Centers for Medicare & Medicaid Services, that are administered by AHS in
Vermont.
Medicaid applicants means an individual seeking eligibility
for health benefits authorized in Title XIX of the Social Security Act for
themselves through an application submission.
Medicaid enrollees means an individual who has been approved
and is currently receiving health benefits authorized in Title XIX of the
Social Security Act.
Minimum Essential Coverage means health coverage under
government-sponsored programs, employer-sponsored plans that meet specific
criteria, grandfathered health plans, individual health plans, and certain
other health-benefits coverage as provided in
42 C.F.R. §
435.4.
Modified Adjusted Gross Income (MAGI) has the same meaning as
defined in HBEE § 28.02(b) for Medicaid applicants and enrollees.
MAGI-based income is defined in subsection 6.02(b) of this
rule.
Plain language means language that the intended audience,
including individuals with limited English proficiency, can readily understand
and use because the language is concise, well-organized, and follows other best
practices of plain language writing.
Pregnant person means an individual during pregnancy and the
post partum period. The post partum period shall have the same meaning as
defined in HBEE § 7.03(a)(2) for Medicaid applicants and enrollees.
Quality control means a system of continuing review to
measure the accuracy of eligibility decisions. It is also the name of the AHS
unit that is responsible for administering quality control measures.
Redetermination means to determine eligibility following a
change of circumstance, or to determine eligibility as a result of a State fair
hearing request before the request is sent to the Human Services Board.
Renew means to determine eligibility again at a specified
periodic interval (e.g., annual renewal of eligibility).
Third party means any person, entity, or program that is or
may be responsible to pay all or part of the expenditure for another person's
medical benefits.
Uninsured means to lack minimum essential coverage including
under government sponsored programs (e.g., Medicaid, Medicare), employer
sponsored plans, individual health plans, and other health benefits coverage
(e.g., Refugee Medical Assistance).
Section 3.00 Rights and responsibilities,
authorized representatives, accessibility and nondiscrimination, AHS
assistance, case records, privacy, quality control, and fraud.
3.01 Rights of applicants and enrollees
(a) Notice of rights and responsibilities.
AHS will provide individuals with information about their rights and
responsibilities at the time of their application and subsequent reviews of
eligibility.
(b) Right to
nondiscrimination and equal treatment. AHS will not unlawfully discriminate on
the basis of race, color, religion, national origin, disability, age, sex,
gender identity, or sexual orientation in the administration of the Immigrant
Health Insurance Plan.
(c) Right to
confidentiality.
(1) AHS will not make any
information regarding applicants and enrollees of the Immigrant Health
Insurance Plan available to the United States government.
(2) All applications submitted and records
received or created concerning any applicant for or enrollee of the Immigrant
Health Insurance Plan:
(i) Are protected in
accordance with federal and state laws regarding confidentiality, privacy,
disclosure, and personally identifiable information, and
(ii) Will be made available only to persons
authorized by AHS, by the State of Vermont, or by the United States government
for purposes directly connected with the administration of the Immigrant Health
Insurance Plan or as otherwise required by law.
(A) "Purposes directly connected with the
administration of the Immigrant Health Insurance Plan" includes establishing
eligibility, determining the amount of medical assistance, providing services
to the individual, conducting or assisting with an investigation or
prosecution, and civil or criminal proceedings, or audits, related to the
administration of the Immigrant Health Insurance Plan.
(d) Right to timely
eligibility decision on application. Applicants for the Immigrant Health
Insurance Plan have the right to the timely decision on their application, as
defined in subsection 7.02(h) of this rule.
(e) Right to information. Individuals who
inquire about the Immigrant Health Insurance Plan have the right to receive
information about eligibility, services, and the rights and responsibilities of
program enrollees.
(f) Right to
apply. Any person, individually or through an authorized representative or
legal representative, has the right, and will be afforded the opportunity
without delay, to apply for Immigrant Health Insurance Plan.
(g) Right to be assisted by others.
(1) The individual has the right to be:
(i) represented by a legal representative,
and
(ii) accompanied and
represented by an authorized representative during the eligibility or appeal
processes.
(2) Upon
request by the individual, copies of all eligibility notices and all documents
related to the eligibility or appeal process will be provided to the
individual's authorized or legal representative.
(h) Right to inspect the case file. An
individual has the right to inspect information in their case file and contest
the accuracy of the information.
(i) Right to appeal. An individual has right
to appeal, as provided in Section 9.00 of this rule.
(j) Right to interpreter services.
Individuals will be informed of the availability of interpreter services.
Unless the individual chooses to provide their own interpreter services, AHS
will provide telephonic or other interpreter services whenever:
(1) The individual who is seeking assistance
has limited English proficiency or sensory impairment (for example, a seeing or
hearing disability) and requests interpreter services, or
(2) AHS determines that such services are
necessary.
(l) Right to
information about Medicaid application. An individual who reports to AHS that
they are pregnant has the right to be informed that, if they apply for and are
determined eligible for Medicaid (including pursuant to HBEE § 17.02(d))
their child will be deemed to have applied and been determined eligible for
Medicaid effective as of the date of birth, provided the child's mother was
eligible for and received covered services under Medicaid on that date
(regardless of whether payment for services for the mother is limited to those
defined in HBEE § 17.02(d)), and that the child will remain eligible for
Medicaid until they reach age one regardless of changes in circumstances
(except if the child dies or ceases to be resident of the state or the child's
representative requests a voluntary termination of the child's
eligibility).
3.02
Responsibilities of applicants and enrollees
(a) Responsibility to cooperate. An
individual must cooperate in providing information necessary to establish and
maintain their eligibility and must comply with all relevant laws. Failure to
cooperate may result in an application being denied or eligibility being
terminated because AHS is not able to determine eligibility due to the
individual's failure to cooperate.
(b) Responsibility to report changes. An
individual must report changes that may affect eligibility. Such changes
include, but are not limited to, contact information, immigration status,
income, household members, third-party liability, and coverage by other health
insurance. An enrollee must report such changes to AHS within 10 days of
learning of the change.
3.03 Authorized Representatives
(a) Rules that govern authorized
representatives. The same rights, responsibilities, and procedures as those set
forth in HBEE § 5.02 for Medicaid applicants and enrollees apply to
Immigrant Health Insurance Plan and extend to its applicants and
enrollees.
3.04
Accessibility, Americans with Disabilities Act, and nondiscrimination
(a) Accessibility requirements
(1) Plain language. AHS will provide
information and communications, including program information, applications,
and notices, in plain language as defined at Section 2.00 of this rule, and in
a manner that is accessible and timely.
(2) Individuals living with disabilities.
Individuals living with disabilities will be provided with, among other things,
accessible websites and auxiliary aids and services at no cost to the
individual, in accordance with the Americans with Disabilities Act and §
504 of the Rehabilitation Act.
(3)
Individuals with limited English proficiency. For individuals with limited
English proficiency, language services will be provided at no cost to the
individual, including:
(i) Oral
interpretation,
(ii) Written
translations,
(iii) Taglines in
non-English languages indicating the availability of language services,
and
(iv) Website
translations.
(4)
Individuals will be informed of the availability of the services described in
this paragraph and how they may access such services.
(b) Americans with Disabilities Act
(1) Reasonable Accommodation for persons
living with disabilities. As required by the Americans with Disabilities Act,
AHS will make reasonable accommodations and modifications to its policies,
practices, or procedures, when necessary to provide access to Immigrant Health
Insurance Plan, as determined by the appropriate commissioner or their
designee, or when necessary to avoid discrimination on the basis of disability.
An individual may appeal the commissioner's determination to the appropriate
entity within AHS.
(c)
Non-discrimination. In the administration of the Immigrant Health Insurance
Plan, AHS will comply with all applicable non-discrimination statutes and will
not discriminate on the basis of race, color, national origin, disability, age,
sex, gender identify or sexual orientation.
3.05 AHS assistance (including call center,
website, and one on one assistance) and outreach and education
(a) In general. AHS will provide assistance
to any individual seeking help with the application or renewal process or an
appeal, in person or over the telephone, and in a manner that is accessible to
individuals with disabilities and those who are limited English proficient.
Eligibility and enrollment assistance that meets the
accessibility standards in this section is provided, and referrals are made to
assistance programs in the state when available and appropriate. These
functions include assistance provided directly to any individual seeking help
with the application or renewal process.
(b) Assistance available
(1) Call center. A toll-free call center will
be provided to serve the needs of all applicants for and enrollees in health
benefits.
(2) Internet website. AHS
will maintain an internet webpage that meets the accessibility requirements at
section 3.04(a) of this rule that provides information to applicants and
enrollees regarding Immigrant Health Insurance Plan including eligibility
requirements, available health benefits, rights and responsibilities of
applicants and enrollees, information about the Assister Program, and the
toll-free telephone number of the call center.
(3) One on one assistance. The Assister
Program will provide one on one assistance to individuals in understanding
their health care coverage options, and in enrolling in and maintaining health
care coverage. They will assist an individual in the application processes and
in reporting changes. The requirements of HBEE § 5.03 through § 5.05
apply to and are extended to the Immigrant Health Insurance Plan.
(c) Outreach and education. AHS
will conduct outreach and educational activities that meet the standards
outlined in subsection 3.04(a) of this rule.
3.06 Case records
(a) Case records of applicants and enrollees
must comply with the requirements of HBEE § 4.04 to the same extent the
requirements apply to Medicaid applicants and enrollees.
3.07 Quality control review
(a) AHS will conduct independent reviews of
eligibility facts in a sampling of Immigrant Health Insurance Plan cases. These
reviews ensure that program rules are clear and consistently applied and that
individuals understand program requirements and provide correct information in
support of their application for Immigrant Health Insurance Plan. AHS will
periodically review a sample of active enrollees to review eligibility
determinations, and a sample of negative actions (e.g., denials, terminations)
to review the accuracy of the action.
(b) When there is a discrepancy between the
eligibility facts, as discovered in a review, and those contained in the case
record, AHS will conduct an eligibility review and take action to correct
errors.
3.08 Fraud
(a) A person commits fraud in Vermont if
they:
(1) "[K]nowingly fails, by false
statement, misrepresentation, impersonation, or other fraudulent means, to
disclose a material fact used in making a determination as to the
qualifications of that person to receive aid or benefits under a state or
federally funded assistance program, or who knowingly fails to disclose a
change in circumstances in order to obtain or continue to receive under a
program aid or benefits to which he or she is not entitled or in an amount
larger than that to which he or she is entitled, or who knowingly aids and
abets another person in the commission of any such act ..." or
(2) "[K]nowingly uses, transfers, acquires,
traffics, alters, forges, or possesses, or who knowingly attempts to use,
transfer, acquire, traffic, alter, forge, or possess, or who knowingly aids and
abets another person in the use, transfer, acquisition, traffic, alteration,
forgery, or possession of a . . . certificate of eligibility for medical
services, or State health care program identification card in a manner not
authorized by law "
(b)
Legal consequences. An individual who commits fraud may be prosecuted under
Vermont law. If convicted, the individual may be fined or imprisoned or both.
Action may also be taken to recover the value of benefits paid in error due to
fraud.
(c) AHS's responsibilities.
When AHS suspects that fraud has been committed, it has authority to
investigate the case, and, if appropriate, refer the case to State's Attorney
or Attorney General for a decision on whether or not to prosecute. Any
investigation of a case of suspected fraud is pursued with the same regard for
confidentiality and protection of the legal and other rights of the individual
as with a determination of eligibility. The final decision regarding referral
to a law enforcement agency shall be the responsibility of the Commissioner or
their designee.
(d) Suspected
fraud. The following criteria will be used to evaluate cases of suspected fraud
to determine whether they should be referred to a law enforcement agency:
(1) Does the act committed appear to be a
deliberately fraudulent one?
(2)
Was the omission or incorrect representation an error or result of the
individual's misunderstanding of eligibility requirements or the responsibility
to provide information?
(3) Did the
act result from AHS omission, neglect, or error in securing or recording
information?
(4) Did the individual
receive prior warning from a state employee that the same or similar conduct
was improper?
3.09 Privacy and security of personally
identifiable information
(a) When
personally-identifiable information is collected or created for the purposes of
determining eligibility and coverage of services, such information will be used
or disclosed only to the extent such information is necessary to administer
health care program functions in accordance with federal and state
laws.
(b) Requirements of AHS. AHS
responsibilities for establishing and implementing privacy and security
standards for Immigrant Health Insurance Plan are the same as those at HBEE
§ 4.08(b) for Medicaid applicants and enrollees. AHS will not make any
information regarding applicants for and enrollees in the Immigrant Health
Insurance Plan available to the United States government.
3.10 Use of standards and protocols for
electronic transactions.
(a) The requirements
for HIPAA administrative simplification at HBEE § 4.09(a) apply to the
Immigrant Health Insurance Plan.
Section 5.00
Nonfinancial Eligibility Requirements.
5.01
Immigration status requirement
(a) Individuals
are eligible for the Immigrant Health Insurance Plan only if they have an
immigration status for which Medicaid coverage is not available pursuant to
HBEE § 17.00. This includes persons who are not lawfully residing in the
United States, including persons who entered the country without the permission
of the United State government.
(b)
Citizens and nationals of the United States, as defined at HBEE § 17.01(a)
through (c), are not eligible for the Immigrant Health Insurance
Plan.
5.02 Incarceration
in a correctional facility
(a) An individual
who is incarcerated is ineligible for the Immigrant Health Insurance Plan.
Incarceration begins on the date of admission to the correctional facility and
ends when the individual moves out of the facility.
5.03 Residency requirement
(a) An individual must be a resident of
Vermont to be eligible for the Immigrant Health Insurance Plan, and must be a
Vermont resident at the time that a medical service is provided in order for it
the service to be covered by the Immigrant Health Insurance Plan.
(b) Who is a Vermont resident. A resident of
Vermont is an individual who meets the requirements of subsection 5.03(g) or
5.03(h) of this rule.
(c)
Incapability of indicating intent. An individual is considered incapable of
indicating intent regarding residency for the Immigrant Health Insurance Plan
based on the standards set forth in HBEE § 21.02 for Medicaid applicants
and enrollees.
(d) Individuals
placed by a state in an out of state institution. For applicants and enrollees
who were placed by a state in an out of state institution, residency is
determined by HBEE § 21.04 to the same extent that it applies to Medicaid
applicant and enrollees.
(e)
Prohibitions. AHS will not:
(1) Deny Immigrant
Health Insurance Plan eligibility because an individual has not resided in
Vermont for a specified period.
(2)
Deny Immigrant Health Insurance Plan eligibility to an individual in an
institution who satisfies the residency rules set forth in this section, on the
grounds that the individual did not establish residency in Vermont before
entering an institution.
(3) Deny
or terminate Immigrant Health Insurance Plan eligibility to an individual due
to their temporary absence from the state, as defined in subsection 5.03(f) of
this rule, if the person intends to return to Vermont when the purpose of the
absence has been accomplished.
(f) Temporary absences from the state.
Temporary absences from Vermont do not interrupt or end Vermont residence. An
absence is considered temporary if an individual leaves the state with the
intent to return when the purpose of the absence has been accomplished, such as
absences for visiting others or obtaining necessary medical care. Temporary
absence does not include when an individual moves to another state to work or
to seek employment.
(g) Residency
requirements for individuals 19 years old or older.
(1) Individuals 19 years old or older who are
not living in an institution. The state of residence for an individual 19 years
old or older who is not living in an institution, is as follows:
(i) For individuals who are capable of
indicating intent regarding residency, they are a resident of the state in
which they are living and:
(A) intend to
reside, including without a fixed address, or
(B) have entered the state with a job
commitment or are seeking employment (whether or not currently employed),
including migrant workers who are employed in seasonal occupations in the
state.
(ii) For
individuals who are incapable of indicating intent regarding residency, the
state of residence is where the individual is living.
(2) Individuals 19 years old or older who are
living in an institution. The state of residency for an individual 19 years old
or older who lives in an institution, is determined by HBEE §
21.06(c)-(e).
(h)
Residency requirements for individuals under 19 years old.
(1) Individual under 19 years old who are not
living in an institution. The state of residence for an individual under 19
years old who is not living in an institution is as follows:
(i) If the individual is capable of
indicating intent regarding residency and is emancipated from their parents, is
married, or is at least 18 years old, the state of residence is determined in
accordance with subsection 5.03(g) of this rule.
(ii) For other individuals, the state of
residence is the state in which the individual is living and:
(A) intends to reside, including without a
fixed address, or
(B) is the state
of residency of the parent or caretaker with whom the individual
lives.
(2)
Individuals under 19 years old who are living in an institution. The state of
residency for an individual under 19 years old, who lives in an institution,
who is not married and is not emancipated, is determined by HBEE §
21.08(c).
5.04
Assignment of rights and cooperation requirements
(a) The assignment of rights to third party
payments for medical care to AHS is a condition of Immigrant Health Insurance
Plan eligibility. If an individual has the legal authority to do so, they must
also assign such rights of any other individual who is also applying for or
enrolled in the Immigrant Health Insurance Plan. The exceptions to this rule
are set forth in HBEE § 18.02(b).
(b) Cooperation includes identifying and
providing information to assist in pursuing third parties who may be liable to
pay for care and services provided by the Immigrant Health Insurance Plan,
unless the individual has good cause for not cooperating. Good cause for
noncooperation is defined in HBEE § 18.04.
5.05 Uninsured requirement
(a) In general. An individual must be
uninsured to qualify for the Immigrant Health Insurance Plan.
(b) Eligibility for government sponsored
minimum essential coverage. An individual who meets the eligibility criteria
for government sponsored minimum essential coverage, including Medicaid, is
considered insured for purposes of this rule and therefore ineligible for the
Immigrant Health Insurance Plan.
5.06 Pursuit of potential unearned income
requirement
(a) As a condition of Immigrant
Health Insurance Plan eligibility, an individual is required to take all
necessary steps to obtain unearned income to which they may be entitled (e.g.,
pensions, retirement, disability, unemployment compensation), unless they can
show good cause for not doing so.
Section 6.00 Financial Methodologies.
The financial methodologies set forth in this section will be
applied in determining the financial eligibility of all individuals for health
benefits under the Immigrant Health Insurance Plan. Financial eligibility is
determined based on household income, as defined in subsection 6.02 of this
rule. Household composition is determined separately for each individual; see
subsection 6.01 of this rule for details on household composition.
6.01 Household composition
(a) For purposes of household composition,
the terms "child", "parent", and "sibling" include a natural or biological,
adopted or step-child/parent/sibling.
(b) The Immigrant Health Insurance Plan
household consists of the individual and, if living with the individual:
(1) The individual's spouse;
(2) The individual's children under the age
of 19; and
(3) In the case of an
individual under the age of 19, the individual's parents and siblings under the
age of 19.
(c) Special
counting rule for pregnant person. In the case of determining the family size
of a pregnant person, or the family size of other individuals who have a
pregnant person in their household, the pregnant person is counted as one
person plus the number of children they are expected to deliver.
6.02 Household income
(a) Except as provided in subsection 6.02(c),
household income for the Immigrant Health Insurance Plan is the sum of the
MAGI-based income of every person included in the individual's household, as
defined in subsection 6.01 of this rule.7
(b) MAGI-based income8 means income
calculated using the same financial methodologies used to determine MAGI, with
the following exceptions:
(1) An amount
received as a lump sum is counted as income only in the month received unless
otherwise required by federal law with respect to qualified lottery and
gambling winnings of $ 80,000 or greater.
(2) Scholarships, awards, or fellowship
grants used for education purposes and not for living expenses are excluded
from income.
(c) Income
of children. The MAGI-based income of a person who is included in the household
of their natural, adopted, or step-parent, and is not expected to be required
to file a federal tax return for the benefit year in which eligibility for the
Immigrant Health Insurance Plan is being determined, is not included in the
household income whether or not such person files a federal tax
return.
(d) Five-percent disregard.
In determining the eligibility of an individual for the Immigrant Health
Insurance Plan under the eligibility group with the highest income standard
under which the individual may be determined eligible, an amount equivalent to
5 percentage points of the FPL for the applicable family size is deducted from
household income.
6.03
Budget period
(a) Financial eligibility for
applicants and new enrollees is based on current monthly household income and
family size.
(b) For an enrollee
who has been determined financially eligible for the Immigrant Health Insurance
Plan using the financial methodologies set forth in this section, AHS will base
financial eligibility on projected annual household income and family size for
the remainder of the current calendar year.
Section 7.00 Eligibility and Enrollment
Procedures.
The Eligibility and Enrollment Procedures section of the
Immigrant Health Insurance Plan rule sets forth the application processing and
enrollment requirements for health benefits, including verification of
eligibility factors and periodic renewals of eligibility.
7.01 Application
(a) An individual will be afforded the
opportunity to apply for health benefits under the Immigrant Health Insurance
Plan at any time. An individual can apply for health benefits under the
Immigrant Health Insurance Plan in one of two ways:
(1) By completing an application for Vermont
Medicaid and being approved for Medicaid coverage of emergency medical
conditions only (pursuant to HBEE § 17.02(d)); or
(2) By completing a non-Medicaid application
specific to the Immigrant Health Insurance Plan.
(b) A separate application for the Immigrant
Health Insurance Plan is not required for an individual who is approved for
Medicaid coverage of emergency medical conditions only (pursuant to HBEE §
17.02(d)) and who is otherwise categorically eligible for the Immigrant Health
Insurance Plan.
(c) AHS may request
that an individual enrolled in the Immigrant Health Insurance Plan complete a
Medicaid application if they incur claims for emergency medical services or
labor and delivery, provided the individual has not already completed a
Medicaid application within the past 12 months.
(d) AHS will provide assistance to any
individual seeking help with the application or renewal process, in the manner
prescribed in subsection 3.05 of this rule.
(e) An application will be accepted from:
(1) The applicant;
(2) An adult who is in the applicant's
household;
(3) An authorized
representative; or
(4) If the
applicant is a minor or incapacitated, someone acting responsibly for the
applicant.
(f) Missing
Information
(1) The applicant's eligibility
for health benefits will not be determined before the applicant provides
answers to all required questions on the application. If an incomplete
application is received, the applicant will be sent a request for answers to
all of the unanswered questions necessary to determine eligibility. The request
will include a response due date, which will be no earlier than 15 days after
the date the request is sent to the applicant.
(2) If a full response to the request is
received on or before the due date, the eligibility process will be activated
for determining:
(i) Coverage, based on the
date the application was originally received; or
(ii) The need to request any corroborative
information necessary to determine eligibility.
(3) If responses to all unanswered questions
necessary for determining eligibility are not received by the response due
date, the applicant will be notified that AHS is unable to determine their
eligibility for Immigrant Health Insurance Plan benefits. The date that the
incomplete application was received will not be used in any subsequent
eligibility determinations.
(g) Limits on Information
(1) An applicant will be required to provide
only the information necessary to make an eligibility determination or for a
purpose directly connected to the administration of health benefits
programs.
(2) Information regarding
immigration status will not be requested for an individual who is not seeking
health benefits for themselves.
(h) Signature Required on Application
(1) An initial application must be signed
under penalty of perjury.
7.02 Attestation and verification
(a) AHS will verify or obtain information as
described in subsection 7.02 before making a determination about an
individual's eligibility for health benefits. AHS will abide by the
confidentiality provisions described in subsection 3.01(c) of this
rule.
(b) Proof of identity. An
individual seeking health benefits under the Immigrant Health Insurance Plan
must provide proof of identity. Evidence of identity that will be accepted can
be found at HBEE § 54.07(d). AHS will also accept a valid, unexpired
passport or consular identification card as proof of identity.
(c) Proof of state residency. An individual
seeking health benefits under the Immigrant Health Insurance Plan must provide
proof of Vermont residency. Proof of Vermont residency that will be accepted is
as follows:
(1) Two pieces of mail with
current name and street address (if mail is received at the street
address)
(2) If mail is not
received at the street address, provide any two of the following which show
street address:
(i) Rental or lease agreements
with the signatures of the owner/landlord and the tenant/resident
(ii) Home utility bills, including cellular
phone bills (must list service address)
(iii) Vermont driver's license
(iv) Insurance documents, including medical,
life, home, rental, and vehicle
(v)
A property tax bill or statement with physical location
(3) If the individual resides with others and
gets no mail at their street address, an affidavit signed, under penalty of
perjury, certifying that the individual resides in Vermont at a specified
street address may be submitted in addition to one of the documents listed at
subsection 7.02(c)(2).
(4) If the
individual seeking health benefits is a child, the name on the documents at
subsection 7.02(c)(1)-(2) of this rule can be that of a parent or guardian with
whom the child resides.
(d) Proof of age. An individual seeking
health benefits under the Immigrant Health Insurance Plan must provide proof of
age. This could include a date of birth on evidence of identity described at
subsection 7.02(b) of this rule.
(e) Documentary evidence. A photocopy,
facsimile, scanned or other copy of a document will be accepted to the same
extent as an original document under this subsection, unless information on the
submitted document is inconsistent with other information available to AHS, or
AHS otherwise has reason to question the validity of the document or the
information on the document.
(f)
Self-attestation. Unless information from an individual is not reasonably
compatible with other information provided or otherwise available to AHS,
attestation of information needed to determine the following eligibility
requirements of an individual for health benefits will be accepted without
requiring further information (including documentation) from the individual:
(1) Pregnancy;
(2) Family size;
(3) Immigration status; and
(4) Lack of access to minimum essential
coverage
(g) Income
(1) An individual seeking health benefits
under the Immigrant Health Insurance Plan must provide proof of income. Proof
of income that will be accepted includes:
(i)
1040 federal or State tax return
(ii) Complete tax return including all forms
and schedules, if self-employed
(iii) Wages and tax statement
(iv) Pay stub
(v) Signed letter from employer that contains
a description of job, number of hours worked, salary or wages, employer's
address, and employer's telephone number.
(vi) Bank or investment fund
statement
(vii) Agricultural income
certificate
(viii) Bookkeeping
records
(ix) Self-employment
ledger
(x) Business income and
expense sheet
(xi) Most recent
quarterly or year-to-date profit and loss statement
(2) An individual's attestation that their
income is above the highest income standard under which they may be determined
eligible will be accepted without further verification.
(h) Exception for special circumstances. AHS
will provide an exception, on a case-by-case basis, to accept an individual's
attestation as to information which cannot otherwise be verified, because such
documentation:
(1) Does not exist;
or
(2) Is not reasonably
available.
(i) Timely
determination of eligibility. An eligibility decision on an Immigrant Health
Insurance Plan application will be made as soon as possible, but no later than
45 days after the application date.
7.03 Enrollment
(a) Prospective enrollment. An individual
approved for the Immigrant Health Insurance Plan will be enrolled in the plan
on the first day of the month within which their application is received by AHS
provided they are eligible for that month.
(b) Retroactive eligibility. Retroactive
eligibility is effective no earlier than the first day of the third month
before the month an individual's application is received by AHS, regardless of
whether the individual is alive when application is made, if the following
conditions are met:
(1) Eligibility is
determined separately for each of the three months;
(2) A medical need exists; and
(3) Elements of eligibility were met at some
time during each month.
(c) Eligibility redetermination during a
benefit year
(1) AHS must redetermine the
eligibility of an individual in the Immigrant Health Insurance Plan during the
benefit year if it receives and verifies new information reported by the
individual or otherwise identifies updated information that may affect
eligibility.
(2) If a
redetermination is made during a benefit year because of a change in the
individual's circumstances and there is enough information available to renew
eligibility with respect to all eligibility criteria, a new 12-month renewal
period may begin.19 AHS will promptly redetermine the individual's eligibility
in accordance with program standards and notify the individual regarding the
redetermination in accordance with the requirements specified in subsection
9.03 of this rule.
(d)
Eligibility renewal.
(1) Eligibility of an
individual in the Immigrant Health Insurance Plan will be renewed on an annual
basis.
(2) AHS will provide the
individual with:
(i) A form or application
that is needed to renew eligibility;
(ii) At least 30 days from the date of the
form or application to respond and provide any necessary information, and to
sign the form or application; and
(iii) Notice in a timely manner of the
decision concerning the renewal of eligibility in accordance with the
requirements specified in subsection 9.03 of this rule.
(e) Determination of ineligibility
for Immigrant Health Insurance Plan benefits
(1) Immigrant Health Insurance Plan benefits
continue for all individuals until they are found to be ineligible. When an
enrollee has done everything they were asked to do, benefits will not be closed
even though a decision cannot be made within the required review
frequency.
(2) Individuals who are
determined to be ineligible for benefits for any reason besides change in
immigration status or state residency must be provided with information about
applying for Medicaid pursuant to HBEE § 17.02(d) before benefits are
closed.
(3) Individuals who are
determined to be ineligible for benefits because of a change in immigration
status must be advised that they may be eligible for Medicaid. Such individuals
will receive benefits until the end of the calendar month following the month
in which they are determined to be ineligible for the Immigrant Health
Insurance Plan.
Section 8.00 Covered Services.
8.01 Conditions for Coverage
(a) Coverage for services for enrollees is
subject to any service limitations, prior authorizations, and conditions for
coverage described in either Chapter 4: Medicaid Covered Services of the Health
Care Administrative Rules or Medicaid Covered Service Rules adopted by the
Agency of Human Services that govern the scope of benefits available for
Medicaid enrollees, except for the following rules:
(1) For rules governing eligibility and
covered service appeals, please refer to Section 9.00 of this rule.
(2) The exception request process described
in rule 7104 is not available to individuals enrolled in the Immigrant Health
Insurance Plan.
(3) HCAR 4.106 -
Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Services is not
applicable to the Immigrant Health Insurance Plan.
(b) There are no premiums, co-payments, or
other form of cost-sharing for enrollees of the Immigrant Health Insurance
Plan.
8.02 Additional
Covered Service Provisions for Enrollees Under Age 21
(a) For enrollees under age 21, AHS will
inform enrollees of the following:
(1) The
benefits of preventive health care,
(2) Availability of screening and diagnostic
testing services,
(3) How to access
services, and
(4) The availability
of transportation if necessary to access services.
(b) The Immigrant Health Insurance Plan
covers medical, vision, dental, and hearing screenings according to a
periodicity schedule that specifies screening services applicable at each stage
of life, beginning with neonatal examination, up to age 21. Screenings are also
covered on an interperiodic basis, as needed.
(c) Immigrant Health Insurance Plan covers
medical screenings that include a comprehensive health and developmental
history that assess for physical, mental and developmental health and substance
use disorders, a comprehensive physical examination, appropriate immunizations
and laboratory tests (including lead blood level tests), and health education
for both the enrollee and, where appropriate, their caregiver.
(d) Immigrant Health Insurance Plan covers
diagnostic services without delay when a screening indicates a need for further
evaluation.
(e) The medical
necessity standard for all enrollees in the Immigrant Health Insurance Plan,
including those under age 21, is the same as that for Medicaid enrollees age 21
and older pursuant to HCAR 4.101.
8.03 Non-Covered Services
(a) There is no coverage of long-term
services and supports, as defined in Section 2.00 of this rule.
(b) Services that are only available under
the Global Commitment to Health 1115 waiver and not available in the Vermont
Medicaid State Plan are not covered.
8.04 Qualified Providers
(a) Providers of services to enrollees of the
Immigrant Health Insurance Plan must be enrolled in Vermont Medicaid prior to
delivery of services, except in the case of emergency services pursuant to HCAR
4.102.
(b) Providers of services to
enrollees of the Immigrant Health Insurance Plan must abide by the same rights,
responsibilities, and requirements as those that are applicable to Medicaid
enrollees.
Section
9.00 Immigrant Health Insurance Plan state fair hearing requests,
internal appeals and grievances (services only), and notices.
9.01 Eligibility State fair hearing requests
(a) Definitions
(1) State fair hearing request. A clear
expression, orally or in writing, by an applicant or enrollee to have a
decision by AHS affecting the individual's eligibility reviewed by the Human
Services Board.
(2) Human Services
Board rules. State fair hearing requests are processed in accordance with State
fair hearing rules as adopted by the Human Services Board pursuant to 3 VSA
§ 3091(b).
(b) Right
to a State fair hearing.
(1) AHS will grant an
opportunity for a State fair hearing to any applicant or enrollee who requests
it because AHS denies or terminates their eligibility, does not act timely on
their application, or they are aggrieved by another AHS action that affects
their eligibility.
(2) There is no
right to a State fair hearing if the sole issue is a state or federal law
requiring an automatic change adversely affecting some or all individuals. An
individual retains the right to a State fair hearing in an appeal of the
application of the law to the facts of an individual's case.
(3) AHS will provide every individual in
writing with an explanation of their State fair hearing rights:
(i) At the time that the individual applies
for the Immigrant Health Insurance Plan, and
(ii) At the time AHS sends a notice of
decision that affects the individual's eligibility.
(c) Request for a State fair
hearing.
(1) An applicant or enrollee may
submit a State fair hearing request orally or in writing by contacting AHS or
the Human Services Board. With the consent of the individual, a State fair
hearing request may be submitted by an individual's authorized representative,
legal counsel, or another person.
(2) An individual may submit a fair hearing
request by telephone, mail, in person, or through the internet.
(3) An individual must request a State fair
hearing within 90 days from the date that the notice of decision that is the
issue of the appeal is sent by AHS to the individual.
(4) AHS will assist individuals with making a
State fair hearing request, if requested.
(d) AHS review prior to sending State fair
hearing request to the Human Services Board. Prior to referring an individual's
request for a State fair hearing to the Human Services Board, AHS may take up
to 15 days from receipt of the request to review the individual's appeal. If
AHS determines, during its review, that the individual is entitled to relief,
AHS will grant the individual relief and will send the individual a new notice
of decision if eligibility is redetermined.
(e) Judicial review of AHS final decision. An
applicant or enrollee may appeal a final order to the Vermont Supreme Court
pursuant to Vermont Rule of Appellate Procedure 13.
(f) Implementation of State fair hearing
order. AHS will promptly implement an order that is final and binding. If the
order is favorable to the applicant or enrollee, eligibility will be reinstated
to the date of the incorrect action that was taken by AHS. If the decision is
favorable to AHS and results in an individual's ineligibility, AHS will
terminate continued coverage on the last day of the month in which AHS acts to
implement the order.
(g)
Maintaining eligibility pending State fair hearing.
(1) If an applicant or enrollee appeals an
AHS decision that denies or terminates their eligibility, does not act timely
on their application, or is aggrieved by another AHS action that affects their
eligibility, the individual has a right, under certain circumstances, to have
their eligibility continue as it was before the decision that resulted in the
appeal. This continued eligibility will continue until the State fair hearing
is resolved, provided the individual submits the request for a State fair
hearing before the effective date of the adverse action. If the last day before
the adverse action goes into effect is on a weekend or State holiday, the
individual has until the end of the first subsequent business day to request
the State fair hearing. An individual may waive their right to continued
Immigrant Health Insurance Plan coverage.
(2) There is no right to continued health
care benefits without change when AHS's decision does not require the minimum
advance notice, as described in subsection 9.03(c)(2), or if the sole issue is
a state or federal law requiring an automatic change adversely affecting some
or all individuals.
(h)
Recovery of value of continued Immigrant Health Insurance Plan benefits. AHS
may recover from the individual the value of any continued benefits paid during
the State fair hearing process if the individual withdraws the State fair
hearing request before a decision is made, or following a final disposition of
the matter in favor of AHS.
9.02 Services appeals
(a) For rules that govern internal appeals,
State fair hearings, and grievances on services covered by the Immigrant Health
Insurance Plan, refer to Health Care Administrative Rule (HCAR) 8.100.
Applicants and enrollees have the same rights and responsibilities regarding
services internal appeals, State fair hearings, and grievances as those set
forth in HCAR 8.100 for Medicaid applicants and enrollees except:
(1) There is no requirement that Immigrant
Health Insurance Plan individuals exhaust the internal appeals process prior to
requesting a State fair hearing.
(b) The following rules in HCAR 8.100 do not
apply or have limited application, as indicated below, to Immigrant Health
Insurance Plan applicants and enrollees:
(1)
HCAR 8.100.3(b)(1)(E) - There is no requirement that a notice of adverse
benefit determination provide information about the exhaustion requirement or
when exhaustion is deemed.
(2) HCAR
8.100.4(g)(d) - Not applicable in its entirety.
(3) HCAR 8.100.4(g)(1)(B) - Not applicable in
its entirety.
(4) HCAR
8.100.4(g)(2) - Not applicable in its entirety.
(5) HCAR 8.100.5(e) - Not applicable in its
entirety.
(6) HCAR 8.100.5(l) - Not
applicable in its entirety.
(7)
HCAR 8.100.5(j)(1) - Modified to provide that:
(i) For individuals who file an internal
appeal, the standard timeframe for final administrative action by AHS is 90
days from the date the internal appeal was filed, not including the days the
individual took to subsequently file a request for a State fair hearing;
and
(ii) For individuals who file a
request for a State fair hearing without first having an internal appeal, the
standard timeframe for final administrative action by AHS is 90 days from the
date the State fair hearing request was filed.
9.03 General Notice Standards
(eligibility and services)
(a) All notices
that AHS is required to send will conform to the accessibility requirements set
forth in subsection 3.04 of this rule.
(b) Notices related to eligibility. AHS will
send a timely notice of decision when it makes a decision that affects
eligibility. Notices of decision are generally sent in advance of the effective
date of the change. Notices of decision that adversely affect an individual's
eligibility (e.g., termination) will comply with notice requirements set forth
at subsection 9.03(c) of this rule. Notices of decision concerning eligibility
will contain clear statements of the following content, as applicable:
(1) AHS's decision, its basis, and the
specific reasons supporting the decision,
(2) The effective date of the
decision,
(3) If the decision is
adverse, the state rule supporting the decision,
(4) If the decision is adverse, information
about how to apply for Medicaid (including Medicaid pursuant to HBEE §
17.02(d))
(5) An explanation of the
right to appeal, including the right to request a State fair hearing,
(6) A description of the methods by which an
individual can request a State fair hearing,
(7) The timeframe in which AHS must enter a
final administrative decision,
(8)
Information about the individual's right to represent themself at a State fair
hearing or use legal counsel, a friend, or another person as their
spokesperson,
(9) In cases of a
decision based on a change in law, an explanation of the limited circumstances
in which a fair hearing may be granted,
(10) An explanation of when the individual's
Immigrant Health Insurance Plan eligibility will continue pending a State fair
hearing decision, and
(11) Contact
information for AHS customer services.
(c) Advance notice of Immigrant Health
Insurance Plan adverse decisions concerning eligibility.
(1) AHS will send a notice of decision that
adversely affects eligibility (e.g., termination) at least 11 days before the
date that the adverse action is to take effect except as described at
subsection 9.03(c)(2) of this rule.
(2) Advance notice of an adverse action is
not required in these circumstances:
(i) There
is factual information confirming the death of an applicant or
enrollee,
(ii) The enrollee has
provided a clear, signed statement that they no longer wish to be
enrolled,
(iii) The enrollee has
been admitted to an institution where they are ineligible for the Immigrant
Health Insurance Plan,
(iv) The
enrollee's whereabouts are unknown, and the post office returns mail directed
to the enrollee and does not indicate a forwarding address,
(v) AHS establishes the fact that the
enrollee has been enrolled in Medicaid in Vermont or in another
state.
(d)
Notices related to services. For adverse benefit determinations concerning
coverage of services, the content and timing of the notice will follow Heath
Care Administrative Rule 8.100.3, except that HCAR 8.100.3(b)(1)(E) is replaced
with the following:
(1) HCAR 8.100(b)(1)(E).
An explanation of when there is a right to request a State fair hearing,
including the option to request an internal appeal or go directly to a State
fair hearing.
3 V.S.A. §801(b)(11); 33 V.S.A.
§2092(d)