Code of Vermont Rules
Agency 13 - AGENCY OF HUMAN SERVICES
Sub-Agency 174 - HEALTH CARE ADMINISTRATIVE RULES (HCAR)
Chapter 001 - GENERAL PROVISIONS AND DEFINITIONS
Section 13 174 001 - GENERAL PROVISIONS AND DEFINITIONS

Universal Citation: VT Code of Rules 13 174 001

Current through August, 2024

1.100 Health Care Administrative Rules Introduction.

(12/16/2016, GCR 16-076)

(a) The Agency of Human Services is the "single State agency," pursuant to 42 U.S.C. 1396a(a)(5), responsible for the operation of the Medicaid program in Vermont.

(b) The Agency of Human Services administers Vermont's Medicaid program with the support and assistance of the Departments that comprise the Agency. The Agency of Human Services includes the Department of Vermont Health Access, Department of Mental Health, Department of Disabilities, Aging, and Independent Living, Department for Children and Families, Department of Corrections, and Vermont Department of Health. The Agency assigns the Departments the responsibility for ensuring that persons eligible for Medicaid services are properly enrolled, covered services are provided, health care providers are paid, and the rights of beneficiaries in the program are respected.

(c) These Health Care Administrative Rules coordinate and consolidate the State of Vermont rules that pertain to the operation of Vermont's Medicaid program. Consolidated and well-organized rules written in plain language permit Medicaid beneficiaries and providers convenient access to the regulations, increases comprehension of sometimes technical concepts and program requirements, and ensures consistent policy administration of the program throughout the Agency of Human Services.

(d) The Health Care Administrative Rules are applicable to the entirety of Vermont's Medicaid program, without regard to whether the programs are operated and managed by any individual Department within the Agency of Human Services. As such, with two limited exceptions, the Health Care Administrative Rules take precedence over any rules, policies, and guidelines maintained by individual Departments in connection with their operation of the portions of the Medicaid program for which they are responsible, if any inconsistencies between them exist. The first exception concerns certain specialized services contained in programs and services authorized by federal "waivers" of Medicaid program requirements. Those programs and services are reflected at Chapter 7 of these rules, entitled Specialized Services and Programs. The rules, policies, and guidelines relating to such Specialized Services and Programs take precedence over the more general coverage, limitation, prior authorization, and eligibility rules contained throughout these Health Care Administrative Rules. The second exception relates to the provision of Early and Periodic, Screening, Diagnostic, and Treatment (EPSDT) required under the Medicaid Act. Vermont Medicaid pays for all medically necessary services for beneficiaries under the age of 21 without regard to service limitations otherwise specified in these Health Care Administrative Rules. Further, federal EPSDT requirements may require in individual cases exceptions to the general Medicaid program rules.

1.101 Health Care Administrative Rules Definitions.

(09/01/2023, GCR 22-107)

For the purposes of these Health Care Administrative Rules, the term:

"Adverse benefit determination" means any of the following

(1) Denial or limited authorization of a requested service, including determinations based on the type or level of service, requirements of medical necessity, appropriateness, setting, or effectiveness of a covered service,

(2) Reduction, suspension, or termination of a previously authorized service,

(3) Denial, in whole or in part, of payment for a service,

(4) Failure to provide services in a timely manner, as defined by the Agency of Human Services,

(5) Failure to act within timeframes regarding standard resolution of grievances and appeals,

(6) Denial of a beneficiary's request to obtain services outside the network,

(7) Denial of a beneficiary's request to dispute a financial liability, including cost sharing, copayments, premiums, deductibles, coinsurance, and other beneficiary liabilities.

"Agency or AHS" means the Vermont Agency of Human Services or any of its departments, offices, or divisions.

"Beneficiary" means any individual eligible to have benefits paid to him or her, or on his or her behalf, under Vermont Medicaid.

"Centers for Medicare and Medicaid Services" or "CMS" mean a federal agency within the U.S. Department of Health and Human Services. Programs administered by CMS include Medicare, Medicaid, the Children's Health Insurance Program (CHIP), and the federal Health Insurance Marketplace.

"Code of Federal Regulations" or "CFR" mean the codification of rules published in the Federal Register by the departments and agencies of the Federal Government.

"Day" means calendar day unless otherwise specified.

"Durable Medical Equipment" or "DME" means equipment and appliances that:

(1) Are primarily and customarily used to serve a medical purpose,

(2) Are generally not useful to an individual in the absence of disability, illness, or injury,

(3) Can withstand repeated use, and

(4) Can be reusable or removable.

"DVHA" means the Department of Vermont Health Access.

"Early and Periodic, Screening, Diagnostic, and Treatment" or "EPSDT" mean the items and services defined in 1905(r) of the Social Security Act which include screening, vision services, dental services, hearing services, and such other necessary health care, diagnostic services, treatment, and other measures described in section 1905(a) to correct or ameliorate defects and physical and mental illnesses and conditions discovered by the screening services, whether or not such services are covered under the State Plan.

"Global Commitment to Health Waiver" means a Medicaid Demonstration Waiver authorized by Section 1115 of the Social Security Act, which provides Vermont Medicaid with federally approved waivers of specific requirements of the Social Security Act that would otherwise apply to Vermont Medicaid. These waivers provide Vermont with expenditure and policy authority to expand Medicaid eligibility and to pay for programs and services that promote the objectives of the Medicaid program outside of the Medicaid State Plan.

"Health Care Administrative Rules" or "HCAR" mean 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.

"HIPAA" means the Health Insurance Portability and Accountability Act, which establishes national standards to protect individuals' medical records and other personal health information.

"Hospital" means a facility that:

(1) is primarily engaged in providing, by or under the supervision of doctors of medicine or osteopathy, inpatient hospital services for the diagnosis, treatment, and care or rehabilitation of persons who are sick, injured, or disabled;

(2) is not primarily engaged in providing skilled nursing care and related services for inpatients who require medical or nursing care;

(3) provides 24-hour nursing service; and

(4) is licensed or approved as meeting the standards for licensing by the State or local licensing agency.

"Human Services Board" means the independent part of AHS that serves as the external appeals entity for compliance with 42 CFR 431, Subpart E, and 3 VSA 3090.

"Medicare" means the health insurance program for the aged and disabled under Title XVIII of the Social Security Act.

"Network" means the providers who are enrolled in Vermont Medicaid and who provide services to beneficiaries.

"Plain Language" means language that the intended audience, including individuals with limited English proficiency, can readily understand and use because that language is concise, well organized, and follows best practices of plain language writing for that audience.

"Provider" means any individual or entity who has entered into an agreement with the Agency of Human Services or any of its departments, offices, or divisions, to provide services covered by Vermont Medicaid.

"Provider Manuals" means policy and procedure documents outlining the policies and practices for medical providers enrolled with Vermont Medicaid. Manuals are made publicly available for medical coverage and medical programs administered by the Agency.

"Service Authorization Request" means a request for the provision of a service, including prior authorization and concurrent review, that requires authorization pursuant to 42 CFR 438.210.

"Services" means a benefit (1) covered under the Global Commitment to Health Waiver, (2) included in the State Medicaid Plan, (3) authorized by state rule or other law, (4) required by federal law, or (5) identified in the Intergovernmental Agreement between DVHA and AHS for the administration and operation of the Global Commitment to Health Waiver.

"State Fair Hearing" means an appeal to AHS for a hearing before the Human Services Board.

"State Plan" means the agreement between Vermont and the Centers for Medicare and Medicaid Services approved under Title XIX of the Social Security Act describing how Vermont administers its Medicaid program.

"Vermont 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 CMS.

STATUTORY AUTHORITY:

3 V.S.A. § 802; 33 V.S.A. § 1901

Disclaimer: These regulations may not be the most recent version. Vermont may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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