Part ONE GENERAL PROVISIONS AND DEFINITIONS
Section 1.00 Administration of Health
Benefits
(01/15/2017, GCR 16-094)
The Agency of Human Services (AHS) was created in 1969 to
serve as the umbrella organization for all human-service activities within
state government. It is the Single State Agency for Medicaid purposes and the
adopting authority for this rule.
Section 2.00 General Description of Health
Benefits in Vermont (Subject to Specific Criteria in Subsequent Sections)
(01/15/2017, GCR 16-094)
Section 2.01 Types of health benefits
(01/15/2017, GCR 16-094)
(a) In general
The state offers several types of health benefits,
including:
* Medicaid;
* Children's Health Insurance Program (CHIP);
* Enrollment in a Qualified Health Plan (QHP) with financial
assistance.
The benefits for which a person is eligible is determined
based on the individual's income, resources (in specified cases), and
circumstances as covered in succeeding sections.
(b) Benefit choice
Except as may be otherwise restricted, an individual may
select the particular health benefit or benefits that they wish to be
considered for. In the absence of such a selection, AHS will determine an
individual's eligibility for the most advantageous benefit that they qualify
for.
(c) Redetermination of
eligibility
If an individual becomes ineligible for one benefit, AHS will
determine eligibility for the next most advantageous benefit that they then
qualify for.
Section
2.02 Medicaid
(01/15/2017, GCR 16-094)
(a) Overview of the Medicaid Program
The Medicaid program is authorized in Title XIX of the Social
Security Act (the Act).
(b)
Medicaid eligibility
Vermont provides Medicaid to those who meet the requirements
of one of three eligibility groups:
* Mandatory categorically needy;
* Optional categorically needy; and
* Medically needy.
To be eligible for federal funds, states are required to
provide
Medicaid coverage for certain groups of individuals. These
groups-the mandatory categorically needy-derive from the historic ties to
programs that provided federally-assisted income-maintenance payments ( e.g.,
SSI and Aid to Families with Dependent Children).
States are also required to provide Medicaid to related
groups not receiving cash payments.
States also have the option of providing Medicaid coverage
for other "categorically related" groups. These optional groups share
characteristics of the mandatory groups (that is, they fall within defined
categories), but the eligibility criteria are somewhat more liberally
defined.
The medically-needy option allows states to extend Medicaid
eligibility to additional groups of people. These individuals would be eligible
for Medicaid under one of the mandatory or optional groups, except that they do
not meet the income or resource standards for those groups. Individuals may
qualify immediately or may "spend down" by incurring medical expenses greater
than the amount by which their income or resources exceed their state's
medically-needy standards. [1]
(c) Vermont's Medicaid Program [2]
The Vermont Medicaid program covers all mandatory categories
of enrollees. It also offers all mandatory services-general hospital inpatient;
outpatient hospital and rural health clinics; other laboratory and x-ray;
nursing facility, Early Periodic Screening, Diagnosis and Treatment (EPSDT),
and family planning services and supplies; physician's services and medical and
surgical services of a dentist; home health services; and nurse-midwife and
nurse practitioner services. Vermont includes certain, but not all, optional
categories of enrollees. Vermont has also elected to cover certain, but not
all, optional services for which federal financial participation is available.
It also operates health care programs permitted by research demonstration
waiver authority under § 1115 of the Social Security Act.
The scope of coverage for children under the EPSDT provisions
of Title XIX is different and more extensive than coverage for adults. The
EPSDT provisions of Medicaid law specify that services that are optional for
adults are mandatory covered services for all Medicaid- eligible children under
age 21 when such services are determined necessary as a result of an EPSDT
screen. Specifically, Vermont is required to provide such other necessary
health care, diagnostic services, treatment, and other measures described in
subsection (a) of [1396d] 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 [Medicaid] plan. [3]
A further definition of the scope of EPSDT services is found
in
42 USC §
1396 d(a)(13) which requires states to
provide other diagnostic, screening, preventive, and rehabilitative services,
including any medical or remedial services (provided in a facility, home, or
other setting) recommended by a physician or other licensed professional of the
healing arts within the scope of their practice under State Law, for the
maximum reduction of physical or mental disability and restoration of an
individual to the best functional level.
Vermont is authorized to establish reasonable standards,
consistent with the objectives of the Medicaid statute, for determining the
extent of coverage in the optional categories [4] based on such criteria as
medical necessity or utilization control. [5] In establishing such standards
for coverage, Vermont ensures that the amount, duration, and scope of coverage
are reasonably sufficient to achieve the purpose of the service. [6] Vermont
may not limit services based upon diagnosis, type of illness, or condition.
[7]
Section 2.03
Children's Health Insurance Program (CHIP)
(01/15/2017, GCR 16-094)
(a) In general
CHIP (known from its inception until March 2009 as the State
Children's Health Insurance Program, or SCHIP) is authorized by Title XXI of
the Social Security Act.
(b) Vermont CHIP
Vermont utilizes CHIP to provide health coverage to uninsured
children with household incomes between 237% and 312% of the federal poverty
level (FPL). CHIP is part of the coverage array known as "Dr. Dynasaur." All of
the provisions in this rule that apply to the "child" Medicaid coverage group (
§ 7.03(a)(3)) apply with equal effect to an individual who is enrolled in
CHIP.
Section
2.04 The Health Benefits Exchange
(01/15/2017, GCR 16-094)
(a) In general
Vermont has elected to establish and operate its own
Exchange. Vermont Act No. 48 of 2011, "An act relating to a universal and
unified health system," established the Vermont health benefit exchange
(Vermont Health Connect, VHC). The purpose of VHC is to facilitate the purchase
of affordable, qualified health benefit plans by individuals, and small
employers in the merged individual and small group markets; and later in the
large group market in Vermont in order to reduce the number of uninsured and
underinsured; to reduce disruption when individuals lose employer-based
insurance; to reduce administrative costs in the insurance market; to contain
costs; to promote health, prevention, and healthy lifestyles by individuals;
and to improve quality of health care.
Qualified health plans (QHPs) must provide a comprehensive
set of services (essential health benefits), meet specific standards for
actuarial value and the limitation of cost-sharing.
Additionally, catastrophic plans are available to individuals
up to age 30 or to individuals who are exempt from the federal penalty for not
having coverage.
The state will certify health plans offered through VHC on an
annual basis.
(b) Financial
assistance through VHC
Eligible individuals who purchase insurance through VHC may
receive federal premium tax credits and Vermont premium reductions. Some also
qualify for federal and Vermont cost-sharing reductions (CSR).
Federal premium tax credits are available to eligible
individuals and families with incomes up to 400 percent of the FPL to purchase
insurance through VHC. [8]
The state will supplement the federal premium tax credits
with premium reductions for individuals and families with income at or below
300% of the federal poverty level.
In addition to premium subsidies, eligible individuals
receive federal and state CSRs for silver level plans (see level of coverage in
§ 3.00) and in other limited circumstances. These subsidies reduce the
cost- sharing amounts and annual cost-sharing limits and have the effect of
increasing the actuarial value of the plan.
Modified adjusted gross income (MAGI) is used to determine
eligibility for federal and state premium subsidies and CSRs. In order to be
eligible for federal CSR, state premium reductions and state CSR, the
individual must be eligible for federal premium tax credits. [9]
(c) Administrative Requirements
Federal health-care regulations contain a number of
provisions aimed at the administration of the health-benefits
eligibility-determination process. These provisions are intended to promote
administratively- efficient, streamlined, and coordinated eligibility business
processes.
Section
2.05 Administration of eligibility for health benefits
(01/15/2017, GCR 16- 094)
(a) AHS administers eligibility for the
state's health-benefits programs and for enrollment in a QHP in accordance with
applicable provisions of federal and state law and regulations.
(b) The eligibility determination process is
administered such that: [10]
(1) Individual
dignity and self-respect are maintained;
(2) The constitutional and other legal rights
of individuals are respected;
(3)
Practices do not violate the individual's privacy or dignity or harass the
individual in any way;
(4)
Disclosure of information concerning applicants or enrollees is limited to
purposes directly connected with the administration of the applicable
health-benefits program or with enrollment in a QHP or as otherwise required by
law;
(5) Each individual who wishes
to do so is given an opportunity to apply or reapply for benefits without
delay;
(6) Prompt action is taken
on each application and reapplication and individuals are notified in writing
of the decision on the application;
(7) Decisions are based on recorded
information showing either that all pertinent eligibility requirements are met
or that one or more requirements are not met;
(8) Benefits are given promptly and continue
regularly to all eligible individuals until they are found to be
ineligible;
(9) Eligibility is
redetermined when circumstances change or at the time of renewal, in accordance
with the same principles as initial application;
(10) Individuals are the primary sources of
information about their eligibility;
(11) Individuals are informed of their
responsibility to furnish complete and accurate information, including prompt
notification of changes affecting their eligibility or amount of aid or
benefits, and of the penalties for willful misrepresentation to obtain benefits
to which they are not entitled;
(12) Individuals are helped to obtain needed
information; and
(13) Verification
of conditions of eligibility are limited to what is reasonably necessary to
assure that expenditures under a health-benefits program are legal, in
accordance with federal and state law and regulations.
(c) Application of these principles in
specific areas is covered in succeeding sections.
Section 3.00 Definitions
(01/15/2017, GCR 16-094)
As used in this rule, the following terms have the following
meanings:
Adjusted monthly premium [11]
The premium an insurer charges for the applicable benchmark
plan (ABP) to cover all members of the tax filer's coverage family.
Advance payment of the premium tax credit (APTC) [12 ]
The payment of premium tax credits specified in section 36B
of the Internal Revenue Code that are provided on an advance basis on behalf of
an eligible individual enrolled in a QHP through VHC and paid directly to the
QHP issuer.
Affordable Care Act (ACA) [13]
The Patient Protection and Affordable Care Act of 2010 ( Pub.
L. 111- 148), as amended by the Health Care and Education Reconciliation Act
of 2010 ( Pub. L.
111-152), as amended by the Three Percent
Withholding Repeal and Job Creation Act (
Pub. L.
112-56).
Aid to the Aged, Blind, or Disabled (AABD) [14]
Vermont's supplemental security income (SSI) state supplement
program.
Alternate reporter
A person who is authorized to receive either original
notifications or copies of such notifications on behalf of an individual. (See,
§ 5.02(b)(1)(iv)).
Annual open enrollment period (AOEP) [15]
The period each year during which a qualified individual may
enroll or change coverage in a QHP.
Applicable benchmark plan (ABP) [16]
As defined in § 60.06, the second-lowest-cost silver
plan offered through VHC.
Applicant [17]
(a)
An individual seeking eligibility for health benefits for themselves through an
application submission.
(b) An
employer or employee seeking eligibility for enrollment in a QHP, where
applicable.
Application [18]
A single, streamlined application for health benefits,
submitted by or on behalf of an applicant. For determining eligibility on a
basis other than the applicable MAGI standard, the single, streamlined
application may be supplemented with form(s) to collect additional information
needed, or an appropriate alternative application may be used.
Application date
(a)
The day the application is received by AHS, if it is received on a business
day; or
(b) The first business day
after the application is received, if it is received on a day other than a
business day.
If an application is supplemented with form(s) to collect
additional information, including the use of an alternative application, the
application date is the date the initial application is received by AHS.
Application filer [19]
(a) Applicant;
(b) Adult who is in the applicant's
household;
(c) Authorized
representative; or
(d) If the
applicant is a minor or incapacitated, someone acting responsibly for the
applicant.
Approve
To determine that an individual is eligible for health
benefits.
Approval month
The month in which the individual's eligibility is
approved.
Authorized representative
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. See, § 5.02
Benefit year (or taxable year) [20]
A calendar year for which a health plan provides coverage for
health benefits.
Broker [21]
A person or entity licensed by the state as a broker or
insurance producer
Business day
Any day during which state offices are open to serve the
public.
Cancel
To determine that an applicant who was approved for health
benefits but not yet enrolled is no longer eligible for health benefits.
Caretaker relative [22]
(a) A relative of a dependent child (as
defined in this § 3.00) by blood, adoption, or marriage, with whom the
dependent child is living, who assumes primary responsibility for the dependent
child's care (as may, but is not required to, be indicated by claiming the
dependent child as a tax dependent for Federal income tax purposes).
(b) As used in this definition, a "relative"
is the child's father, mother, grandfather, grandmother, brother, sister,
stepfather, stepmother, stepbrother, stepsister, uncle, aunt, first cousin,
nephew, or niece. The term relative includes:
(1) An individual connected to the dependent
child by blood, including half-blood;
(2) An individual of preceding generations
denoted by grand, great, or great-great;
(3) The spouses or civil-union partners of
such relatives, even after the marriage or union is terminated by death or
dissolution; and
(4) An adult not
related to the dependent child by blood, adoption, or marriage, but who lives
with the dependent child and has primary responsibility for the dependent
child's care.
Case file
The permanent collection of documents and information
required to determine eligibility and to provide benefits to
individuals.
Categorically needy [23]
Families and children; aged, blind, or disabled individuals;
and pregnant women, described under subparts B and C of 42 CFR part 435 who are
eligible for Medicaid. Subpart B describes the mandatory eligibility groups
who, generally, are receiving or are deemed to be receiving cash assistance
under the Act. These mandatory groups are specified in §§
1902(a)(10)(A)(i),
1902(e),
1902(f),
and 1928 of the Act. Subpart C describes the optional eligibility groups of
individuals who, generally, meet the categorical requirements or income or
resource requirements that are the same as or less restrictive than those of
the cash assistance programs and who are not receiving cash payments. These
optional groups are specified in §§
1902(a)(10)(A)(ii),
1902(e),
and
1902(f)
of the Act.
Catastrophic plan [24]
A health plan available to an individual up to age 30 or to
an individual who is exempt from the mandate to purchase coverage that:
(a) Meets all applicable requirements for
health insurance coverage in the individual market and is offered only in the
individual market;
(b) Does not
provide a bronze, silver, gold, or platinum level of coverage; and
(c) Provides coverage of essential health
benefits once the annual limitation on cost sharing is reached, with the
following exceptions:
(1) A catastrophic plan
must provide coverage for at least three primary-care visits per year before
reaching the deductible.
(2) A
catastrophic plan may not impose any cost-sharing requirements for preventive
services, in accordance with § 2713 of the Public Health Service Act.
Certified application counselors
Staff and volunteers of organizations who are authorized and
registered by AHS to provide assistance to individuals with the application
process and during renewal of eligibility. See, § 5.05
Close
To determine that an enrollee is no longer eligible to
receive health benefits.
Code
Internal Revenue Code.
Combined eligibility notice [25]
An eligibility notice that informs an individual, or multiple
family members of a household when feasible, of eligibility for each of the
health-benefits programs, and enrollment in a QHP, for which a determination or
denial was made. A combined notice must meet the requirements of §
68.01.
Community spouse (CS)
For purposes of Medicaid, the spouse of an institutionalized
individual who is not living in a medical institution or a nursing facility. An
individual is considered a community spouse even when receiving Medicaid
coverage of long-term care services and supports in a home and community-based
setting if they are the spouse of an individual who is also receiving Medicaid
coverage of long-term care services and supports.
Cost sharing [26]
Any expenditure required by or on behalf of an individual
with respect to essential health benefits; such term includes deductibles,
coinsurance, copayments, or similar charges, but excludes premiums,
balance-billing amounts for non-network providers, and spending for non-covered
services.
Cost-sharing reductions (CSR) [27]
Reductions in cost sharing for an individual who is enrolled
in a silver- level QHP or for an individual who is an Indian enrolled in a
QHP.
Couple
Two individuals who are married to each other or are parties
to a civil union, according to the laws of the State of Vermont, except, for
purposes of APTC/CSR, two individuals who are married to each other within the
meaning of
26 CFR §
1.7703-1. IRS's regulations do not recognize
parties to civil unions as married couples. Couples in civil unions are not
permitted to file joint federal tax returns, but may qualify for APTC/CSR by
filing separate tax returns.
Coverage
The scope of health benefits provided to an
individual.
Coverage date
The date coverage begins.
Coverage family [28]
See, § 60.02(b)
Coverage group [29]
Category of Medicaid eligibility, defined by particular
categorical, financial, and nonfinancial criteria.
Coverage island
A discrete period of Medicaid coverage that is available in
certain defined circumstances. See, § 70.02(d)
Coverage month [30]
A month for which, as of the first day of the month:
(a) An individual is receiving
coverage;
(b) If a premium is
charged for coverage, the individual's premium is paid in full or, if the
individual is enrolled in a QHP with APTC, the individual is in the first month
of a premium grace period (see § 64.06(a)(1) for a description of the
grace period for an individual enrolled in a QHP with APTC); and
(c) If the individual is enrolled in a QHP
with APTC, the individual is not eligible for Minimum Essential Coverage (MEC)
other than coverage in the individual market, as referenced in §
5000A(f)(1)(C) of the Code.
Date of application
See, application date
Day
A calendar day unless a business day is specified.
Deny
To determine that an applicant is ineligible for health
benefits.
Dependent child [31]
An individual who is:
(a) Under the age of 18; or
(b) Age 18 and a full-time student in
secondary school (or equivalent vocational or technical training), if before
attaining age 19 the child may reasonably be expected to complete such school
or training.
Disability [32]
(a)
Individual age 18 and older
An individual age 18 and older is considered "disabled" if
they are unable to engage in any substantial gainful activity because of any
medically-determinable physical or mental impairment, or combination of
impairments, that can be expected to result in death, or has lasted or can be
expected to last for a continuous period of not fewer than 12 months. To meet
this definition, an individual must have a severe impairment, which makes them
unable to do their previous work or any other substantial gainful activity that
exists in the national economy. To determine whether an individual is able to
do any other work, AHS considers their residual functional capacity, age,
education, and work experience.
(b) Individual under age 18
An individual under age 18 is considered disabled if they
have a medically-determinable physical or mental impairment, or combination of
impairments, resulting in marked and severe functional limitations, that can be
expected to result in death or that have lasted or can be expected to last for
at least 12 consecutive months. An individual under age 18 who engages in
substantial gainful activity may not be considered disabled.
Disenroll
To end coverage.
Dr. Dynasaur
The collection of programs that provide health benefits to
children under age 19 in the group defined in § 7.03(a)(3) and pregnant
women in the group defined in § 7.03(a)(2).
Electronic account [33]
An electronic file that includes all information collected
and generated by the state regarding each individual's health-benefits
eligibility and enrollment, including all documentation required under §
4.04 and including information collected or generated as part of a fair hearing
process conducted with regard to health-benefits eligibility and
enrollment.
Eligible
The status of an individual determined to meet all financial
and nonfinancial qualifications for health benefits.
Eligible employer-sponsored plan [34]
(a) With respect to an employee, a group
health plan or group health insurance coverage offered by an employer to the
employee which is:
(1) A governmental plan
(within the meaning of § 2791(d)(8) of the Public Health Service (PHS)
Act); or
(2) Any other plan or
coverage offered in the small or large group market within a state.
(b) This term also includes a
grandfathered health plan35 offered in a group market.
Eligibility determination [36]
An approval or denial of eligibility as well as a renewal or
termination of eligibility.
Eligibility process
Activities conducted for the purposes of determining,
redetermining, and maintaining the eligibility of an individual.
Employer contributions [37]
Any financial contributions toward an employer-sponsored
health plan, or other eligible employer-sponsored benefit made by the employer
including those made by salary reduction agreement that is excluded from gross
income.
Enroll
To initiate coverage for an approved individual.
Enrollee [38]
An individual who has been approved and is currently
receiving health benefits. The term "enrollee" includes the term "beneficiary,'
which is an individual who has been determined eligible for, and is currently
receiving, Medicaid.
Exchange (Vermont Health Connect (VHC)) [39]
A state-managed entity through which individuals, qualified
employees, and small businesses can compare, shop for, purchase, and enroll in
QHPs; and individuals can apply for and enroll in health- benefits programs. In
Vermont, the Exchange is known as Vermont Health Connect (VHC).
Exchange service area [40]
The area in which the Exchange (in Vermont, VHC) is certified
to operate.
Family size
See, § 28.02(b)
Federal poverty level (FPL) [41]
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 budget period used to determine an individual's
income eligibility for means-tested health benefits.
Financial responsibility group
For purposes of MABD, the individuals whose income or
resources are considered when determining eligibility for a Medicaid group
(defined below). See § 29.03 for rules on the formation of the financial
responsibility group for MABD eligibility purposes.
Grace period
The period of time during which an enrollee who has failed to
pay all outstanding premiums remains enrolled in coverage, with or without
pended claims.
Grandfathered health plan coverage [42]
Coverage provided by a group health plan, or a group or
individual health insurance issuer, in which an individual was enrolled on
March 23, 2010 (for as long as it maintains that status under federal
criteria).
Group health plan [43]
An employee welfare benefit plan to the extent that the plan
provides medical care (including items and services paid for as medical care)
to employees (including both current and former employees) or their dependents
(as defined under the terms of the plan) directly or through insurance,
reimbursement, or otherwise.
Health-benefits program [44]
A program that is one of the following:
(a) A state Medicaid program under Title XIX
of the Act.
(b) A state children's
health insurance program (CHIP) under Title XXI of the Act.
(c) A program that makes available coverage
in QHPs with financial assistance.
Health benefits
Any health-related program or benefit, administered or
regulated by the state, including, but not limited to, QHPs, APTC, premium
reductions, federal or state CSR, and Medicaid.
Health insurance coverage [45]
Benefits consisting of medical care (provided directly,
through insurance or reimbursement, or otherwise) under any hospital or medical
service policy or certificate, hospital or medical service plan contract, or
HMO contract offered by a health insurance issuer. Health insurance coverage
includes group health insurance coverage and individual health insurance
coverage.
Health insurance issuer or issuer [46]
An insurance company, nonprofit hospital and medical service
corporation, insurance service, or insurance organization (including an HMO)
that is required to be licensed to engage in the business of insurance in a
state and that is subject to state law that regulates insurance (within the
meaning of section 514(b)(2) of ERISA).
Health plan [47]
This term has the meaning given in §
1301(b)(1)
of the ACA. That section incorporates the definition found in § 2791(a) of
the Public Health Service Act.
Human Services Board
AHS's fair hearings entity for eligibility issues. See,
§ 80.01
Indian [48]
A person who is a member of an Indian tribe.
Indian tribe [49]
Any Indian tribe, band, nation or other organized group, or
community, including pueblos, rancherias, colonies and any Alaska Native
Village, or regional or village corporation as defined in or established
pursuant to the Alaska Native Claims Settlement Act, which is recognized as
eligible for the special programs and services provided by the United States to
Indians because of their status as Indians.
Individual
An applicant or enrollee for health benefits.
Institution [50]
An establishment that furnishes (in single or multiple
facilities) food, shelter, and some treatment or services to four or more
individuals unrelated to the proprietor.
Institutionalized individual
A person requesting Medicaid coverage of long-term care
services and supports, whether the care is received in a home and community-
based setting or in an institution licensed by AHS.
Institutionalized spouse (IS)
For purposes of Medicaid, an institutionalized individual
whose spouse qualifies as a community spouse.
Interpreter
A person who orally translates for an individual who has
limited English proficiency or an impairment.
Lawfully present
See, § 17.01(g)
Level of coverage [51]
One of four standardized actuarial values for plan coverage
as defined by §
1302(d)(1)
of the ACA: bronze, silver, gold or platinum.
Limited English proficiency
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 care
Highest-need and high-need care, as determined by AHS,
received by an individual living in a nursing facility, rehabilitation center,
intermediate-care facility for the developmentally disabled (ICF-DD), and other
medical facility for at least 30 consecutive days. It also includes care
received by an individual in a home and community- based setting as specified
in relevant waiver authorizations and any related program regulations.
For more information on Vermont's waiver governing terms and
conditions, see: http://dvha.vermont.gov/administration.
Long-term care services and supports [52]
A range of medical, personal, and social services that can
help an individual with functional limitations live their life more
independently. Supports range from daily living (e.g. grocery shopping and food
preparation) to 24-hour medical care provided in nursing facilities. Examples
of long-term care services and supports include nursing facility services; a
level of care in any institution equivalent to nursing facility services; home
and community-based services to qualifying individuals as specified in relevant
waiver authorizations or in any related program regulations, to include:
(a) Home-based and enhanced residential care
services for the aged and disabled (known as "Choices for Care");
(b) Traumatic brain injury services
(TBI);
(c) Home and community-based
waiver services for the developmentally disabled (DS); and
(d) Children's mental health services.
For more information on Vermont's waiver governing terms and
conditions, see: http://dvha.vermont.gov/administration.
See, also, DVHA's Medicaid Covered Services Rule 7601.
MAGI-based income [53]
See, § 28.03(c)
Medicaid for Children and Adults (MCA)
The health-benefits program available to a member of a
Medicaid coverage group for parents and other caretaker relatives, children,
pregnant women, or adults under 65 years of age.
Medicaid for the Aged, Blind, and Disabled (MABD)
The health-benefits program available to a member of a
Medicaid coverage group for people who are aged, blind, or disabled. MABD is
based on the requirements for two financial assistance programs federally
administered by the Social Security Administration: the supplemental security
income program (SSI) and aid to the aged, blind, and disabled program
(AABD).
Medicaid group
Individuals who are considered in the financial-eligibility
determination for MABD. The countable income and resources of the financial
responsibility group are compared against the income and resource standards
applicable to the Medicaid group's size. See § 29.04 for rules on the
formation of the Medicaid group.
Medicaid services [54]
Medical benefits funded through Medicaid. They include
Medicaid services (Medicaid Covered Services Rules 7201 - 7508. 7), long-term
care services and supports (Medicaid Covered Services Rules 7601 - 7608),
services defined in regulations for Choices for Care, Developmental
Disabilities, and the waiver for Traumatic Brain Injury supports, as specified
in relevant waiver authorizations.
Medical incapacity
See, § 64.09.
Medical institution [55]
An institution that:
(a) Is organized to provide medical care,
including nursing and convalescent care;
(b) Has the necessary professional personnel,
equipment, and facilities to manage the medical, nursing and other health needs
of patients on a continuing basis and in accordance with accepted
standards;
(c) Is authorized under
state law to provide medical care; and
(d) Is staffed by professional personnel who
are responsible to the institution for professional medical and nursing
services. The services must include adequate and continual medical care and
supervision by a physician; registered nurse or licensed practical nurse
supervision and services and nurses' aid services, sufficient to meet nursing
care needs; and a physician's guidance on the professional aspects of operating
the institution.
Medically needy [56]
Families; children; individuals who are aged, blind, or
disabled; and pregnant women who are not categorically needy but who may be
eligible for Medicaid because their income and, for individuals who are aged,
blind or disabled, their resources are within limits set by the state under its
Medicaid plan (including persons whose income and, if applicable, resources
fall within these limits after their incurred expenses for medical or remedial
care are deducted).
Minimum essential coverage (MEC) [57]
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.
See, § 23.00.
Minimum value [58]
When used to describe coverage in an eligible
employer-sponsored plan, minimum value means that the percentage of the total
allowed costs of benefits provided under the plan is greater than or equal to
60 percent, and the benefits under the plan include substantial coverage of
inpatient hospital services and physician services.
Modified adjusted gross income (MAGI)
See, § 28.00
Navigator [59]
An entity or individual selected by AHS and awarded a grant
to provide assistance to individuals and employers with enrollment in Medicaid
programs and qualified health plans, and to engage in the activities and meet
the standards described in § 5.03.
Non-applicant [60]
A person who is not seeking an eligibility determination for
himself or herself and is included in an applicant's or enrollee's household to
determine eligibility for such applicant or enrollee.
Nonpayment
Failure to pay any or all of a premium due.
OASDI [61]
Old age, survivors, and disability insurance under Title II
of the Act.
Optional state supplement [62]
A cash payment made by a state, under § 1616 of the Act,
to an aged, blind, or disabled individual. See, AABD.
Patient share
See, § 24.00.
Physician's certificate
See, § 64.09.
Plan year [63]
A consecutive 12-month period during which a health plan
provides coverage. For plan years beginning on January 1, 2015, a plan year
must be a calendar year.
Plain language [64]
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 other best practices of plain
language writing.
Pregnant woman [65]
A woman during pregnancy and the post partum period, which
begins on the date the pregnancy ends, extends 60 days, and then ends on the
last day of the month in which the 60-day period ends.
Premium
(a) In
general
A monthly charge that must be paid by an individual as a
condition of initial and ongoing health-benefits eligibility and
enrollment.
(b) Initial
premium
The premium for the first month of coverage.
(c) Ongoing premium
The premium for successive months of coverage, which are
billed and due on a monthly basis.
Premium due date
The day on which a health-benefits premium is due.
Premium Reduction
State subsidy paid directly to the QHP issuer to reduce
monthly premiums for an eligible individual enrolled in a QHP through
VHC.
Private facility [66]
Any home privately owned and operated, or any home or
institution supported by private or charitable funds, over which neither the
state nor any of its subdivisions has supervision or control even though
individuals may be boarded or cared for therein at public expense. Vermont
private institutions include boarding homes, fraternal homes, religious homes,
community care homes, residential care facilities, medical facilities (i.e.
general hospitals) and nursing facilities licensed by the State of
Vermont.
Protected Income Level (PIL)
The income standard for the medically-needy Medicaid coverage
groups.
Public Institution [67]
Any institution meeting all of the following
conditions:
(a) The institution is
owned, maintained, or operated in whole or in part by public funds;
(b) Control is exercised, in whole or in
part, by any public agency or an official or employee of that agency;
and
(c) The institution furnishes
shelter and care and can be termed a public institution by reason of its
origin, charter, ownership, maintenance or supervision.
Qualified Health Plan (QHP)
A health plan certified by Vermont's Department of Financial
Regulation (DFR) and offered by Vermont Health Connect.68
QHP issuer [69]
A health insurance issuer that offers a QHP in accordance
with a certification from DFR.
Qualified individual [70]
For purposes of QHP, an individual who has been determined
eligible by AHS to enroll in a QHP.
Qualifying coverage in an employer-sponsored plan [71
]
Coverage in an eligible employer-sponsored plan that meets
the affordability and minimum-value standards specified in 26 CFR § 1.36
B- 2(c)(3), and described in §§ 23.02 (affordable) and 23.03 (minimum
value).
Quality control (QC)
A system of continuing review to measure the accuracy of
eligibility decisions. Also, the name of the AHS unit that is responsible for
administering quality-control functions.
Reasonable compatibility
See, § 57.00(a)
Reenroll
To restore coverage after closure.
Reinstate
To restore eligibility after cancellation or closure.
Renew
To redetermine eligibility at a specified periodic interval (
e.g., annual renewal of eligibility).
Secure electronic interface [72]
An interface that allows for the exchange of data between
information technology systems and adheres to the requirements in subpart C of
42 CFR part 433.
Self-only coverage [73]
Health insurance that covers one individual.
Special enrollment period (SEP) [74]
A period during which a qualified individual or enrollee who
experiences certain qualifying events may enroll in, or change enrollment in, a
QHP outside of AOEPs.
Spouse
A husband, a wife or a party to a civil union according to
the laws of the State of Vermont, except, for purposes of APTC/CSR, a husband
or a wife if married within the meaning of
26 CFR §
1.7703-1. IRS's regulations do not recognize
parties to civil unions as "spouses." Parties to civil unions are not permitted
to file joint federal tax returns, but may qualify for APTC/CSR by filing
separate tax returns.
SSI
Supplemental security income program under Title XVI of the
Act.
Substantial gainful activity
(a) Work activity that is both substantial
and gainful, defined as follows:
(1)
Substantial work activity involves doing significant physical or mental
activities. Work may be substantial even if it is done on a part-time basis or
if individuals do less, get paid less or have less responsibility than when
they worked before.
(2) Gainful
work activity is the kind of work done for pay or profit whether or not a
profit is realized.
(b)
Individuals who are working with disabilities shall be exempt from the
substantial gainful activity (SGA) step of the sequential evaluation of the
disability determination if they otherwise meet the requirements set forth in
§ 8.05 for the categorically needy working disabled.
Tax filer [75]
For purposes of eligibility for a QHP with financial
assistance, an individual who indicates that they expect:
(a) To file an income tax return for the
benefit year;
(b) If married
(within the meaning of
26 CFR §
1.7703-1) , to file a joint tax return for
the benefit year with their spouse (who, together with the individual, is
considered the tax filer) unless the tax filer meets the exceptions criteria
defined in § 12.03(b) (victim of domestic abuse or spousal
abandonment);
(c) That no other
taxpayer will be able to claim them as a tax dependent for the benefit year;
and
(d) To claim a personal
exemption deduction under § 151 of the Code on their tax return for one or
more applicants, who may or may not include the individual or their
spouse.
Tax dependent
(a)
For purposes of eligibility for MAGI-based Medicaid, see, §
28.03(a).
(b) For purposes of
eligibility for a QHP with financial assistance, see, § 28.05(a).
Third party
Any person, entity, or program that is or may be responsible
to pay all or part of the expenditures for another person's medical
benefits.
Section
4.00 General Program Rules
(01/15/2017, GCR 16-094)
Section 4.01 Receiving health benefits from
another state
(01/15/2017, GCR 16-094)
An individual who is receiving health benefits from another
state is not eligible for health benefits in Vermont.
Section 4.02 Rights of individuals with
respect to application for and receipt of health benefits through AHS
(01/15/2017, GCR 16-094)
(a) Notice of rights and responsibilities
Policies are administered in accordance with federal and
state law. Individuals will be informed of their rights and responsibilities
with respect to application for and receipt of health benefits.
(b) Right to nondiscrimination and
equal treatment [76]
AHS does not discriminate on the basis of race, color, sex,
sexual orientation, religion, national origin, disability, or age in admission
or access to, or treatment or employment in, its programs or activities.
(c) Right to confidentiality
The confidentiality of information obtained during the
eligibility process is protected in accordance with federal and state laws and
regulations. The use and disclosure of information concerning applicants,
enrollees, and legally-liable third parties is restricted to purposes directly
connected with the administration of health-benefits programs, with enrollment
in a QHP or as otherwise required by law.
(d) Right to timely provision of benefits
Eligible individuals have the right to the timely provision
of benefits, as defined in § 61.00.
(e) Right to information
Individuals who inquire have the right to receive information
about health benefits, coverage-type requirements, and their rights and
responsibilities as enrollees of health-benefits programs or as enrollees in
QHPs.
(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 benefits.
(g) Right to be assisted by others
(1) The individual has the right to be
represented by a legal representative.
(2) The individual has the right to be
accompanied and represented by an authorized representative during the
eligibility or appeal processes.
(3) 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.
(4) An authorized
representative may file an application for health benefits or an appeal on
behalf of a deceased person.
(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 the right to appeal, as provided in §
68.00.
(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 either 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.
Section 4.03 Responsibilities of individuals
with respect to application for and receipt of health benefits through AHS
(01/15/2017, GCR 16-094)
(a) Responsibility to cooperate
An individual must cooperate in providing information
necessary to establish and maintain their eligibility, and must comply with all
rules and regulations, including recovery and obtaining or maintaining
available health insurance.
(b) Responsibility to report changes [77]
(1) An individual must report changes that
may affect eligibility. Such changes include, but are not limited to, income,
the availability of health insurance, and third-party liability.
(2) A Medicaid enrollee must report such
changes within 10 days of learning of the change.
(3) Except as specified in paragraphs (b)(4)
and (5) of this subsection, a QHP enrollee must report such changes within 30
days of such change.
(4) A QHP
enrollee who did not request an eligibility determination for APTC or CSR, and
is not receiving APTC or CSR, need not report changes that affect eligibility
for health-benefits programs.
(5)
An individual, or an application filer on behalf of the individual, will be
allowed to report changes via the channels available for the submission of an
application, as described in § 52.02.
(c) Cooperation with quality control
An individual enrolled in a health-benefits program must
cooperate with any quality-control (QC) review of their case. ( § 4.05
)
Section 4.04
Case records
(01/15/2017, GCR 16-094)
(a) Contents
Case records include the following information:
(1) Applications for benefits;
(2) Factual data that supports eligibility
findings, including, but not limited to:
(i)
Documentation of verification of information submitted and any supplementary
investigation of eligibility factors;
(ii) Budgetary computations;
(iii) Eligibility decisions; and
(iv) Payment authorizations.
(3) Copies of all correspondence
with and concerning individuals, including, but not limited to, notices of case
decisions.
(b) Use of
case information
Case information may contribute in statistical or other
general terms to material needed for planning, research, and overall
administration of human-services programs. Individual case information shall,
however, be held in accordance with the confidentiality requirements set forth
in § 4.08.
(c)
Retention [78]
Case records are retained as required by federal and state
requirements for audit and/or review.
Section 4.05 Quality-control review79
(01/15/2017, GCR 16-094)
(a) AHS's Quality Control (QC) Unit
periodically conducts independent reviews of eligibility factors in a sampling
of cases. These reviews help to ensure that program rules are clear and
consistently applied and that individuals understand program requirements and
give correct information in support of their applications for
benefits.
(b) A random sample of
active Medicaid enrollees is chosen each month for a full field review of their
eligibility. Each eligibility factor must be verified with the enrollee and
with collateral sources.
(c) A
similar sample of negative actions (e.g., denials, closures, benefit decreases)
is also chosen each month. These reviews do not usually require a contact with
the individual, although the reviewer may sometimes need to check facts with
the individual.
(d) When a case is
selected for review, the individual must cooperate with the QC representative.
Cooperation includes, but is not limited to, participation in a personal
interview and the furnishing of requested information. If the individual does
not cooperate, eligibility for the individual's household may be closed and the
individual members may be disenrolled.
(e) When there is a discrepancy between the
eligibility facts, as discovered during a QC review, and those contained within
the case record, AHS will schedule an eligibility review and take action to
correct errors or review the effect of the changes.
Section 4.06 Fraud
(01/15/2017, GCR 16-094)
(a) Fraud
A person commits fraud in Vermont if he or she:
(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...;" [80] 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 Medicaid identification card in a manner
not authorized by law...." [81]
(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
An individual may report suspected fraud to AHS. When AHS
suspects that fraud may have been committed, it will investigate the case. If
appropriate, the case will be referred to the State's Attorney or Attorney
General for a decision on whether or not to prosecute.
(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§
(e) Examples
(1) The following are examples of instances
in which fraud might be suspected and referral considered:
(i) The individual accepts and continues paid
employment without reporting such employment after having been clearly informed
of the necessity of such notification.
(ii) The individual fails to acknowledge or
report income from pensions, Social Security, or relatives when it is
reasonably clear that there was a willful attempt to conceal such
income.
(iii) The individual
disposes of property (either real or personal) and attempts to conceal such
disposal.
(iv) The individual
misrepresents a material fact, such as residency status or dependent
relationship or status, in order to receive benefits to which they would not
otherwise be eligible.
(2) These examples are intended as a
guideline; each case will be evaluated individually.
(f) Methods of investigation
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.
(g) Review and documentation of
investigation
Procedures will be established for review and documentation
of a fraud investigation.
(h) Referral to Law Enforcement Agencies
The final decision regarding referral to a law enforcement
agency shall be the responsibility of the appropriate department's
commissioner.
Section
4.07 Reserved
(01/15/2017, GCR 16-094)
Section 4.08 Privacy and security of
personally identifiable information82
(01/15/2017, GCR 16-094)
(a) When personally-identifiable information
is collected or created for the purposes of determining eligibility for
enrollment in a QHP, determining eligibility for health-benefits programs, or
determining eligibility for exemptions from the individual responsibility
provisions in § 5000A of the Code, 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 must establish and implement privacy and security
standards that are consistent with the following principles.
(1)
(i)
Individual access. Individuals should be provided with a simple and timely
means to access and obtain their personally identifiable information in a
readable form and format;
(ii)
Correction. Individuals should be provided with a timely means to dispute the
accuracy or integrity of their personally identifiable information and to have
erroneous information corrected or to have a dispute documented if their
requests are denied;
(iii) Openness
and transparency. There should be openness and transparency about policies,
procedures, and technologies that directly affect individuals and/or their
personally identifiable information;
(iv) Individual choice. Individuals should be
provided a reasonable opportunity and capability to make informed decisions
about the collection, use, and disclosure of their personally identifiable
information;
(v) Collection, use,
and disclosure limitations. Personally identifiable information should be
created, collected, used, and/or disclosed only to the extent necessary to
accomplish a specified purpose(s) and never to discriminate
inappropriately;
(vi) Data quality
and integrity. Persons and entities should take reasonable steps to ensure that
personally identifiable information is complete, accurate, and up-to-date to
the extent necessary for the person's or entity's intended purposes and has not
been altered or destroyed in an unauthorized manner;
(vii) Safeguards. Personally identifiable
information should be protected with reasonable operational, administrative,
technical, and physical safeguards to ensure its confidentiality, integrity,
and availability and to prevent unauthorized or inappropriate access, use, or
disclosure; and
(viii)
Accountability. These principles should be implemented, and adherence assured,
through appropriate monitoring and other means and methods should be in place
to report and mitigate non-adherence and breaches.
(2) Safeguards
For the purposes of implementing the principle described in
paragraph (a)(1)(vii) of this subsection, AHS must establish and implement
operational, technical, administrative and physical safeguards that are
consistent with any applicable laws (including this subsection) to
ensure:
(i) The confidentiality,
integrity, and availability of personally identifiable information created,
collected, used, and/or disclosed by AHS;
(ii) Personally identifiable information is
only used by or disclosed to those authorized to receive or view it, for
example as described in the Interpretive Memo dated 01/24/1997 to All Programs
Rule 2000;
(iii) Return
information, as such term is defined by § 6103(b)(2) of the Code, is kept
confidential under § 6103 of the Code;
(iv) Personally identifiable information is
protected against any reasonably anticipated threats or hazards to the
confidentiality, integrity, and availability of such information;
(v) Personally identifiable information is
protected against any reasonably anticipated uses or disclosures of such
information that are not permitted or required by law; and
(vi) Personally identifiable information is
securely destroyed or disposed of in an appropriate and reasonable manner and
in accordance with retention schedules.
(3) Monitoring
AHS must monitor, periodically assess, and update the
security controls and related system risks to ensure the continued
effectiveness of those controls.
(4) Secure interfaces
AHS must develop and utilize secure electronic interfaces
when sharing personally identifiable information electronically.
Section 4.09
Use of standards and protocols for electronic transactions
(01/15/2017, GCR 16-094)
(a) HIPAA administrative simplification [83]
To the extent that electronic transactions are performed with
a covered entity, standards, implementation specifications, operating rules,
and code sets adopted by the Secretary of HHS in 45 CFR parts 160 and 162 will
be used.
(b) HIT enrollment
standards and protocols [84]
Interoperable and secure standards and protocols developed by
the Secretary of HHS in accordance with § 3021 of the PHS Act will be
incorporated. Such standards and protocols will be incorporated within VHC
information technology systems.
Section 5.00 Eligibility and Enrollment
Assistance
(01/15/2017, GCR 16-094)
Section 5.01 Assistance offered through AHS
(01/15/2017, GCR 16-094)
(a) In general [85]
AHS will provide assistance to any individual seeking help
with the application or renewal process in person, over the telephone, and
online, 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 paragraph (c) of this subsection 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 tools
(1) Call center [86]
A toll-free call center is provided to address the needs of
individuals requesting assistance and meets the accessibility requirements
outlined in paragraph (c) of this subsection.
(2) Internet website [87]
An up-to-date internet website that meets the requirements
outlined in paragraph (c) of this subsection is maintained. The website:
(i) Supports applicant and enrollee
activities, including accessing information on the health-benefit programs
available in the state, applying for and renewing coverage and providing
assistance to individuals seeking help with the application or renewal
process;
(ii) Provides standardized
comparative information on each available QHP, which may include differential
display of standardized options on consumer-facing plan comparison and shopping
tools, including at a minimum:
(A) Premium and
cost-sharing information;
(B) The
summary of benefits and coverage established under § 2715 of the PHS
Act;
(C) Identification of whether
the QHP is a bronze, silver, gold, or platinum level plan as defined by §
1302(d)
of the ACA, or a catastrophic plan as defined by §
1302(e)
of the ACA;
(D) The results of the
enrollee satisfaction survey, as described in §
1311(c)(4)
of the ACA;
(E) Beginning 2015,
quality ratings assigned in accordance with §
1311(c)(3)
of the ACA;
(F) Medical loss ratio
information as reported to HHS in accordance with 45 CFR part
158;
(G) Transparency of coverage measures
reported to VHC during certification; and
(H) The provider directory made available to
VHC.
(iii) Publishes the
following financial information:
(A) The
average costs of licensing required by VHC;
(B) Any regulatory fees required by
VHC;
(C) Any payments required by
VHC in addition to fees under paragraphs (b)(2)(iii)(A) and (B) of this
subsection;
(D) Administrative
costs of VHC; and
(E) Monies lost
to waste, fraud, and abuse.
(iv) Provides individuals with information
about Navigators as described in § 5.03 and other consumer assistance
services, including the toll-free telephone number of the call center required
in paragraph (b)(1) of this subsection.
(v) Allows for an eligibility determination
to be made in accordance with § 58.00.
(vi) Allows a qualified individual to select
a QHP in accordance with § 71.00.
(vii) Makes available by electronic means a
calculator to facilitate the comparison of available QHPs after the application
of any APTC, premium reductions and any federal or state CSR.
(c) Accessibility [88]
(1) Information is provided in plain language
and in a manner that is accessible and timely.
(2) 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) 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.
(d) Availability of program information [89]
(1) The following information is furnished in
electronic and paper formats, and orally as appropriate, to all individuals who
request it:
(i) The eligibility
requirements;
(ii) Available health
benefits and services; and
(iii)
The rights and responsibilities of individuals.
(2) Bulletins or pamphlets that explain the
rules governing eligibility and appeals in simple and understandable terms will
be published in quantity and made available.
(3) Such information is provided in a manner
that meets the standards in paragraph (c) of this subsection.
(e) Outreach and education [90]
Outreach and education activities that meet the standards in
paragraph (c) of this subsection to educate consumers about VHC and Vermont's
health-benefits programs to encourage participation will be conducted.
(f) Americans with Disabilities
Act (ADA) [91]
As required by the Americans with Disabilities Act,
reasonable accommodations and modifications will be made to policies,
practices, or procedures when necessary, as determined by the appropriate
commissioners or their designees, to provide equal access to programs, services
and activities, or when necessary to avoid discrimination on the basis of
disability. An individual may appeal the commissioner's determination regarding
necessity to the appropriate fair hearings entity or appeals entity in
accordance with departmental regulations governing appeals and fair
hearings.
(g)
Non-discrimination [92]
AHS assistance programs and activities will:
(1) Comply with applicable non-discrimination
statutes; and
(2) Not discriminate
based on race, color, national origin, disability, age, sex, gender identity or
sexual orientation.
Section 5.02 Authorized representatives93
(01/15/2017, GCR 16-094)
(a) In general
(1) An individual may designate another
person or organization to accompany, assist, and represent or to act
responsibly on their behalf in assisting with the individual's application and
renewal of eligibility and other ongoing communications with AHS. These
include:
(i) Guardians and people with powers
of attorney ( § 5.02(i)); and
(ii) Any other person of the individual's
choice.
(2) AHS may
permit an applicant or enrollee to authorize a representative to perform fewer
than all of the activities described in paragraph (b)(1) of this subsection,
provided that AHS tracks the specific permissions for each authorized
representative.
(3) Except as
provided in paragraph (h) of this subsection, and consistent with current state
policy and practice, designation of an authorized representative must be in
writing, including the individual's signature, or through another legally
binding format subject to applicable authentication and data security
standards.
(4) Designation will be
permitted at the time of application and at other times.
(5) Legal documentation of authority to act
on behalf of an individual under state law, such as a court order establishing
legal guardianship or a power of attorney, shall serve in the place of written
authorization by the individual. In such cases AHS may recognize an individual
as an authorized representative before the legal documentation is provided to
AHS.
(b) Scope of
authority
(1) Representatives may be
authorized to do any or all of the following:
(i) Assist the individual in completing and
submitting any health-benefits application, verification, or other
documentation with AHS;
(ii) Give
and receive information regarding the individual's application or
enrollment;
(iii) Sign an
application on the individual's behalf;
(iv) Receive copies of the individual's
notices and other communications. A person who receives authority to only
receive copies of communications is referred to as an "alternate
reporter";
(v) Request a fair
hearing or file a grievance; and
(vi) Act on behalf of the individual in any
other matters with AHS.
(2) The kinds of information that may be
shared may include the following:
(i)
Information or proofs needed to complete the application or redetermination of
eligibility;
(ii) The status of the
application including the program or programs the household members are
enrolled in and the effective dates of enrollment;
(iii) The reason the individual or household
is not eligible for a benefit, if the application is denied or benefits end;
and
(iv) The effective date of
redetermination and any outstanding information or verifications needed to
complete a redetermination.
(c) Duration of authorization
(1) The power to act as an authorized
representative is valid with AHS until:
(i)
The individual modifies the authorization or notifies AHS, using one of the
methods available for the submission of an application, as described in §
52.02(b)(2), that the representative is no longer authorized to act on their
behalf;
(ii) The authorized
representative informs AHS that they no longer are acting in such capacity;
or
(iii) There is a change in the
legal authority upon which the individual or organization's authority was
based.
(2) Any
notification described in (c)(1) of this subsection, except as stated in
(c)(1)(i), must be in writing and should include the individual's or authorized
representative's signature as appropriate.
(d) Duties of the authorized representative
The authorized representative:
(1) Is responsible for fulfilling all
responsibilities encompassed within the scope of the authorized representation,
as described in paragraph (b) of this subsection, to the same extent as the
individual they represent; and
(2)
Must agree to maintain, or be legally bound to maintain, the confidentiality of
any information regarding the individual provided.
(e) Condition of representation
(1) The authorized representative must agree
to maintain, or be legally bound to maintain, the confidentiality of any
information regarding the applicant or enrollee provided by AHS.
(2) When an organization is designated as an
authorized representative, as a condition of serving, staff members or
volunteers of that organization must sign an agreement that they will adhere to
the regulations in § 4.08 (relating to confidentiality of information),
federal regulations relating to the prohibition against reassignment of
provider claims as appropriate for a health facility or an organization acting
on the facility's behalf, as well as other relevant state and federal laws
concerning conflicts of interest and confidentiality of information.
(f) Form of authorization
For purposes of this subsection, electronic, including
telephonically recorded, signatures and handwritten signatures transmitted by
facsimile or other electronic transmission will be accepted. Designations of
authorized representatives will be accepted through all of the modalities
described in § 52.02(b).
(g) Disclosures
The authorization form or the AHS call center representative
(if the authorization is made over the telephone) shall advise that:
(1) The individual need not give permission
to share information.
(2) If the
individual decides not to give permission, that will not affect eligibility
for, or enrollment in, benefits;
(3) If the individual does not give
permission, the information will not be released unless the law otherwise
allows it;
(4) AHS is not
responsible for what an unrelated authorized representative does with the
individual's information after it is shared pursuant to a valid
authorization;
(5) The individual
may change or stop this authorization at any time by notifying AHS by telephone
or in writing. However, doing so will not affect previously shared
information;
(6) If the individual
does not change or stop the authorization, it will remain in effect as long as
the individual (or household) continues to receive health-care benefits;
and
(7) The individual will be
provided with a copy of the authorization upon request.
(h) Minors and incapacitated adults [94]
If the individual is a minor or an incapacitated adult, no
authorization is required; someone acting responsibly for the individual may
assist in the application process or during a redetermination of eligibility.
Such person may also sign the initial application on the applicant's
behalf.
(i)
Judicially-appointed legal guardian or representative [95]
Upon presentment of a valid document of appointment, a
judicially- appointed legal guardian or representative may act on an
individual's behalf.
Section
5.03 Navigator program
(01/15/2017, GCR 16-094)
(a) General requirements [96]
AHS conducts a Navigator program consistent with this
subsection through which it awards grants to eligible entities to perform the
functions of navigator organizations, and certifies individuals as Navigators.
The functions of navigator organizations include providing assistance to
individuals and employers with enrollment in Medicaid programs and qualified
health plans.
(b) Standards
[97]
AHS maintains and publicly disseminates:
(1) A set of standards, to be met by all
entities and individuals to be awarded Navigator grants, designed to prevent,
minimize, and mitigate any conflicts of interest, financial or otherwise, that
may exist for an entity to be awarded a Navigator grant, and to ensure that all
entities and individuals carrying out Navigator functions have appropriate
integrity; and
(2) A set of
training standards, to be met by all entities and individuals carrying out
Navigator functions under the terms of a Navigator grant, to ensure expertise
in:
(i) The needs of underserved and
vulnerable populations;
(ii)
Eligibility and enrollment rules and procedures;
(iii) Benefits rules and regulations
governing all health-benefits programs and QHPs offered in the state;
(iv) The range of QHP options and
health-benefits programs; and
(v)
The privacy and security standards applicable under § 4.08.
(c) Entities and
individuals eligible to be a Navigator [98]
To receive a Navigator grant, an entity must:
(1) Be capable of carrying out at least those
duties described in paragraph (f) of this subsection;
(2) Demonstrate to AHS that the entity has
existing relationships, or could readily establish relationships, with
employers and employees, consumers (including uninsured and underinsured
consumers), or self-employed individuals likely to be eligible for enrollment
in a QHP;
(3) Meet any licensing,
certification or other standards prescribed by the state or AHS;
(4) Not have a conflict of interest during
the term as Navigator; and
(5)
Comply with the privacy and security standards applicable under §
4.08.
(d) Prohibition on
Navigator conduct [99]
A Navigator must not:
(1) Be a health insurance issuer or issuer of
stop loss insurance;
(2) Be a
subsidiary of a health insurance issuer or issuer of stop loss
insurance;
(3) Be an association
that includes members of, or lobbies on behalf of, the insurance
industry;
(4) Receive any
consideration directly or indirectly from any health insurance issuer or issuer
of stop loss insurance in connection with the enrollment of any individuals or
employees in a QHP or a non-QHP;
(5) Charge any applicant or enrollee, or
request or receive any form of remuneration from or on behalf of an individual
applicant or enrollee, for application or other assistance related to Navigator
duties;
(6) Provide to an applicant
or potential enrollee gifts of any value as an inducement for enrollment. The
value of gifts provided to applicants and potential enrollees for purposes
other than an inducement for enrollment must not exceed nominal value, either
individually or in the aggregate, when provided to that individual during a
single encounter. For purposes of this paragraph, the term gifts includes gift
items, gift cards, cash cards, cash, and promotional items that market or
promote the products or services of a third party, but does not include the
reimbursement of legitimate expenses incurred by a consumer in an effort to
receive application assistance, such as, but not limited to, travel or postage
expenses;
(7) Use AHS funds to
purchase gifts or gift cards, or promotional items that market or promote the
products or services of a third party, that would be provided to any applicant
or potential enrollee;
(8) Solicit
any individual for application or enrollment assistance by going door-to-door
or through other unsolicited means of direct contact, including calling an
individual to provide application or enrollment assistance without the
individual initiating the contact, unless the individual has a pre-existing
relationship with the individual Navigator or Navigator entity and other
applicable state and federal laws are otherwise complied with. Outreach and
education activities may be conducted by going door-to-door or through other
unsolicited means of direct contact, including calling an individual;
or
(9) Initiate any telephone call
to an individual using an automatic telephone dialing system or an artificial
or prerecorded voice, except in cases where the individual Navigator or
Navigator entity has a relationship with the individual and so long as other
applicable state and federal laws are otherwise complied with.
(e) Conflict-of-interest standards
[100]
In addition to prohibited conduct in (d) of this subsection,
the following standards apply to Navigators:
(1) All Navigator entities must submit to VHC
a written attestation that the Navigator, including the Navigator's staff,
complies with (d)(1).
(2) All
Navigator entities must submit to VHC a written plan to remain free of
conflicts of interest during the term as a Navigator.
(3) All Navigator entities, including the
Navigator's staff, must provide information to consumers about the full range
of QHP options and health-benefits programs for which they are
eligible.
(4) All Navigator
entities, including the Navigator's staff, must disclose to VHC and, in plain
language, to each consumer who receives application assistance from the
Navigator:
(i) Any lines of insurance
business, not covered by the restrictions on participation and prohibitions on
conduct in (d) of this subsection, which the Navigator intends to sell while
carrying out the consumer assistance functions;
(ii) Any existing or anticipated financial,
business, or contractual relationships with one or more health insurance
issuers or issuers of stop loss insurance, or subsidiaries of health insurance
issuers or issuers of stop loss insurance; and
(iii) For Navigator staff, any existing
employment relationships, or any former employment relationships within the
last 5 years, with any health insurance issuers or issuers of stop loss
insurance, or subsidiaries of health insurance issuers or issuers of stop loss
insurance, including any existing employment relationships between a spouse or
domestic partner and any health insurance issuers or issuers of stop loss
insurance, or subsidiaries of health insurance issuers or issuers of stop loss
insurance.
(f) Duties of a Navigator [101]
An entity that serves as a Navigator must carry out at least
the following duties:
(1) Maintain
expertise in eligibility, enrollment, and program specifications and conduct
public education activities to raise awareness about VHC;
(2) Conduct public education activities to
raise awareness of the availability of qualified health benefit
plans;
(3) Distribute information
to health care professionals, community organizations, and others to facilitate
the enrollment of individuals who are eligible for Medicaid, Dr. Dynasaur,
VPharm, other public health-benefits programs, or QHP;
(4) Provide information about and facilitate
employers' establishment of cafeteria or premium-only plans under § 125 of
the Code that allow employees to pay for health insurance premiums with pretax
dollars.
(5) Provide information
and services in a fair, accurate and impartial manner, which includes providing
information that assists individuals with submitting the eligibility
application; clarifying the distinctions among health coverage options,
including QHPs; and helping individuals make informed decisions during the
health coverage selection process. Such information must acknowledge other
health programs;
(6) Distribute
fair and impartial information concerning enrollment in QHPs and concerning the
availability of premium tax credits, premium reductions, and cost-sharing
reductions;
(7) Facilitate
selection of a QHP or public health-benefits program such as Medicaid, Dr.
Dynasaur, or VPharm;
(8) Provide
referrals to any applicable office of health insurance consumer assistance,
health insurance ombudsman, or any other appropriate state agency or agencies,
for any individual with a grievance, complaint, or question regarding their
health plan, coverage, or a determination under such plan or
coverage;
(9) Provide information
in a manner that is culturally and linguistically appropriate to the needs of
the population being served by VHC, including individuals with limited English
proficiency, and ensure accessibility and usability of Navigator tools and
functions for individuals with disabilities in accordance with the Americans
with Disabilities Act and §
504
of the Rehabilitation Act;
(10)
Ensure that individuals:
(i) Are informed,
prior to receiving assistance, of the functions and responsibilities of
Navigators, including that Navigators are not acting as tax advisers or
attorneys when providing assistance as Navigators and cannot provide tax or
legal advice within their capacity as Navigators;
(ii) Provide authorization in a form and
manner as determined by AHS prior to a Navigator's obtaining access to an
individual's personally identifiable information, and that the Navigator
maintains a record of the authorization provided in a form and manner as
determined by AHS. AHS will establish a reasonable retention period for
maintaining these records; and
(iii) May revoke at any time the
authorization provided to a Navigator.
(11) Maintain a physical presence in the
service area, so that face-to-face assistance can be provided to applicants and
enrollees.
(g) Funding
for Navigator grants
Funding for navigator grants may not be from Federal funds
received by the state to establish VHC.
Section 5.04 Brokers
(01/15/2017, GCR 16-094)
(a) General rule [102]
A broker may:
(1)
Facilitate enrollment of an individual, employer, or employee in any QHP as
soon as the QHP is offered;
(2)
Subject to paragraphs (b) and (c) of this subsection, assist an individual in
applying for a QHP with financial assistance; and
(3) Subject to paragraphs (b) and (c) of this
subsection assist an employee or an employer in enrolling in any QHP.
(b) Agreement [103]
Prior to enrolling a qualified individual, employee, or
employer in a QHP through VHC, or assisting an individual in applying for a QHP
with financial assistance, a broker must have an executed agreement with AHS,
and must comply with the terms of that agreement, which includes at least the
following requirements:
(1)
Registering with AHS in advance of assisting a qualified individual, employee
or employer, enrolling in QHPs through VHC;
(2) Receiving training in the range of QHP
options and health- benefit programs; and
(3) Complying with AHS's privacy and security
standards adopted consistent with § 4.08.
(c) Payment mechanisms [104]
A broker who facilitates enrollment of an individual,
employer, or employee in any QHP must comply with procedures, including payment
mechanisms and standard fee or compensation schedules, established by AHS, that
allow brokers to be appropriately compensated for assisting with the enrollment
of qualified individuals and qualified employers in any QHP offered through VHC
for which the individual or employer is eligible; and assisting a qualified
individual in applying for financial assistance for a QHP purchased through
VHC.
Section
5.05 Certified application counselors105
(01/15/2017, GCR 16-094)
(a) In general
AHS certifies staff and volunteers of state-partner
organizations to act as application counselors, authorized to provide
assistance to individuals with the application process and during renewal of
eligibility.
(b)
Certification
(1) To be certified,
application counselors must:
(i) Be authorized
and registered by AHS to provide assistance at application and
renewal;
(ii) Be effectively
trained in the eligibility and benefits rules and regulations governing
enrollment in a QHP and all health- benefits programs operated in Vermont;
and
(iii) Have successfully
completed the required training and received a passing score on the
certification examination.
(2) Application counselors are certified by
AHS to provide assistance at application and renewal with respect to one, some,
or all of the permitted assistance activities, and enter into certification
agreements with AHS.
(3) Disclose
to AHS and potential applicants any relationships the certified application
counselor or sponsoring agency has with QHPs or insurance affordability
programs, or other potential conflicts of interest;
(4) Comply with AHS's privacy and security
standards adopted consistent with § 4.08 and applicable authentication and
data security standards;
(5) Agree
to act in the best interest of the applicants assisted;
(6) Either directly or through an appropriate
referral to a Navigator or to the VHC call center, provide information in a
manner that is accessible to individuals with disabilities, as defined by the
Americans with Disabilities Act, as amended,
42 U.S.C. §
12101 et seq. and §
504
of the Rehabilitation Act, as amended,
29 USC §
794;
(7) Enter into an agreement with the
organization regarding compliance with the standards specified in paragraphs
(b), (d), (e) and (f) of this subsection; and
(8) Is recertified on at least an annual
basis after successfully completing recertification training as required by
AHS.
(c) Withdrawal of
certification
AHS will establish procedures to withdraw certification from
individual application counselors, or from all application counselors
associated with a particular organization, when it finds noncompliance with the
terms and conditions of the application counselor agreement.
(d) Duties
Certified application counselors are certified to:
(1) Provide information to individuals and
employees about the full range of QHP options and health-benefits programs for
which they are eligible, which includes providing fair, impartial and accurate
information that assists individuals with submitting the eligibility
application; clarifying the distinctions among health coverage options,
including QHPs; and helping individuals make informed decisions during the
health coverage selection process;
(2) Assist individuals and employees to apply
for coverage in a QHP through VHC and for health-benefits programs;
and
(3) Help to facilitate
enrollment of eligible individuals in QHPs and health-benefits
programs.
(e)
Availability of information; authorization
AHS must establish procedures to ensure that:
(1) Individuals are informed, prior to
receiving assistance, of the functions and responsibilities of certified
application counselors, including that certified application counselors are not
acting as tax advisers or attorneys when providing assistance as certified
application counselors and cannot provide tax or legal advice within their
capacity as certified application counselors;
(2) Individuals are able to provide
authorization in a form and manner as determined by AHS prior to a certified
application counselor obtaining access to personally identifiable information
about the individual related to the individual's application for, or renewal
of, health benefits, and that the organization or certified application
counselor maintains a record of the authorization in a form and manner as
determined by AHS. AHS will establish a reasonable retention period for
maintaining these records;
(3) AHS
does not disclose confidential individual information to an application
counselor unless the individual has authorized the application counselor to
receive such information; and
(4)
Individuals may revoke at any time the authorization provided the certified
application counselor.
(f) No charge for services
Application counselors may not:
(1) Impose any charge on individuals for
application or other assistance related to VHC;
(2) Receive any consideration directly or
indirectly from any health insurance issuer or issuer of stop-loss insurance in
connection with the enrollment of any individual in a QHP or a
non-QHP;
(3) Provide to an
applicant or potential enrollee gifts of any value as inducement for
enrollment. The value of gifts provided to applicants and potential enrollees
for purposes other than as an inducement for enrollment must not exceed nominal
value, either individually or in the aggregate, when provided to that
individual during a single encounter. For purposes of this paragraph, the term
gifts includes gift items, gift cards, cash cards, cash and promotional items
that market or promote the products or services of a third party, but does not
include the reimbursement of legitimate expenses incurred by a consumer in an
effort to receive application assistance, such as, but not limited to, travel
or postage expenses;
(4) Solicit
any individual for application or enrollment assistance by going door-to-door
or through other unsolicited means of direct contact, including calling an
individual to provide application or enrollment assistance without the
individual initiating the contact, unless the individual has a pre-existing
relationship with the individual certified application counselor or designated
organization and other applicable state and federal laws are otherwise complied
with. Outreach and education activities may be conducted by going door-to-door
or through other unsolicited means of direct contact, including calling an
individual; or
(5) Initiate any
telephone call to an individual using an automatic telephone dialing system or
an artificial or prerecorded voice, except in cases where the individual
certified application counselor or designated organization has a relationship
with the individual and so long as other applicable state and federal laws are
otherwise complied with.
(g) Non-discrimination and organizations
receiving federal funds to provide services to defined populations [106]
Notwithstanding the non-discrimination provisions of §
5.01(g), an organization that receives federal funds to provide services to a
defined population under the terms of federal legal authorities that
participates in the certified application counselor program may limit its
provision of certified application counselor services to the same defined
population, but must comply with § 5.01(g) with respect to the provision
of certified application counselor services to that defined population, If the
organization limits its provision of certified application counselor services
pursuant to this exception, but is approached for certified application
counselor services by an individual who is not included in the defined
population that the organization serves, the organization must refer the
individual to other AHS-approved resources that can provide assistance. If the
organization does not limit its provision of certified application counselor
services pursuant to this exception, the organization must comply with §
5.01(g).
Part TWO ELIGIBILITY STANDARDS
Section 6.00 Medicaid in General
(01/15/2017, GCR 16-095)
(a) In general
To qualify for Medicaid, an individual must meet
nonfinancial, categorical, and financial eligibility criteria.
(b) Nonfinancial criteria
The nonfinancial criteria include the following:
(1) Citizenship or immigration status (
§ 17.00);
(2) Vermont
residency ( § 21.00);
(3)
Social Security number requirements ( § 16.00);
(4) Assignment-of-rights and cooperation
requirements ( § 18.00);
(5)
Living-arrangement requirements ( § 20.00); and
(6) Pursuit of potential unearned income (
§ 22.00).
(c)
Categorical criteria
An individual must meet the categorical criteria ( e.g., age,
disability, etc.) of at least one coverage group to be eligible for health
benefits through the Medicaid program.
(d) Financial criteria
Although there are a few coverage groups with no financial
requirements, financial eligibility generally requires that an individual have
no more than a specified amount of income or, in some cases, resources. The
Medicaid financial eligibility requirements are:
(1) Income within the income limit
appropriate to the individual's covered group.
(2) Resources within the resource limit
appropriate to the individual's covered group.
(3) Asset-transfer limitations for an
individual who needs long-term care services and supports.
Section 7.00 Medicaid for Children
and Adults (MCA)
(01/15/2017, GCR 16-095)
Section 7.01 In general
(01/15/2017, GCR 16-095)
An individual is eligible for MCA if they meet the
nonfinancial, categorical, and financial criteria outlined in this
section.
Section 7.02
Nonfinancial criteria
(01/15/2017, GCR 16-095)
The individual must meet all of the following nonfinancial
eligibility criteria for Medicaid:
(a)
Social Security number ( § 16.00);
(b) Citizenship or immigration status (
§ 17.00) [1];
(c) Residency (
§ 21.00) [2];
(d) Living
arrangements ( § 20.00);
(e)
Assignment of rights and cooperation requirements ( § 18.00) [3];
and
(f) Pursuit of potential
unearned income ( § 22.00).
Section 7.03 Categorical and financial
criteria
(01/15/2017, GCR 16-095)
(a) Coverage groups and income standards
The individual must meet the criteria for at least one of the
following coverage groups:
(1) Parent
and other caretaker relative [4]
A parent or caretaker relative of a dependent child (as
defined in § 3.00) and their spouse, if living within the same household
as the parent or caretaker relative, with a MAGI-based household income, as
defined in § 28.03, that is at or below a specified dollar amount that is
set based on the parent or caretaker relative's family size and whether they
live in or outside of Chittenden County. A chart of these dollar amounts is
made publicly available via website.
(2) Pregnant woman [5]
(i) A pregnant woman, as defined in §
3.00 as a woman during pregnancy and the post partum period, which begins on
the date the pregnancy ends, extends 60 days, and then ends on the last day of
the month in which the 60-day period ends, with a MAGI- based household income,
as defined in § 28.03, that is at or below 208 percent of the FPL for the
applicable family size.
(ii)
Retroactive eligibility:
A woman may be retroactively granted Medicaid eligibility
under this coverage group if she was pregnant and met all eligibility criteria.
However, she would not be eligible for Medicaid under this coverage group for
the 60-day post partum period if she applied for Medicaid after her pregnancy
ended.
(iii) Continuous
eligibility:
(A) An eligible pregnant woman
who would lose eligibility because of a change in household income is deemed to
continue to be eligible throughout the pregnancy and the 60-day post partum
period without regard to the change in income. [6]
(B) This provision applies to a
medically-needy pregnant woman as follows: If the woman meets her spenddown
while pregnant, her spenddown amount in any subsequent budget period during her
pregnancy and post partum period cannot be any higher than her original
spenddown amount. This is so even if she experiences an increase in her
household income.
(3) Child [7]
(i) An individual, who is under the age of 19
[8], with a MAGI-based household income, as defined in § 28.03, that is at
or below 312 percent of the FPL for the applicable family size.
(ii) Continuous eligibility for a
hospitalized child:
(A) This provision
implements section
1902(e)(7)
of the Act.
(B) Medicaid will be
provided to a child eligible and enrolled under this sub clause until the end
of an inpatient stay for which inpatient services are furnished, if the child:
(I) Was receiving inpatient services covered
by Medicaid on the date the child is no longer eligible under this sub clause,
based on the child's age or household income; and
(II) Would remain eligible but for attaining
such age.
(4) [Reserved]
(5) Adult [9]
(i) Effective January 1, 2014, an individual
who:
(A) Is age 19 or older and under age
65;
(B) Is not pregnant;
(C) Is not entitled to or enrolled in
Medicare under parts A or B of Title XVIII of the Act; [10]
(D) Is not otherwise eligible for and
enrolled in a mandatory coverage group; and
(E) Has household income that is at or below
133 percent of the FPL for the applicable family size.
(ii) Coverage for children under 21 : [11]
Medicaid cannot be provided under this sub clause to a parent
or other caretaker relative living with a child who is under the age of 21
unless such child is receiving benefits under Medicaid or Dr. Dynasaur, or
otherwise is enrolled in MEC.
(6) Families with Medicaid eligibility
extended because of increased earnings
(i)
Transitional Medical Assistance under § 1925 of the Social Security Act
[12]
Families who become ineligible for Medicaid because a parent,
caretaker relative, or pregnant woman has new or increased earnings may be
eligible for Transitional Medical Assistance (TMA) for up to 12 months,
beginning with the month immediately following the month in which they become
ineligible. TMA will be provided to:
(A) A pregnant woman who was eligible and
enrolled for Medicaid under § 7.03(a)(2) with household income at or below
the income limit for parents and other caretaker relatives under 7.03(a)(1) for
the pregnant woman's family size in at least 3 out of the 6 months immediately
preceding the month that eligibility under § 7.03(a)(2) was lost due to
increased earnings; and
(B) A
parent or other caretaker relative who was eligible and enrolled for Medicaid
under § 7.03(a)(1), and any dependent child of such parent or other
caretaker relative who was eligible and enrolled under § 7.03(a)(3), in at
least 3 out of the 6 months immediately preceding the month that eligibility
for the parent or other caretaker relative under § 7.03(a)(1) was lost due
to increased earnings. If a dependent child of the parent or caretaker relative
remains eligible for Medicaid under § 7.03(a)(3), the child will continue
to receive Medicaid coverage under that category.
(C) Initial six-month extension:
For a parent or caretaker relative to remain eligible for the
first six-month extension, they must continue to have a dependent child, as
defined in § 3.00, living with them. Parents, caretaker relatives,
pregnant women, and children eligible for TMA must continue to reside in
Vermont.
(D) Additional
six-month extension:
To be eligible for TMA for the six-month period following the
initial six-month extension, parents, caretaker relatives, and pregnant women
must meet the criteria for the initial six-month extension in (C) above, and
must also:
(I) Report, by the 21st day
of the fourth, seventh, and tenth months of the 12-month TMA period, gross
earnings and child care expenses necessary for employment in the preceding
three months, or establish good cause, as determined by AHS, for failure to
report on a timely basis;
(II) Have
earnings in all of the previous three months, unless the lack of earnings was
due to an involuntary loss of employment, illness, or other good cause as
determined by AHS; and
(III) Have
average gross monthly earnings (less costs for child care necessary for
employment) during the immediately preceding 3-month period less than or equal
to 185 percent of the FPL for the applicable family size.
If TMA for a parent, caretaker relative, pregnant woman, or
child is terminated due to failure to meet the criteria described above,
Medicaid coverage will continue under another Medicaid category if the parent,
caretaker relative, pregnant woman or child is eligible under that
category.
If a parent, caretaker relative, or pregnant woman fails to
meet the quarterly reporting requirement without good cause, as determined by
AHS, AHS will terminate TMA. TMA will not be reinstated until the month after
the quarterly report is received.
(ii) Transitional Medical Assistance if
§ 1925 of the Social Security Act is not available [13]
(A) If Transitional Medical Assistance under
§ 1925 of the Act is not available or applicable, extended Medicaid
coverage will be provided to:
(I) A pregnant
woman who was eligible and enrolled for Medicaid under § 7.03(a)(2) with
household income at or below the income limit for parents and other caretaker
relatives under § 7.03(a)(1) for the pregnant woman's family size in at
least 3 out of the 6 months immediately preceding the month that eligibility
under § 7.03(a)(2) was lost due to increased earnings; and
(II) A parent or other caretaker relative who
was eligible and enrolled for Medicaid under § 7.03(a)(1), and any
dependent child of such parent or other caretaker relative who was eligible and
enrolled under § 7.03(a)(3), in at least 3 out of the 6 months immediately
preceding the month that eligibility for the parent or other caretaker relative
under § 7.03(a)(1) was lost due to increased earnings If a dependent child
of the parent or caretaker relative remains eligible for Medicaid under §
7.03(a)(3), the child will continue to receive Medicaid coverage under that
category.
(B) The
extended Medicaid coverage period is for 4 months following the month in which
the individual becomes ineligible for Medicaid due to new or increased earnings
by the parent, caretaker relative, or pregnant woman.
(7) Families with Medicaid
eligibility extended because of increased collection of spousal support [14]
(i) Eligibility
Extended Medicaid coverage will be provided to:
(A) A pregnant woman who was eligible and
enrolled for Medicaid under § 7.03(a)(2) with household income at or below
the income limit for parents and other caretaker relatives under §
7.03(a)(1) for the pregnant woman's family size in at least 3 out of the 6
months immediately preceding the month that eligibility under § 7.03(a)(2)
was lost due to increased collection of spousal support; and
(B) A parent or other caretaker relative who
was eligible and enrolled for Medicaid under § 7.03(a)(1), and any
dependent child of such parent or other caretaker relative who was eligible and
enrolled under § 7.03(a)(3), in at least 3 out of the 6 months immediately
preceding the month that eligibility for the parent or other caretaker relative
under § 7.03(a)(1) was lost due to increased collection of spousal support
under Title IV-D of the Act.
(ii) The extended Medicaid coverage is for 4
months following the month in which the individual becomes ineligible for
Medicaid due to increased collection of spousal support by the parent,
caretaker relative or pregnant woman.
(8) Medically Needy
(i) In general [15]
An individual under age 21, a pregnant woman, or a parent or
other caretaker relative, as described above, may qualify for MCA as medically
needy even if their income exceeds coverage group limits.
(ii) Income eligibility [16]
For purposes of determining medically-needy eligibility under
this sub clause, AHS applies the MAGI-based methodologies defined in §
28.03 subject to the requirements of § 28.04.
(iii) Eligibility based on countable income
If countable income determined under paragraph (a)(8)(ii) of
this sub clause is equal to or less than the PIL for the individual's family
size, the individual is eligible for Medicaid.
(iv) Spenddown rules
The provisions under § 30.00 specify how an individual
may use non- covered medical expenses to "spend down" their income to the
applicable limits.
(9) Coverage of long- term care services and
supports [17]
For an individual eligible for MCA who seeks Medicaid
coverage of long- term care services and supports under MCA, AHS will apply the
following rules in determining the individual's eligibility for such
coverage:
(i) Substantial home-equity
under § 29.09(d)(6); and
(ii)
Income and resource transfers under § 25.00.
(b) No resource tests
There are no resource tests for the coverage groups described
under (a) of this subsection.
Section 8.00 Medicaid for the Aged, Blind,
and Disabled (MABD). [18]
(01/15/2017, GCR 16- 095)
Section 8.01 In general
(01/15/2017, GCR 16-095)
An individual is eligible for MABD if they meet the
nonfinancial, categorical, and financial criteria outlined in this section.
[19]
Section 8.02
Nonfinancial criteria
(01/15/2017, GCR 16-095)
The individual must meet all of the following nonfinancial
eligibility criteria for Medicaid:
(a)
Social Security number ( § 16.00);
(b) Citizenship or immigration status (
§ 17.00);
(c) Residency (
§ 21.00);
(d) Living
arrangements ( § 20.00);
(e)
Assignment of rights and cooperation requirements ( § 18.00);
and
(f) Pursuit of potential
unearned income ( § 22.00).
Section 8.03 Categorical relationship to SSI
(01/15/2017, GCR 16-095)
An individual applying for MABD must establish their
categorical relationship to SSI by qualifying as one or more of the
following:
(a) Aged
An individual qualifying on the basis of age must be at least
65 years of age in or before the month in which eligibility begins.
(b) Blind
An individual qualifying on the basis of blindness must
be:
(1) Determined blind by AHS's
disability determination unit, or
(2) In receipt of social security disability
benefits based on blindness.
(c) Disabled
An individual qualifying on the basis of disability must
be:
(1) Determined disabled by AHS's
disability determination unit, or
(2) In receipt of social security disability
benefits based on disability.
(d) Definition: blind or disabled child
A blind or disabled individual who is either single or not
the head of a household; and
(1) Under
age 18, or
(2) Under age 22 and a
student regularly attending school, college, or university, or a course of
vocational or technical training to prepare them for gainful employment.
See, also, § 29.02(a)(1).
Section 8.04 Determination of
blindness or disability
(01/15/2017, GCR 16-095)
(a) Disability and blindness determinations
Disability and blindness determinations are made by AHS in
accordance with the applicable requirements of the Social Security
Administration based on information supplied by the individual and by reports
obtained from the physicians and other health care professionals who have
treated the individual. AHS will explain the disability determination process
to individuals and help them complete the required forms.
(b) Bases for a determination of disability
or blindness
AHS may determine an individual is disabled in any of the
following circumstances:
(1) An
individual who has not applied for SSI/AABD.
(2) An individual who has applied for
SSI/AABD and was found ineligible for a reason other than disability.
(3) An individual who has applied for
SSI/AABD and SSA has not made a disability determination within 90 days from
the date of their application for Medicaid.
(4) An individual who has been found "not
disabled" by SSA, has filed a timely appeal with SSA, and a final determination
has not been made by SSA.
(5) An
individual who claims that:
(i) Their
condition has changed or deteriorated since the most recent SSA determination
of "not disabled;"
(ii) A new
period of disability meets the durational requirements of the Act;
(iii) The SSA determination was more than 12
months ago; and
(iv) They have not
applied to SSA for a determination with respect to these allegations.
(6) An individual who claims that:
(i) Their condition has changed or
deteriorated since the most recent SSA determination of "not
disabled,"
(ii) The SSA
determination was fewer than 12 months ago;
(iii) A new period of disability meets the
durational requirements of the Act; and
(iv) They have applied to SSA for
reconsideration or reopening of its disability decision and SSA refused to
consider the new allegations, or they no longer meet the nondisability
requirements for SSI but may meet AHS's nondisability requirements for
Medicaid.
(c)
Additional examinations
AHS has responsibility for assuring that adequate information
is obtained upon which to base the determination. If additional information is
needed to determine whether individuals are disabled or blind according to the
Act, consulting examinations may be required. AHS will pay the reasonable
charge for any medical examinations required to render a decision on disability
or blindness.
Section
8.05 The categorically-needy coverage groups
(01/15/2017, GCR 16-095)
An individual applying for MABD must meet the criteria of one
or more of the following categories.
(a) Individual enrolled in SSI/AABD [20]
(1) An individual who is granted SSI/AABD by
the SSA is automatically eligible for MABD. In addition to SSI/AABD enrollees,
this group includes an individual who is:
(i)
Receiving SSI pending a final determination of blindness or disability;
or
(ii) Receiving SSI under an
agreement with the SSA to dispose of resources that exceed the SSI dollar
limits on resources (recoupment).
(2) Medicaid eligibility for an individual in
this group is automatic; there are no Medicaid income or resource standards
that apply.
(b)
Individual who is SSI- eligible [21]
(1) An
individual who would be eligible for SSI/AABD except that they:
(i) Have not applied for SSI/AABD;
or
(ii) Do not meet SSI/AABD
requirements not applicable to Medicaid (e.g., participation in vocational
rehabilitation or a substance abuse treatment program).
(2) An individual in this group must:
(i) Have MABD income for the individual's
financial responsibility group (as defined in § 29.03) that is at or
below the SSI/AABD payment level for the individual's Medicaid group (as
defined in § 29.04);
(ii)
Have MABD resources for the individual's financial responsibility group that is
at or below the SSI/AABD maximum for the individual's Medicaid group;
and
(iii) Meet the MABD
nonfinancial criteria.
(c) Individual eligible for SSI but for
earnings [22] ( Section 1619(b) of the Social Security Act)
(1) An individual whom the SSA determines
eligible under the Act ( § 1619(b)) because they meet all SSI/AABD
eligibility requirements except for the amount of their earnings and who:
(i) Does not have sufficient earnings to
provide the reasonable equivalent of publicly-funded attendant care services
that would be available if they did not have such earnings; and
(ii) Is seriously inhibited by the lack of
Medicaid coverage in their ability to continue to work or obtain
employment.
(2) Medicaid
eligibility for an individual in this group is automatic; there are no Medicaid
income or resource standards that apply.
(d) Individual with disabilities who is
working (Medicaid for working people with disabilities (MWPD))
(1) An individual with disabilities who is
working and, except for the amount of their income and resources, is otherwise
eligible for MABD, and who:
(i) Has MABD
income for the individual's financial responsibility group (as defined in
§ 29.03), that is:
(A) Below 250% of the
FPL for the individual's Medicaid group (as defined in § 29.04);
and
(B) After disregarding their
earnings, [23] Social Security Disability Insurance benefits (SSDI), and any
veterans' disability benefits, has MABD income that is:
(I) Less than the applicable PIL if they are
in a Medicaid group of one; or
(II)
Less than the applicable SSI/AABD payment level if they are in a Medicaid group
of two.
(ii)
Has resources at the time of enrollment in the group that do not exceed $ 5,000
for a single individual and $ 6,000.00 for a couple (see § 29.08(i)(8) for
resource exclusion after enrollment).
(2) The individual's earnings must be
documented by evidence of:
(i) Federal
Insurance Contributions Act tax payments;
(ii) Self-employment Contributions Act tax
payments; or
(iii) A written
business plan approved and supported by a third-party investor or funding
source.
(3) Earnings,
SSDI, and veterans' disability benefits are not disregarded for an individual
with spend-down requirements who does not meet all of the above requirements
and seeks coverage under the medically-needy coverage group (see § 8.06
).
(e) Child under 18
who lost SSI because of August 1996 change in definition of disability
An individual under the age of 18 who lost their SSI or
SSI/AABD eligibility because of the more restrictive definition of disability
enacted in August 1996 but who continues to meet all other MABD criteria until
their 18th birthday. [24] The definition of disability for this group is the
definition of childhood disability in effect prior to the 1996 revised
definition.
(f) Certain
spouses and surviving spouses
An individual with a disability if they meet all of the
following conditions:
(1) The
individual is:
(i) A surviving spouse;
or
(ii) A spouse who has obtained a
legal dissolution and:
(A) Was the spouse of
the insured for at least 10 years; and
(B) Remains single.
(2) The individual meets one of
the following groups of criteria under the Act: [25]
(i) The individual:
(A) Applied for SSI-related Medicaid no later
than July 1, 1988;
(B) Was
receiving SSI/AABD in December 1983;
(C) Lost SSI/AABD in January 1984 due to a
statutory elimination of an additional benefit reduction factor for surviving
spouses before attainment of age 60;
(D) Has been continuously entitled to
surviving spouse insurance based on disability since January 1984;
and
(E) Would continue to be
eligible for SSI/AABD if they had not received the increase in social security
disability or retirement benefits.
(ii) The individual:
(A) Lost SSI/AABD benefits due to a mandatory
application for and receipt of social security disability, retirement or
survivor benefits;
(B) Is not yet
eligible for Medicare Part A;
(C)
Is at least age 50 [26], but has not yet attained age 65; and
(D) Would continue to be eligible for
SSI/AABD if they were not receiving social security disability or retirement
benefits.
(3)
An individual in this group must:
(i) After
deducting the increase in social security disability or retirement benefits,
have MABD income for the individual's financial responsibility group (as
defined in § 29.03) that is at or below the SSI/AABD payment level for
the individual's Medicaid group (as defined in § 29.04);
(ii) Have MABD resources for the individual's
financial responsibility group that is at or below the SSI/AABD maximum for the
individual's Medicaid group; and
(iii) Meet the MABD nonfinancial
criteria.
(g)
Disabled adult child (DAC) [27]
(1) An
individual with a disability under the Act ( § 1634(c)) who:
(i) Is at least 18 years of age;
(ii) Has blindness or a disability that began
before age 22;
(iii) Is entitled to
social security benefits on their parents' record due to retirement, death, or
disability benefits and lost SSI/AABD due to receipt of this benefit or an
increase in this benefit; and
(iv)
Would remain eligible for SSI/AABD in the absence of the social security
retirement, death, or disability benefit or increases in that
benefit.
(2) An
individual in this group must:
(i) After
deducting the social security benefits on their parents' record, have MABD
income for the individual's financial responsibility group (as defined in
§ 29.03) that is at or below the SSI/AABD payment level for the
individual's Medicaid group (as defined in § 29.04);
(ii) Have MABD resources for the individual's
financial responsibility group that is at or below the SSI/AABD maximum for the
individual's Medicaid group; and
(iii) Meet the MABD nonfinancial
criteria.
(h)
Individual eligible under the Pickle Amendment [28]
(1) An individual determined eligible under
the Pickle Amendment to Title XIX of the Act ( § 1935(a)(5)(E)) who:
(i) Is receiving social security retirement
or disability benefits (OASDI);
(ii) Became eligible for and received SSI or
SSI/AABD for at least one month after April 1977; and
(iii) Lost SSI/AABD benefits but would be
eligible for them if all increases in the social security benefits due to
annual cost-of- living adjustments (COLAs) were deducted from their
income.
(2) An
individual in this group must:
(i) After
deducting the increase in social security benefits due to annual COLAs, have
MABD income for the individual's financial responsibility group (as defined in
§ 29.03) that is at or below the SSI/AABD payment level for the
individual's Medicaid group (as defined in § 29.04);
(ii) Have MABD resources for the individual's
financial responsibility group that is at or below the SSI/AABD maximum for the
individual's Medicaid group; and
(iii) Meet the MABD nonfinancial
criteria.
(i)
Individual eligible for Medicaid in December 1973 [29]
An individual who was eligible for Medicaid in December 1973
and meets at least one of the following criteria:
(1) An institutionalized individual who was
eligible for Medicaid in December 1973, or any part of that month, as an
inpatient of a medical institution or intermediate care facility that was
participating in the Medicaid program and who, for each consecutive month after
December 1973:
(i) Continues to meet the
Medicaid eligibility requirements in effect in December 1973 for
institutionalized individuals;
(ii)
Continues to reside in the institution; and
(iii) Continues to be classified as needing
institutionalized care.
(2) A blind or disabled individual who does
not meet current criteria for blindness or disability, but:
(i) Was eligible for Medicaid in December
1973 as a blind or disabled individual, whether or not they were receiving cash
assistance in December 1973;
(ii)
For each consecutive month after December 1973 continues to meet the criteria
for blindness or disability and the other conditions of eligibility in effect
in December 1973;
(iii) Has MABD
income for the individual's financial responsibility group (as defined in
§ 29.03) that is at or below the SSI/AABD payment level for the
individual's Medicaid group (as defined in § 29.04);
(iv) Has MABD resources for the individual's
financial responsibility group that are at or below the SSI/AABD maximum for
the individual's Medicaid group; and
(v) Meets the MABD nonfinancial
criteria.
(3) An
individual who was eligible for Medicaid in December 1973 as an essential
spouse of an aged, blind, or disabled individual who was receiving cash
assistance, if the following conditions are met: [30]
(i) The aged, blind, or disabled individual
continues to meet the December 1973 Medicaid eligibility requirements;
and
(ii) The essential spouse
continues to meet the conditions that were in effect in December, 1973 for
having their needs included in computing the payment to the aged, blind, or
disabled individual.
(j) Individual eligible for AABD in August
1972 [31]
(1) An individual who meets the
following conditions:
(i) In August 1972 the
individual was entitled to social security retirement or disability and
eligible for AABD, or would have been eligible if they had applied, or were not
in a medical institution or intermediate care facility; and
(ii) Would currently be eligible for SSI or
SSI/AABD except that the 20 percent cost-of-living increase in social security
benefits effective September 1972 raised their income over the AABD
limit.
(2) An individual
in this group must:
(i) After deducting the
increase in social security benefits due to COLA increase effective September
1972, have MABD income for the individual's financial responsibility group (as
defined in § 29.03) that is at or below the SSI/AABD payment level for
the individual's Medicaid group (as defined in § 29.04);
(ii) Have MABD resources for the individual's
financial responsibility group that is at or below the SSI/AABD maximum for the
individual's Medicaid group; and
(iii) Meet the MABD nonfinancial
criteria.
(k)
Individual eligible for MABD-based Medicaid coverage of long-term care services
and supports
(1) [Reserved]
(2) Individual who would be eligible for cash
assistance if they were not in a medical institution [32]
(i) Basis
This section implements section
1902(a)(10)(A)(ii)(IV)
of the Act.
(ii)
Eligibility
An aged, blind, or disabled individual who is in a medical
institution and who:
(A) Is ineligible
for SSI/AABD because of lower income standards used under the program to
determine eligibility for institutionalized individuals; but
(B) Would be eligible for SSI/AABD if they
were not institutionalized.
(3) Individual living in a medical
institution eligible under a special income level [33]
An aged, blind or disabled individual who is living in a
medical institution and who:
(i) Has
lived in an institution for at least 30 consecutive days;
(ii) Has MABD income for the individual's
financial responsibility group (as defined in § 29.03) that does not
exceed 300 percent of the maximum SSI federal payment to an individual living
independently in the community (institutional income standard (IIS)); [34
]
(iii) Has MABD resources for the
individual's financial responsibility group that is at or below the SSI/AABD
maximum for the individual's Medicaid group (as defined in § 29.04),
except that if an individual's resources are in excess of the SSI/AABD maximum
and the individual has a spouse, a resource evaluation process of assessment
and allocation must be performed at the beginning of the individual's first
continuous period of long-term care, as set forth in § 29.10(e);
and
(iv) Meets the MABD
non-financial criteria.
(4) Individual in special income group who
qualifies for home and community- based services
An individual who qualifies for home and community-based
services and who:
(i) Would be
eligible for MABD under paragraph (k)(3) of this subsection if they were living
in a medical institution;
(ii) Has
MABD income for the individual's financial responsibility group that is between
the PIL and the IIS; and
(iii) Can
receive appropriate long-term medical care in the community as determined by
AHS.
(5) Individual
under special income level who is receiving hospice services
An individual who:
(i) Would be eligible for MABD under
paragraph (k)(3) of this subsection if they were living in a medical
institution;
(ii) Can receive
appropriate medical care in the community, the cost of which is no greater than
the estimated cost of medical care in an appropriate institution; and
(iii) Receives hospice care as described in
§ 30.01(d) and defined in §
1905(o)
of the SSA.
(6) Disabled
child in home care (DCHC, Katie Beckett) [35]
A disabled individual who:
(i) Requires the level of care provided in a
medical institution;
(ii) Except
for income or resources, would be eligible for MABD if they were living in a
medical institution;
(iii) Can
receive appropriate medical care in the community, the cost of which is no
greater than the estimated cost of medical care in an appropriate
institution;
(iv) Is age 18 or
younger;
(v) Has MABD income (
§ 29.11), excluding their parents' income, no greater than the IIS;
and
(vi) Has MABD resources (
§ 29.07), excluding their parents' resources, no greater than the
resource limit for a Medicaid group of one.
(7) Individual eligible for MWPD
An individual who qualifies for home and community-based
services and meets the financial eligibility requirements for MWPD as set forth
in § 8.05(d).
Section 8.06 Medically-needy coverage group
(01/15/2017, GCR 16-095)
(a) In general [36]
An individual who would be a member of a categorically-needy
coverage group, as described in § 8.05, may qualify for MABD as medically
needy even if their income or resources exceed coverage group limits.
(b) Income standard
An otherwise-qualifying individual is eligible for this
coverage group if their MABD income for the individual's financial
responsibility group (as defined in § 29.03) is at or below the PIL for
the individual's Medicaid group (as defined in § 29.04), or, as described
in paragraph (d) of this subsection, they incur enough non-covered medical
expenses to reduce their income to that level.
(c) Resource standard
To qualify for this coverage group, an individual must have
MABD resources for the individual's financial responsibility group that are at
or below the SSI/AABD maximum for the individual's Medicaid group, or, as
described in paragraph (d) of this subsection, they incur enough expenses to
reduce their resources to that level.
(d) Spenddown rules
The rules in § 30.00 specify how an individual may use
non-covered medical expenses to "spend down" their income or resources to the
applicable limits.
Section
8.07 Medicare Cost-Sharing
(01/15/2017, GCR 16-095)
(a) In general
(1) An individual is eligible for Medicaid
payment of certain Medicare costs if they meet one of the criteria specified in
paragraph (b) of this subsection.
(2) An individual eligible for one of the
Medicare cost-sharing coverage groups identified in (b) below may also be
eligible for the full range of Medicaid covered services if they also meet the
requirements for one of the categorically-needy ( § 8.05) or
medically-needy ( § 8.06) coverage groups.
(3) An individual may not spend down income
to meet the financial eligibility tests for these coverage groups.
(b) Coverage groups
(1) Qualified Medicare Beneficiaries (QMB)
[37]
(i) An individual is eligible for
Medicaid payment of their Medicare part A and part B premiums, deductibles, and
coinsurance if the individual is:
(A) A member
of a Medicaid group (as defined in § 29.04) with MABD income at or below
100 percent of the FPL; and
(B)
Entitled to Medicare part A with or without a premium (but not entitled solely
because they are eligible to enroll under § 1818A of the Act, which
provides that certain working disabled individuals may enroll for premium part
A).
(ii) There is no
resource test for this group.
(iii)
Benefits become effective on the first day of the calendar month immediately
following the month in which the individual is determined to be
eligible.
(iv) Retroactive
eligibility is not available. [38]
(v) Special income disregard for an
individual who is receiving a monthly insurance benefit under Title II of the
Social Security Act. If an individual receives a Title II benefit, any amounts
attributable to the most recent increase in the monthly insurance benefit
payable as a result of a Title II cost-of-living adjustment (COLA) is not
counted as income until the beginning of the second month following the month
of publication of the revised annual FPL. For individuals who have Title II
income, the new poverty levels are effective beginning with the month after the
last month for which COLAs are disregarded. For individuals without Title II
income, the new poverty levels are effective no later than the date of
publication in the Federal Register. [39]
(2) Specified Low- Income Medicare
Beneficiaries (SLMB) [40]
(i) An individual
is eligible for Medicaid payment of their Medicare part B premiums if the
individual:
(A) Would be eligible for
benefits as a QMB, except for income; and
(B) Is a member of a Medicaid group (as
defined in § 29.04) with MABD income greater than 100 percent but less
than 120 percent of the FPL.
(C)
There is no resource test for this group.
(ii) Benefits become effective on either the
date of application or the date on which all eligibility criteria are met,
whichever is later.
(iii)
Retroactive eligibility (of up to three calendar months prior to the effective
date) applies if the individual met all SLMB eligibility criteria in the
retroactive period.
(iv) Special
income disregard for an individual who is receiving a monthly insurance benefit
under Title II of the Social Security Act. If an individual receives a Title II
benefit, any amounts attributable to the most recent increase in the monthly
insurance benefit payable as a result of a Title II cost-of-living adjustment
(COLA) is not counted as income until the beginning of the second month
following the month of publication of the revised annual FPL. For individuals
who have Title II income, the new poverty levels are effective beginning with
the month after the last month for which COLAs are disregarded. For individuals
without Title II income, the new poverty levels are effective no later than the
date of publication in the Federal Register. [41]
(3) Qualified Individuals (QI- 1) [42]
(i) An individual is eligible for Medicaid
payment of their Medicare part B premiums if the individual:
(A) Would be eligible for benefits as a QMB,
except for income;
(B) Is a member
of a Medicaid group (as defined in § 29.04) with MABD income that is at
least 120 percent but less than 135 percent of the FPL; and
(C) Does not receive other federally-funded
medical assistance (except for coverage for excluded drug classes under part D
when the individual is enrolled in part D).
(ii) There is no resource test for this
group.
(iii) Benefits under this
provision become effective on the first day of the calendar month immediately
following the month in which the individual is determined to be
eligible.
(iv) Retroactive
eligibility (of up to three calendar months prior to application) applies if:
(A) The individual met all QI-1 eligibility
criteria in the retroactive period; and
(B) The retroactive period is no earlier than
January 1 of that calendar year. [43]
(v) The benefit period ends in December of
each calendar year. An individual requesting this coverage must reapply each
calendar year.
(4)
Qualified Disabled and Working Individuals (QDWI)
(i) An individual is eligible for Medicaid
payment of their Medicare part A premiums if the individual:
(A) Has lost their Medicare benefits based on
disability because they returned to work;
(B) Is disabled;
(C) Is a member of a Medicaid group (as
defined in § 29.04) with MABD income at or below 200 percent of the
FPL;
(D) Is a member of a Medicaid
group with MABD resources at or below twice the MABD resource limit;
and
(E) Is not otherwise eligible
for Medicaid.
(ii)
Benefits become effective on either the date of application or the date on
which all eligibility criteria are met, whichever is later.
(iii) Benefits for a retroactive period of up
to three months prior to that effective date may be granted, provided that the
individual meets all eligibility criteria during the retroactive
period.
Section
9.00 Special Medicaid Groups
(01/15/2017, GCR 16-095)
Section 9.01 In general
(01/15/2017, GCR 16-095)
An individual is eligible for a special Medicaid group if
they meet the nonfinancial, categorical, and financial criteria outlined in
this section.
Section 9.02
Nonfinancial criteria
(01/15/2017, GCR 16-095)
The individual must meet all of the following nonfinancial
eligibility criteria for Medicaid:
(a)
Social Security number ( § 16.00);
(b) Citizenship or immigration status (
§ 17.00);
(c) Residency (
§ 21.00);
(d) Living
arrangements ( § 20.00);
(e)
Assignment of rights and cooperation requirements ( § 18.00);
and
(f) Pursuit of potential
unearned income ( § 22.00).
Section 9.03 Categorical and financial
criteria
(01/15/2017, GCR 16-095)
(a) Coverage groups and income standards
An individual must meet the criteria for at least one of the
following coverage groups:
(b) Deemed newborn [44]
(1) Basis
This sub clause implements §§
1902(e)(4)
and 2112(e) of the Act.
(2)
Eligibility
(i) Medicaid coverage will be
provided to a child from birth until the child's first birthday without
application if, on the date of the child's birth, the child's mother was
eligible for and received covered services under Medicaid or CHIP (including
during a retroactive period of eligibility under § 70.01(b)) regardless
of whether payment for services for the mother is limited to services necessary
to treat an emergency medical condition, as defined in § 17.02(d);
[45]
(ii) The child is deemed to
have applied and been determined eligible for Medicaid effective as of the date
of birth, and remains eligible regardless of changes in circumstances (except
if the child dies or ceases to be a resident of the state or the child's
representative requests a voluntary termination of the child's eligibility)
until the child's first birthday.
(iii) A child qualifies for this group
regardless of whether they continue to live with their mother.
(iv) This provision applies in instances
where the labor and delivery services were furnished prior to the date of
application and covered by Medicaid based on retroactive eligibility.
(v) Exception: A child born to a woman who
has not met her spenddown on the day of delivery is ineligible for coverage
under this group.
(vi) There are no
Medicaid income or resource standards that apply.
(3) Medicaid identification number
(i) The Medicaid identification number of the
child's mother serves as the child's identification number, and all claims for
covered services provided to the child may be submitted and paid under such
number, unless and until AHS issues the child a separate identification number
in accordance with (3)(ii) of this paragraph.
(ii) AHS will issue a separate Medicaid
identification number for the child prior to the effective date of any
termination of the mother's eligibility or prior to the date of the child's
first birthday, whichever is sooner, unless the child is determined to be
ineligible (such as, because the child is not a state resident), except that
AHS will issue a separate Medicaid identification number for the child promptly
after it is notified of a child under 1 year of age residing in the state and
born to a mother whose coverage is limited to services necessary for the
treatment of an emergency medical condition, consistent with §
17.02(c).
(c)
Children with adoption assistance, foster care, or guardianship care under
title IV-E [46]
(1) Basis
This sub clause implements §§
1902(a)(10)(A)(i)(I)
and 473(b)(3) of the Act.
(2) Eligibility
Medicaid coverage will be provided to an individual under age
21, living in Vermont for whom:
(i) An
adoption assistance agreement is in effect with a state or tribe under Title
IV-E of the Act, regardless of whether adoption assistance is being provided or
an interlocutory or other judicial decree of adoption has been issued;
or
(ii) Foster care or kinship
guardianship assistance maintenance payments are being made by a state or tribe
under Title IV-E of the Act.
(3) Income standard
There is no Medicaid income standard that applies. Committed
children in the custody of the state who are not IV-E eligible must pass the
applicable eligibility tests before their eligibility for Medicaid can be
established.
(d)
Special needs adoption [47]
(1) Basis
This sub clause implements §
1902(a)(10)(A)(ii)
(VIII) of the Act.
(2)
Eligibility
Medicaid coverage will be provided to an individual under age
21:
(i) For whom an adoption
assistance agreement (other than an agreement under Title IV-E of the Act)
between a state and the adoptive parent or parents is in effect;
(ii) Whom the state agency which entered into
the adoption agreement determined could not be placed for adoption without
Medicaid coverage because the child has special needs for medical or
rehabilitative care; and
(iii) Who,
prior to the adoption agreement being entered into, was eligible for
Medicaid.
(3) Income
standard
There is no Medicaid income standard that applies.
(e) Former foster child
[48]
(1) Basis
This sub clause implements §
1902(a)(10)(A)(i)(IX)
of the Act.
(2) Eligibility
Medicaid coverage will be provided to an individual
who:
(i) Is under age 26;
(ii) Is not eligible and enrolled for
mandatory coverage under §§ 7.03(a)(1), (2), (3), (6), (7); 8.05(a),
(b), (c), (f), (h), (i), (j); or 9.03(c); and
(iii) Was in foster care under the
responsibility of the state and enrolled in Medicaid under the state's Medicaid
State plan or 1115 demonstration upon attaining age 18.
(3) Income standard
There is no Medicaid income standard that applies.
(f) Individual with
breast or cervical cancer [49]
(1) Basis
This sub clause implements §§
1902(a)(10)(A)(ii)
(XVIII) and 1902(aa) of the Act.
(2) Eligibility
(i) Medicaid coverage will be provided to an
individual who:
(A) Is under age 65;
(B) Is not eligible and enrolled for
mandatory coverage under the state's Medicaid State plan;
(C) Has been determined to need treatment for
breast or cervical cancer through a screening under the Centers for Disease
Control and Prevention (CDC) breast and cervical cancer early detection program
(BCCEDP); [50] and
(D) Does not
otherwise have creditable coverage, as defined in § 2704(c) of the PHS
Act, for treatment of their breast or cervical cancer. Creditable coverage is
not considered to be available just because the individual may:
(I) Receive medical services provided by the
Indian Health Service, a tribal organization, or an Urban Indian organization;
or
(II) Obtain health insurance
coverage only after a waiting period of uninsurance.
(ii) An individual whose
eligibility is based on this group is entitled to full Medicaid coverage;
coverage is not limited to coverage for treatment of breast and cervical
cancer.
(iii) Medicaid eligibility
for an individual in this group begins following the screening and diagnosis
and continues as long as a treating health professional verifies the individual
is in need of cancer treatment services.
(iv) There is no waiting period of prior
uninsurance before an individual who has been screened can become eligible for
Medicaid under this group.
(3) Treatment need
An individual is considered to need treatment for breast or
cervical cancer if, in the opinion of the individual's treating health
professional (i.e., the individual who conducts the screen or any other health
professional with whom the individual consults), the screen (and diagnostic
evaluation following the clinical screening) determines that:
(i) Definitive treatment for breast or
cervical cancer is needed, including a precancerous condition or early stage
cancer, and which may include diagnostic services as necessary to determine the
extent and proper course of treatment; and
(ii) More than routine diagnostic services or
monitoring services for a precancerous breast or cervical condition are
needed.
(4) Income
standard
In order to qualify for screening under (f)(2)(i)(C) above,
an individual must be determined by BCCEDP to have limited income. In addition
to meeting the criteria described in this sub clause, the individual must meet
all other Medicaid nonfinancial criteria.
(g) Family planning services [51]
(1) Basis
This provision implements §§
1902(a)(10)(A)(ii)
(XXI) and 1902(ii) and clause (XVI) in the matter following 1902(a)(10)(G) of
the Act.
(2) Eligibility
Medicaid coverage will be provided to an individual (male and
female) who meets all of the following requirements:
(i) Is not pregnant; and
(ii) Meets the income eligibility
requirements under (g)(3) of this sub clause.
(3) Income standard
The individual has MAGI-based household income (as defined in
§ 28.03) that is at or below the income standard for a pregnant woman as
described in § 7.03(a)(2). The individual's household income is determined
in accordance with § 28.03(j).
(4) Covered services
An individual eligible under this sub clause is covered for
family planning and family planning-related benefits.
(h) HIV/AIDS
See, HIV/AIDS Rule 5800 et seq.
(i) Refugee Medical Assistance
See, Refugee Medical Assistance Rule 5100 et seq.
Section 10.00 Pharmacy
Benefits
(01/15/2017, GCR 16-095)
Section 10.01 VPharm program
(01/15/2017, GCR 16-095)
The VPharm program rules located in Rule 5400 et seq. will
remain in effect.
Section
10.02 Healthy Vermonter Program (HVP)
(01/15/2017, GCR 16-095)
The Healthy Vermonter Program (HVP) rules located in Rule
5700 et seq. will remain in effect.
Section 11.00 Enrollment in a QHP
(01/15/2017, GCR 16-095)
Section 11.01 In general
(01/15/2017, GCR 16-095)
Eligibility for enrollment in a QHP [52]
An individual is eligible for enrollment in a QHP if the
individual meets the nonfinancial criteria outlined in this section.
Section 11.02 Nonfinancial
criteria
(01/15/2017, GCR 16-095)
The individual must meet all of the following nonfinancial
criteria:
(a) Citizenship, status as a
national, or lawful presence ( § 17.00). The individual must be
reasonably expected to be a citizen, national, or a non-citizen who is lawfully
present for the entire period for which enrollment is sought;
(b) Incarceration ( § 19.00);
and
(c) Residency ( § 21.00
).
Section 11.03
Eligibility for QHP enrollment periods53
(01/15/2017, GCR 16-095)
An individual is eligible for a QHP enrollment period if they
meet the criteria for an enrollment period, as specified in §
71.00.
Section 12.00
Advance Payments of the Premium Tax Credit (APTC)
(01/15/2017, GCR 16-095)
Section 12.01 In general
(01/15/2017, GCR 16-095)
A tax filer is eligible for APTC on behalf of an individual
if the tax filer meets the criteria outlined in this section. A tax filer must
be eligible for APTC on behalf of an individual in order for the individual to
receive the Vermont Premium Reduction. APTC and the Vermont Premium Reduction
are paid directly to the QHP issuer on behalf of the tax filer.
Section 12.02 Nonfinancial
criteria54
(01/15/2017, GCR 16-095)
An applicable tax filer (within the meaning of § 12.03)
is eligible for APTC for any month in which one or more individuals for whom
the tax filer expects to claim a personal exemption deduction on their tax
return for the benefit year, including the tax filer and their spouse:
(a) Meets the requirements for eligibility
for enrollment in a QHP, as specified in § 11.00; and
(b) Is not eligible for MEC (within the
meaning of § 23.00) other than coverage in the individual
market.
Section 12.03
Applicable tax filer55
(01/15/2017, GCR 16-095)
(a) In general
Except as otherwise provided in this subsection, an
applicable tax filer is a tax filer who expects to have household income of at
least 100 percent but not more than 400 percent of the FPL for the tax filer's
family size for the benefit year.
For purposes of calculating the household income of an
applicable tax filer and determining their financial eligibility for APTC, see
§ 28.05.
(b) Married
tax filers must file joint return
(1) Except
as provided in (2) below, a tax filer who is married (within the meaning of
26 CFR §
1.7703-1) at the close of the benefit year
is an applicable tax filer only if the tax filer and the tax filer's spouse
file a joint return for the benefit year.
(2) Victims of domestic abuse and spousal
abandonment: Except as provided in (5) below, a married tax filer will satisfy
the joint filing requirement if the tax filer files a tax return using a filing
status of married filing separately and:
(i)
Is living apart from their spouse at the time they file their tax
return;
(ii) Is unable to file a
joint return because they are a victim of domestic abuse as defined in (3)
below or spousal abandonment as defined in (4) below; and
(iii) Certifies on their tax return, in
accordance with the relevant instructions, that they meet the criteria under
(i) and (ii) above.
(3)
Domestic abuse. Domestic abuse includes physical, psychological, sexual, or
emotional abuse, including efforts to control, isolate, humiliate and
intimidate, or to undermine the victim's ability to reason independently. All
the facts and circumstances are considered in determining whether an individual
is abused, including the effects of alcohol or drug abuse by the victim's
spouse. Depending on the facts and circumstances, abuse of the victim's child
or another family member living in the household may constitute abuse of the
victim.
(4) Abandonment. The tax
filer is a victim of spousal abandonment for the taxable year if, taking into
account all facts and circumstances, the tax filer is unable to locate their
spouse after reasonable diligence.
(5) Three-year rule. Paragraph (2) above does
not apply if the tax filer met the requirements of the paragraph for each of
the three preceding taxable years.
(c) Tax dependent
An individual is not an applicable tax filer if another tax
filer may claim a deduction under
26 USC §
151 for the individual for a benefit year
beginning in the calendar year in which the individual's benefit year
begins.
(d) Individual not
lawfully present or incarcerated [56]
An individual who is not lawfully present in the United
States or is incarcerated (other than incarceration pending disposition of
charges) is not eligible to enroll in a QHP through VHC. However, the
individual may be an applicable tax filer for purposes of claiming the premium
tax credit if a family member is eligible to enroll in a QHP.
(e) Individual lawfully present
An individual is also an applicable tax filer if:
(1) The tax filer would be an applicable tax
filer but for income;
(2) The tax
filer expects to have household income of less than 100 percent of the FPL for
the tax filer's family size for the benefit year for which coverage is
requested;
(3) One or more
applicants for whom the tax filer expects to claim a personal exemption
deduction on their tax return for the benefit year, including the tax filer and
spouse, is a non-citizen who is lawfully present and ineligible for Medicaid by
reason of immigration status.
(f) Special rule for tax filers with
household income below 100 percent of the FPL for the benefit year [57]
A tax filer (other than a tax filer described in paragraph
(e) of this subsection) whose household income for a benefit year is less than
100 percent of the FPL for the tax filer's family size is treated as an
applicable tax filer for purposes of claiming the premium tax credit if:
(1) The tax filer or a family member enrolls
in a QHP;
(2) AHS estimates at the
time of enrollment that the tax filer's household income will be at least 100
but not more than 400 percent of the FPL for the benefit year;
(3) APTCs are authorized and paid for one or
more months during the benefit year; and
(4) The tax filer would be an applicable tax
filer if the tax filer's household income for the benefit year was at least 100
but not more than 400 percent of the FPL for the tax filer's family
size.
(g) Computation of
premium-assistance amounts for tax filers with household income below 100
percent of the FPL.
If a tax filer is treated as an applicable tax filer under
paragraph (e) or (f) of this subsection, the tax filer's actual household
income for the benefit year is used to compute the premium-assistance amounts
under § 60.00.
Section
12.04 Enrollment required58
(01/15/2017, GCR 16-095)
APTC will only be provided on behalf of a tax filer if one or
more individuals for whom the tax filer attests that they expect to claim a
personal exemption deduction for the benefit year, including the tax filer and
spouse, is enrolled in a QHP.
Section
12.05 Compliance with filing requirement59
(01/15/2017, GCR 16-095)
AHS may not determine a tax filer eligible for APTC if HHS
notifies AHS as part of the process described in § 56.03 that APTCs were
made on behalf of the tax filer or either spouse if the tax filer is a married
couple for a year for which tax data would be utilized for verification of
household income and family size in accordance with § 56.01(a), and the
tax filer or their spouse did not comply with the requirement to file an income
tax return for that year as required by
26 USC §
6011,
6012,
and implementing regulations, and reconcile the APTCs for that period.
Section 12.06 Vermont Premium
Reduction eligibility criteria
(01/15/2017, GCR 16-095)
An individual is eligible for the Vermont Premium Reduction
if the individual:
(a) Meets the
requirements for eligibility for enrollment in a QHP, as specified in §
11.00;
(b) Meets the requirements
for APTC, as specified in this § 12.00; and
(c) Is expected to have household income, as
defined in § 28.05(c), that does not exceed 300 percent of the FPL for the
benefit year for which coverage is requested.
Section 13.00 Cost-Sharing Reductions (CSR)
(01/15/2017, GCR 16-095)
Section 13.01 Eligibility criteria60
(01/15/2017, GCR 16-095)
(a) An individual is eligible for federal
and/or state CSR if the individual:
(1) Meets
the requirements for eligibility for enrollment in a QHP, as specified in
§ 11.00;
(2) Meets the
requirements for APTC, as specified § 12.00; and
(3) Is expected to have household income, as
defined in § 28.05(c), that does not exceed 300 percent of the FPL for the
benefit year for which coverage is requested.
(b) An individual who is not an Indian may
receive CSR only if they are enrolled in a silver-level QHP.
Section 13.02 Eligibility
categories61
(01/15/2017, GCR 16-095)
The following eligibility categories for CSR will be used
when making eligibility determinations under this section:
(a) An individual who is expected to have
household income at least 100 but not more than 150 percent of the FPL for the
benefit year for which coverage is requested, or for an individual who is
eligible for APTC under § 12.03(e), household income less than 100 percent
of the FPL for the benefit year for which coverage is requested;
(b) An individual who is expected to have
household income greater than 150 but not more than 200 percent of the FPL for
the benefit year for which coverage is requested;
(c) An individual who is expected to have
household income greater than 200 but not more than 250 percent of the FPL for
the benefit year for which coverage is requested; and
(d) An individual who is expected to have
household income greater than 250 but not more than 300 percent of the FPL for
the benefit year for which coverage is requested.
Income and benefit levels are as shown in the chart below.
The actuarial value of the plan must be within one percentage point of the
actuarial value listed below.
|
Income as a Percent of Federal Poverty Level
|
Tier
|
Actuarial Value of Plan with Federal and State
CSR
|
|
Not more than 150%
|
I
|
94%
|
|
More than 150% but not more than 200%
|
II
|
87%
|
|
More than 200% but not more than 250%
|
III
|
77%
|
|
More than 250% but not more than 300%
|
IV
|
73%
|
Section 13.03 Special rule for family
policies62
(01/15/2017, GCR 16-095)
To the extent that an enrollment in a QHP under a single
policy covers two or more individuals who, if they were to enroll in separate
policies would be eligible for different cost sharing, AHS will deem the
individuals under such policy to be collectively eligible only for the category
of eligibility last listed below for which all the individuals covered by the
policy would be eligible.
(a)
Individuals not eligible for changes to cost sharing;
(b)
§ 59.02 (Special cost-sharing rules
for Indians, regardless of income);
(c)
§ 13.02(d);
(d)
§ 13.02(c);
(e)
§ 13.02(b);
(f)
§ 13.02(a);
(g)
§ 59.01 (Eligibility for CSR for
Indians).
Example: Person A is the mother of Person B, her 24-year-old
son.
Person A and Person B both work and file taxes separately.
However, they are covered under the same QHP. Person A's income is equal to 125
percent of the FPL and Person B's income is 225 percent of the FPL. Since
Person B's income is at the 225 percent level, the CSR that Person A and Person
B will receive will be that available at the 225 percent level, which is in the
200 percent to 250 percent range.
Section 14.00 Eligibility for Enrollment in a
Catastrophic Plan. [63]
(01/15/2017, GCR 16-095)
An individual is eligible for enrollment in a catastrophic
plan [64] if they have met the requirements for eligibility for enrollment in a
QHP, as specified in § 11.00, and they:
(a) Have not attained the age of 30 before
the beginning of the plan year; or
(b) Have a certification in effect for any
plan year that they are exempt from the requirement to maintain MEC by reason
of hardship, including coverage being unaffordable (see § 23.06(b)(7)).
Part THREE NONFINANCIAL ELIGIBILITY REQUIREMENTS
Section 15.00
Nonfinancial Eligibility Requirements, in General
(01/15/2017, GCR 16-096)
This part catalogs the nonfinancial eligibility requirements
that apply across all health benefits. The provisions that assign these
requirements to a particular program or benefit are set forth in Part Two of
this rule.
Section 16.00
Social Security Number
(01/15/2017, GCR 16-096)
Section 16.01 Medicaid [1]
(01/15/2017, GCR 16-096)
(a) In general
(1) Except as provided in paragraph (b) of
this subsection, as a condition of Medicaid eligibility, each individual
(including children) seeking Medicaid must furnish their Social Security
number.
(2) AHS will advise the
individual of:
(i) The statute or other
authority under which it is requesting the individual's Social Security number;
and
(ii) The uses that will be made
of each Social Security number, including its use for verifying income,
eligibility, and amount of medical assistance payments under §§ 53.00
through 56.00.
(3) If an
individual cannot recall their Social Security number or Social Security
numbers or has not been issued a Social Security number, AHS will:
(i) Assist the individual in completing an
application for a Social Security number;
(ii) Obtain evidence required under SSA
regulations to establish the age, the citizenship or non-citizenship status,
and the true identity of the individual; and
(iii) Either send the application to SSA or,
if there is evidence that the individual has previously been issued a Social
Security number, request SSA to furnish the number.
(4) Services to an otherwise eligible
individual will not be denied or delayed pending issuance or verification of
the individual's Social Security number by SSA or if the individual meets one
of the exceptions in paragraph (b) of this subsection.
(5) The Social Security number furnished by
an individual will be verified to insure the Social Security number was issued
to that individual, and to determine whether any other Social Security numbers
were issued to that individual. See § 55.02(a) for information on the
verification process.
(b) Exception
(1) The requirement of paragraph (a)(1) of
this subsection does not apply, and a Medicaid identification number will be
given, to an individual who:
(i) Is not
eligible to receive a Social Security number;
(ii) Does not have a Social Security number
and may only be issued a Social Security number for a valid non-work reason in
accordance with
20 CFR §
422.104; or
(iii) Refuses to obtain a Social Security
number because of well-established religious objections. The term "well-
established religious objections" means that the individual is a member of a
recognized religious sect or division of the sect, and adheres to the tenets or
teachings of the sect or division of the sect and for that reason is
conscientiously opposed to applying for or using a national identification
number including a Social Security number.
(2) The Medicaid identification number may be
either a Social Security number obtained on the individual's behalf or another
unique identifier.
(3) An
individual who has a Social Security number is not subject to this exception
and must provide such number.
(c) Social Security numbers of Medicaid
non-applicants [2]
AHS may request the Social Security number of a person who is
not applying for Medicaid for themselves provided that:
(1) Provision of such Social Security number
is voluntary;
(2) Such Social
Security number is used only to determine an applicant's or enrollee's
eligibility for a health-benefits program or for a purpose directly connected
to the administration of the state plan; and
(3) At the time such Social Security number
is requested, AHS provides clear notice to the individual seeking assistance,
or person acting on such individual's behalf, that provision of the
non-applicant's Social Security number is voluntary and information regarding
how the Social Security number will be used.
Section 16.02 QHP [3]
(01/15/2017, GCR 16-096)
(a) An individual applying for a QHP, with or
without APTC or CSR, and who has a Social Security number must provide it. The
number provided will be verified by AHS. See § 55.02(a) for information on
the verification process.
(b)
Except as provided in paragraph (c) of this subsection, a person who is not
seeking coverage for themselves need not provide a Social Security
number.
(c) An application filer
seeking APTC must provide the Social Security number of a tax filer who is not
an applicant only if an applicant attests that the tax filer has a Social
Security number and filed a tax return for the year for which tax data would be
utilized for verification of household income and family size. [4]
Section 17.00 Citizenship and
Immigration Status [5]
(01/15/2017, GCR 16-096)
Section 17.01 Definitions
(01/15/2017, GCR 16-096)
(a) U.S. Citizen
(1) An individual born in the 50 states, the
District of Columbia, Puerto Rico, Guam, Virgin Islands, and the Northern
Mariana Islands (except for individuals born to foreign diplomats);
(2) A naturalized citizen; or
(3) An individual who otherwise qualifies for
U.S. citizenship under §
301 of the
Immigration and Nationality Act (INA),
8 USC §§
1401.
(b) Citizenship [6]
Includes status as a "national of the United States" that
includes both citizens of the United States and non-citizen nationals of the
United States.
(c) National
[7]
(1) An individual who:
(i) Is a U.S. citizen; or
(ii) Though not a citizen, owes permanent
allegiance to the United States.
(2) For purposes of determining
health-benefits eligibility, including verification requirements, citizens and
non-citizen nationals of the United States are treated the same.
(3) As a practical matter, non-citizen
nationals include individuals born in American Samoa or Swains
Island.
(d) Qualified
non-citizen [8]
An individual who is:
(1) A lawful, permanent resident of the
United States (LPR);
(2) A refugee,
including:
(i) An individual admitted to the
United States under §
207
of the INA;
(ii) A Cuban or Haitian
entrant, as defined in §
501(e)(2)
of the Refugee Education Assistance Act of 1980. There are three general
categories of individuals who are considered "Cuban and Haitian entrants." A
Haitian national meets the definition of "Cuban and Haitian entrant" if he or
she:
(A) Was granted parole status as a
Cuban/Haitian entrant (Status Pending) on or after April 21, 1980 or has been
paroled into the United States on or after October 10, 1980;
(B) Is the subject of removal, deportation or
exclusion proceedings under the Immigration and Nationality Act and with
respect to whom a final, nonappealable, and legally enforceable order of
removal, deportation or exclusion has not been entered; or
(C) Has an application for asylum pending
with the Department of Homeland Security (DHS) and with respect to whom a
final, nonappealable, removal, deportation or exclusion has not been
entered.
(3)
An Amerasian, admitted to the United States under § 584 of the Foreign
Operations Export Financing, and Related Programs Appropriation Act, 1988 (as
contained in § 101(e) of Public Law
100-202 and amended by the 9th proviso
under Migration and Refugee Assistance in title II of the Foreign Operations
Export Financing, and Related Programs Act, 1989, Public Law 100- 461 , as
amended);
(4) An asylee, as defined
in §
208
of the INA;
(5) A non-citizen whose
deportation has been withheld under:
(i)
§ 243(h) of the INA, as in effect prior to April 1, 1997, (the effective
date of § 307 of the Illegal Immigration Reform and Immigrant
Responsibility Act of 1996 (IIRIRA), division C of
Public Law
104-208); or
(ii)
§ 241(b)(3) of the INA, as amended
by § 305(a) of division C of
Public Law
104-208;
(6) An non-citizen who has been granted
parole for at least one year by the USCIS under § 212(d)(5) of the
INA;
(7) A non-citizen who has been
granted conditional entry under § 203(a)(7) of the INA;
(8) A battered non-citizen, as defined in
paragraph (e) of this subsection;
(9) A victim of a severe form of trafficking,
in accordance with § 107(b)(1) of the Trafficking Victims Protection Act
of 2000; or
(10) An American
Indian, born outside the U.S. and who enters and re-enters and resides in the
U.S. is, for Medicaid purposes, considered a lawful permanent resident and, as
such, a qualified non-citizen. This includes:
(i) An American Indian who was born in Canada
and who is of at least one-half American Indian blood. This does not include
the non-citizen spouse or child of such an Indian or a non-citizen whose
membership in an Indian tribe or family is created by adoption, unless such
person is of at least 50% American Indian blood.
(ii) An American Indian who is a member of a
Federally- recognized Indian tribe, as defined in §
4(e)
of the Indian Self-Determination and Education Assistance Act,
25
USC §
§
450 b(e). [9]
(e) Battered
non-citizen
(1) An individual who is:
(i) A victim of battering or cruelty by a
spouse or a parent, or by a member of the spouse or parent's family residing in
the same household as the victim and the spouse or parent consented to, or
acquiesced in the battery or cruelty;
(ii) The parent of a child who has been such
a victim, provided that the individual did not actively participate in the
battery or cruelty; or
(iii) The
child residing in the same household of such a victim.
(2) For the purposes of establishing
qualified non-citizen status, the battered non-citizen must meet all of the
following conditions:
(i) The individual must
no longer be residing in the same household as the perpetrator of the abuse or
cruelty;
(ii) The battery or
cruelty must have a substantial connection with the need for medical
assistance; and
(iii) The
individual must have been approved for legal immigration status, or have a
petition pending that makes a prima facie case for legal immigration status,
under one of the following categories:
(A)
Permanent residence under the Violence Against Women Act (VAWA);
(B) A pending or approved petition for legal
permanent residence filed by a spouse or parent on USCIS Form I-130 or Form
I-129f; or
(C) Suspension of
deportation or cancellation of removal under VAWA.
(f) Nonqualified
non-citizen
A non-citizen who does not meet the definition of qualified
non-citizen ( § 17.01(d)).
(g) Lawfully present in the United States
An individual who is a non-citizen and who:
(1) Is a qualified non-citizen, as defined in
paragraph (d) of this subsection;
(2) Is in a valid nonimmigrant status, as
defined in
8 USC
§
1101(a)(15) or
otherwise under the immigration laws (as defined in
8 USC
§
1101(a)(17)
);
(3) Is paroled into the United
States in accordance with
8 USC §
1182(d)(5) for less than 1
year, except for an individual paroled for prosecution, for deferred inspection
or pending removal proceedings;
(4)
Belongs to one of the following classes:
(i)
Granted temporary resident status in accordance with
8 USC §
1160 or
1255
a, respectively;
(ii) Granted
Temporary Protected Status (TPS) in accordance with
8 USC
§
1254 a, and individuals with pending
applications for TPS who have been granted employment authorization;
(iii) Granted employment authorization under
8 CFR §
274a.12(c);
(iv) Family Unity beneficiaries in accordance
with §
301 of 101,
as amended;
(v) Under Deferred
Enforced Departure (DED) in accordance with a decision made by the
President;
(vi) Granted Deferred
Action status;
(vii) Granted an
administrative stay of removal under 8 CFR part
241;
(viii) Beneficiary of approved visa petition
who has a pending application for adjustment of status;
(5) Is an individual with a pending
application for asylum under
8 USC
§
1158, or for withholding of removal
under
8 USC §
1231, or under the Convention Against Torture
who--
(i) Has been granted employment
authorization; or
(ii) Is under the
age of 14 and has had an application pending for at least 180 days;
(6) Has been granted withholding
of removal under the Convention Against Torture;
(7) Is a child who has a pending application
for Special Immigrant Juvenile status as described in
8 USC
§
1101(a)(27)(J);
(8) Is lawfully present in American Samoa
under the immigration laws of American Samoa; or
(9) Is a victim of a severe form of
trafficking in persons, in accordance with the Victims of Trafficking and
Violence Protection Act of 2000,
Public Law
106-386, as amended (
22 USC §
7105(b)) .
(10) Exception. An individual with deferred
action under DHS's deferred action for childhood arrivals process, as described
in the Secretary of Homeland Security's June 15, 2012, memorandum, shall not be
considered to be lawfully present with respect to any of the above categories
in paragraphs (1) through (9) of this definition.
(h) Non-citizen [10]
Has the same meaning as the term "alien," as defined in
section
101(a)(3)
of the INA, (
8 USC
§
1101(a)(3)) and
includes any individual who is not a citizen or national of the United States,
defined at
8 USC
§
1101(a)(22).
Section 17.02 General
Rules
(01/15/2017, GCR 16-096)
(a) Health benefits, in general
Except as provided in paragraphs (b) through (d) of this
subsection, as a condition of eligibility for health benefits, an individual
must be a citizen or national of the United States and, for purposes of
enrollment in a QHP, must reasonably expect to be a citizen or national for the
entire period for which QHP enrollment is sought.
(b) Enrollment in Medicaid
An individual who is a non-citizen is eligible for Medicaid
if the individual otherwise satisfies the eligibility requirements and
is:
(1) A qualified non-citizen who is
not subject to the five-year bar under § 17.03(b); or
(2) A non-citizen who is not subject to the
five-year bar under § 17.03(c).
(c) Enrollment in a QHP, with or without APTC
or CSR
An individual who is a non-citizen who is lawfully present in
the United States is eligible for enrollment in a QHP, with or without APTC or
CSR, if the individual otherwise satisfies the eligibility requirements for a
QHP and is reasonably expected to be a non-citizen who is lawfully present for
the entire period for which QHP enrollment is sought.
(d) Emergency medical services [11]
An individual who is ineligible for Medicaid solely because
of immigration status is eligible for the treatment of emergency medical
conditions if all of the following conditions are met:
(1) The individual has, after sudden onset, a
medical condition (including emergency labor and delivery) manifesting itself
by acute symptoms of sufficient severity (including severe pain) such that the
absence of immediate medical attention could reasonably be expected to result
in serious:
(i) Jeopardy to the individual's
health;
(ii) Impairment of bodily
functions; or
(iii) Dysfunction of
any bodily organ or part.
(2) The individual meets all eligibility
requirements for Medicaid except that non-qualified non-citizens need not
present a Social Security number or document immigration status.
(3) Emergency medical services do not include
organ transplant procedures or routine prenatal or post partum care.
Section 17.03 Medicaid
five-year bar for qualified non-citizens
(01/15/2017, GCR 16- 096)
(a) Qualified non-citizens subject to 5-year
bar [12]
Non-citizens who enter the United States on or after August
22, 1996, as qualified non-citizens are not eligible to receive Medicaid for
five years from the date they enter the country. If they are not qualified non-
citizens when they enter, the five-year bar begins the date they become a
qualified non-citizen. The following qualified non-citizens are subject to the
five-year bar:
(1) Lawful permanent
residents (LPRs);
(2) Non-citizens
granted parole for at least one year;
(3) Non-citizens granted conditional entry
(however, as a practical matter the five-year bar will never apply to such non-
citizens, since, by definition, they entered the U.S. and obtained qualified
non-citizen status prior to August 22, 1996); and
(4) Battered non-citizens.
(b) Qualified non-citizens not
subject to 5-year bar [13]
The following qualified non-citizens are not subject to the
five-year bar:
(1) Refugees;
(2) Asylees;
(3) Cuban and Haitian Entrants;
[14]
(4) Victims of a severe form
of trafficking;
(5) Non-citizens
whose deportation is being withheld;
(6) Qualified non-citizens who are:
(i) Honorably discharged veterans;
(ii) On active duty in the U.S. military;
or
(iii) The spouse (including a
surviving spouse who has not remarried) or unmarried dependent child of an
honorably discharged veteran or individual on active duty in the U.S.
Military;
(7)
Non-citizens admitted to the country as Amerasian immigrants;
(8) Legal permanent residents who first
entered the United States under another exempt category (i.e., as a refugee,
asylee, Cuban or Haitian entrant, trafficking victim, or non-citizen whose
deportation was being withheld) and who later converted to the LPR
status.
(9) Haitians granted
Humanitarian Parole status; and
(10) Citizens and nationals of Iraq and
Afghanistan with Special Immigrant status. [15]
(c) Non-citizens not subject to 5-year bar
[16]
The five-year bar does not apply to:
(1) Non-citizens who are applying for
treatment of an emergency medical condition only;
(2) Non-citizens who entered the United
States and became qualified non-citizens prior to August 22, 1996;
and
(3) Non-citizens who entered
prior to August 22, 1996, and remained "continuously present" in the United
States until becoming a qualified non-citizen on or after that date. Any single
absence of more than 30 consecutive days or a combined total absence of 90 days
before obtaining qualified non-citizen status is considered to interrupt
"continuous presence."
(i) Non-citizens who
do not meet "continuous presence" are subject to the five-year bar beginning
from the date they become a qualified non-citizen.
(ii) Non-citizens do not have to remain
continuously present in the United States after obtaining qualified non-citizen
status.
(4) Members of a
Federally-recognized Indian tribe;
(5) American Indians born in Canada to whom
§ 289 of the INA applies; and
(6) Children up to 21 years of age and women
during pregnancy and the 60-day postpartum period, who are lawfully residing in
the United States and otherwise eligible. AHS will verify that the child or
pregnant woman is lawfully residing in the United States at the time of the
individual's initial eligibility determination and at the time of eligibility
redeterminations. A child or pregnant woman will be considered to be lawfully
residing in the United States if they are:
(i)
A qualified non-citizen as defined in § 431 of PRWORA (
8 USC
§
1641) (see 17.01(d));
(ii) A non-citizen in non-immigration status
who has not violated the terms of the status under which they were admitted or
to which they have changed after admission;
(iii) A non-citizen who has been paroled into
the United States pursuant to § 212(d)(5) of the INA (
8 USC §
1182(d)(5)) for less than 1
year, except for a non-citizen paroled for prosecution, for deferred inspection
or pending removal proceedings;
(iv) A non-citizen who belongs to one of the
following classes:
(A) Non-citizens currently
in temporary resident status pursuant to § 210 or 245A of the INA (
8 USC §
1160 or
1255
a, respectively);
(B) Non-citizens
currently under Temporary Protected Status (TPS) pursuant to § 244 of the
INA (8
USC §
1254 a), and pending applicants
for TPS who have been granted employment authorization;
(D) Family Unity beneficiaries pursuant to
§
301 of
Pub. L.
101-649, as amended;
(E) Non-citizens currently under Deferred
Enforced Departure (DED) pursuant to a decision made by the
President;
(F) Non-citizens
currently in deferred action status; or
(G) Non-citizens whose visa petitions have
been approved and who have pending applications for adjustment of
status;
(v) A pending
applicant for asylum under §
208(a)
of the INA (
8 USC
§
1158) or for withholding of removal
under § 241(b)(3) of the INA (
8 USC §
1231) or under the convention Against
Torture who has been granted employment authorization, and such an applicant
under the age of 14 who has had an application pending for at least 180
days;
(vi) A non-citizen who has
been granted withholding of removal under the Convention Against Torture;
or
(vii) A child who has a pending
application for Special Immigrant Juvenile status as described in §
101(a)(27)(J)
of the INA (
8 USC
§
1101(a)(27)(J)
).
(d)
Ineligible non- citizens/nonimmigrants
The following categories of individuals are ineligible
non-citizens/non- immigrants and are not eligible for Medicaid:
(1) Foreign government representatives on
official business and their families and servants;
(2) Visitors for business or pleasure,
including exchange visitors;
(3)
Non-citizens in travel status while traveling directly through the
U.S.;
(4) Crewmen on shore
leave;
(5) Foreign
students;
(6) International
organization representation personnel and their families and
servants;
(7) Temporary workers
including agricultural contract workers; and
(8) Members of foreign press, radio, film, or
other information media and their families.
Section 18.00 Assignment of Rights and
Cooperation Requirements for Medicaid
(01/15/2017, GCR 16-096)
Section 18.01 In general [17]
(01/15/2017, GCR 16-096)
As a condition of initial and continuing eligibility, a
legally-able individual who is applying for or enrolled in Medicaid must meet
the requirements related to the pursuit of medical support, third-party
payments, and the requirement to enroll or remain enrolled in a group health
insurance plan, as provided for below.
Section 18.02 Assignment of rights to
payments
(01/15/2017, GCR 16-096)
(a) In general
An individual who is applying for, or enrolled in Medicaid,
with the legal authority to do so, must assign their rights to medical support
and third- party payments for medical care. If they have the legal authority to
do so, they must also assign the rights of any other individual who is applying
for or enrolled in Medicaid to such support and payments.
(b) Exceptions
No assignment is required for:
(1) Medicare payments; or
(2) Cash payments from the Department of
Veterans Affairs for aid and attendance.
Section 18.03 Cooperation in Obtaining
Payments
(01/15/2017, GCR 16-096)
(a) In general
(1) Applicants must attest that they will
cooperate, and enrollees must cooperate in:
(i) Establishing paternity and in obtaining
medical support and payments, unless the individual establishes good cause for
not cooperating as described in § 18.04; and
(ii) Identifying and providing information to
assist in pursuing third parties who may be liable to pay for care and services
under the plan, unless the individual establishes good cause for not
cooperating as described in § 18.04.
(2) To meet this requirement, an individual
may be required to:
(i) Provide information or
evidence relevant and essential to obtain such support or payments;
(ii) Appear as a witness in court or at
another proceeding;
(iii) Provide
information or attest to lack of information under penalty of perjury;
or
(iv) Take any other reasonable
steps necessary for establishing parentage or securing medical support or
third-party payments.
(b) Exception
An unmarried pregnant woman with income under 208 percent of
the FPL is exempted from the requirement to cooperate in establishing paternity
or obtaining medical support and payments from, or derived from, the father of
the child she expects to deliver or from the father of any of her children born
out-of-wedlock. She shall remain exempt through the end of the calendar month
in which the 60-day period beginning with the date of her delivery ends.
Section 18.04 Good
cause for noncooperation
(01/15/2017, GCR 16-096)
(a) In general
An individual who is applying for or enrolled in Medicaid may
request a waiver of the cooperation requirement under § 18.03. Those to
whom a good-cause waiver for noncooperation has been granted are eligible for
Medicaid, provided that all other program requirements are met. AHS will grant
such waivers when either of the following circumstances has been substantiated
to AHS's satisfaction:
(1) Compliance
with the cooperation requirement is reasonably anticipated to result in
physical or emotional harm to the individual responsible for cooperating or the
person for whom medical support or third-party payments are sought. Emotional
harm means an emotional impairment that substantially affects an individual's
functioning; or
(2) Compliance with
the cooperation requirement would entail pursuit of medical support for a
child:
(i) Conceived as a result of incest or
rape from the father of that child;
(ii) For whom adoption proceedings are
pending; or
(iii) For whom adoptive
placement is under active consideration.
(b) Required documentation
An Individual requesting a waiver of the cooperation
requirement bears the primary responsibility for providing the documentation
AHS deems necessary to substantiate their claims of good cause. AHS will
consider an individual who has requested a good-cause waiver and submitted the
required documentation to be eligible for Medicaid while a decision on the
request is pending.
(c)
Review of good-cause waiver
A review of the continued existence of good cause
circumstances upon which a waiver has been granted is required no less
frequently than at each redetermination of eligibility for those cases in which
determination of good cause is based on a circumstance that may change. A
formal decision based upon resubmission of evidence is not required, however,
unless AHS determines that a significant change of circumstances relative to
good cause has occurred.
Section 18.05 Enrollment in a health
insurance plan
(01/15/2017, GCR 16-096)
(a) An individual who is applying for, or
enrolled in Medicaid, may be required to enroll or remain enrolled in a group
health insurance plan for which AHS pays the premiums. (See Medicaid Covered
Services Rule (MCSR) 7108.) Payment of group health insurance premiums shall be
made only under the conditions specified in this subsection and in MCSR 7108.1
and remain entirely at AHS's discretion. Such payment of premiums shall not be
considered an entitlement for any individual.
(b) As a condition of continuing eligibility,
an individual may be required to remain enrolled in an individual health
insurance plan, provided that they are enrolled in a plan for which the state
has been paying the premiums on a continuous basis since July 2000.
(c) For the purposes of this subsection and
MCSR 7108.1, a group health insurance plan is a plan that meets the definition
of a group health insurance plan specified in
8 V.S.A. §
4079. An individual health insurance plan is
a plan that does not meet that definition.
Section 19.00 Incarceration and QHP
Eligibility
(01/15/2017, GCR 16-096)
Section 19.01 In general [18]
(01/15/2017, GCR 16-096)
An incarcerated individual, other than an individual who is
incarcerated pending the disposition of charges, is ineligible for enrollment
in a QHP.
Section 19.02
Exception [19]
(01/15/2017, GCR 16-096)
An incarcerated individual may be an applicable tax filer if
a family member is eligible to enroll in a QHP.
Section 20.00 Living Arrangements for
Medicaid Eligibility Purposes
(01/15/2017, GCR 16-096)
Section 20.01 In general [20]
(01/15/2017, GCR 16-096)
Individuals or couples meet the living-arrangement
requirement for Medicaid eligibility purposes if they live in:
(a) Their own home;
(b) The household of another; or
(c) The following public institutions:
(1) The Vermont State Hospital (VSH) or
successor entity or entities, if the individual is:
(i) Under the age of 21 (if a Medicaid
enrollee is a patient of VSH upon reaching their 21st birthday, eligibility may
be continued to the date of discharge or their 22nd birthday, whichever comes
first, upon a finding by the VSH Disability Determination Team that the
individual is blind or disabled according to SSI/AABD standards); or
(ii) Age 65 or older.
(2) An intermediate care facility for people
with developmental disabilities (ICF-DD).
(3) A facility supported in whole or in part
by public funds whose primary purpose is to provide medical care other than the
treatment of mental disease, including nursing and convalescent care, inpatient
care in a hospital, drug and alcohol treatment, etc.
(d) A private facility, if:
(1) The primary purpose of the facility is to
provide medical care other than the treatment of mental diseases, including
nursing and convalescent care, inpatient care in a hospital, drug and alcohol
treatment, etc.; and
(2) The
facility meets the following criteria:
(i)
There is no agreement or contract obliging the institution to provide total
support to the individual;
(ii)
There has been no transfer of property to the institution by the individual or
on their behalf, unless maintenance by the institution has been of sufficient
duration to fully exhaust the individual's equity in the property transferred
at a rate equal to the monthly charges to other residents in the institution;
and
(iii) There is no restriction
on the individual's freedom to leave the institution.
(3) An individual under the age of 21 or age
65 or older meets the living arrangement requirement if they live at the
Brattleboro Retreat. In addition, an individual who is a patient at the
facility upon reaching their 21st birthday, has eligibility continued to the
date of discharge (or end of ten day notice period, if later) or their 22nd
birthday, whichever comes first, as long as they continue to meet all other
eligibility requirements.
Section 20.02 Correctional facility
(01/15/2017, GCR 16-096)
(a) In general [21]
An individual living in a correctional facility, including a
juvenile facility, is not eligible for Medicaid.
(b) Determination of incarceration
Incarceration begins on the date of admission and ends when
the individual moves out of the correctional facility.
(c) Exception: Transfer to a medical facility
[22]
While incarcerated, Medicaid is available when the inmate is
an inpatient in a medical institution not under the control of the corrections
system. Such institutions include a hospital, nursing facility, juvenile
psychiatric facility, or intermediate care facility.
(d) Affect of incarceration on enrollment
Once determined Medicaid eligible, an individual who is
incarcerated retains eligibility. However, their case is placed in suspended
status during the period of incarceration.
Section 20.03 Determination of residence in
an institution
(01/15/2017, GCR 16-096)
Residence in an institution is determined by the dates of
admission and discharge. An individual at home in the community on a visiting
pass is still a resident of the institution.
Section 20.04 Homeless individuals
(01/15/2017, GCR 16-096)
A homeless individual is considered to be living in their own
home.
Section 20.05
Financial responsibility and living arrangement
(01/15/2017, GCR 16-096)
The financial responsibility of relatives varies depending
upon the type of living arrangement.
Section 21.00 Residency
(01/15/2017, GCR 16-096)
Section 21.01 In general [23]
(01/15/2017, GCR 16-096)
AHS will provide health benefits to an eligible Vermont
resident.
Section 21.02
Incapability of indicating intent
(01/15/2017, GCR 16-096)
For purposes of this section, an individual is considered
incapable of indicating intent regarding residency if the individual:
(a) Has an I.Q. of 49 or less or has a mental
age of 7 years or less, based on tests acceptable to AHS;
(b) Is judged legally incompetent;
or
(c) Is found incapable of
indicating intent based on medical documentation obtained from a physician,
psychologist, or other person licensed by the state in the field of
intellectual disabilities.
Section
21.03 Who is a state resident
(01/15/2017, GCR 16-096)
A resident of the state is any individual who:
(a) Meets the conditions in §§
21.04 through 21.08; or
(b) Meets
the criteria specified in an interstate agreement under § 21.10.
Section 21.04 Placement by a state
in an out-of-state institution [24]
(01/15/2017, GCR 16-096)
(a) Any state agency, including an entity
recognized under state law as being under contract with the state for such
purposes, that arranges for an individual to be placed in an institution
located in another state is recognized as acting on behalf of the state in
making a placement. The state arranging or actually making the placement is
considered as the individual's state of residence.
(b) Any action beyond providing information
to the individual and the individual's family would constitute arranging or
making a state placement. However, the following actions do not constitute
state placement:
(1) Providing basic
information to individuals about another state's Medicaid program and
information about the availability of health care services and facilities in
another state.
(2) Assisting an
individual in locating an institution in another state, provided the individual
is capable of indicating intent and independently decides to move.
(3) When a competent individual leaves the
facility in which the individual is placed by a state, that individual's state
of residence for Medicaid purposes is the state where the individual is
physically located.
(4) Where a
placement is initiated by a state because the state lacks a sufficient number
of appropriate facilities to provide services to its residents, the state
making the placement is the individual's state of residence.
Section 21.05 An
individual receiving Aid to the Aged, Blind, and Disabled (AABD) [25]
(01/15/2017, GCR 16-096)
(a) In general
For an individual of any age who is receiving a state
supplemental payment (in Vermont, known as AABD), the state of residence is the
state paying the state supplemental payment.
(b) Exception [26]
A transient worker may claim Vermont as their state of
residence and be granted Medicaid if they meet all other eligibility criteria.
These individuals may be granted Vermont Medicaid even though they continue to
receive a state supplement payment from another state.
Section 21.06 An individual age 21
and over [27]
(01/15/2017, GCR 16-096)
Except as provided in § 21.05, with respect to
individuals age 21 and over:
(a) For
an individual not residing in an institution, as defined in § 3.00,
including a licensed foster care providing food, shelter, and supportive
services to one or more persons unrelated to the proprietor, the state of
residence is the state where the individual is living and:
(1) Intends to reside, including without a
fixed address; or
(2) Has entered
the state with a job commitment or is seeking employment (whether or not
currently employed).
(b)
For an individual not residing in an institution, as described in (a) of this
subsection, who is incapable of stating intent, the state of residence is the
state where the individual is living.
(c) For any institutionalized individual who
became incapable of indicating intent before age 21, the state of residence is:
(1) That of the parent applying for Medicaid
on the individual's behalf, if the parents reside in separate states (if a
legal guardian has been appointed and parental rights are terminated, the state
of residence of the guardian is used instead of the parent's);
(2) The parent's or legal guardian's state of
residence at the time of placement (if a legal guardian has been appointed and
parental rights are terminated, the state of residence of the guardian is used
instead of the parent's);
(3) The
current state of residence of the parent or legal guardian who files the
application if the individual is institutionalized in that state (if a legal
guardian has been appointed and parental rights are terminated, the state of
residence of the guardian is used instead of the parent's); or
(4) The state of residence of the person or
party who files an application is used if the individual has been abandoned by
his or her parent(s), does not have a legal guardian and is institutionalized
in that state.
(d) For
any institutionalized individual who became incapable of indicating intent at
or after age 21, the state of residence is the state in which the individual is
physically present, except where another state makes a placement.
(e) For any other institutionalized
individual, the state of residence is the state where the individual is living
and intends to reside. An institutionalized individual cannot be considered a
Vermont resident if the individual owns a home (see § 29.08(a)(1)) in
another state which the individual intends to return to, even if the likelihood
of return is apparently nil. [28]
Section 21.07 An individual receiving Title
IV-E payments [29]
(01/15/2017, GCR 16-096)
For an individual of any age who is receiving federal
payments for foster care or adoption assistance under Title IV-E of the Act,
the state of residence is the state where the individual lives.
Section 21.08 An individual under
age 21 [30]
(01/15/2017, GCR 16-096)
For an individual under age 21 who is not eligible for
Medicaid based on receipt of assistance under Title IV-E of the Act, as
addressed in § 21.07, and is not receiving a state supplementary payment,
as addressed in § 21.05, the state of residence is as follows:
(a) For an individual who is capable of
indicating intent and who is emancipated from his or her parent or who is
married, the state of residence is determined in accordance with §
21.06(a).
(b) For an individual not
described in paragraph (a) of this subsection, not living in an institution,
not eligible for Medicaid based on receipt of assistance under Title IV-E of
the Act, and not receiving a state supplementary payment, the state of
residence is:
(1) The state where the
individual resides, including without a fixed address; or
(2) The state of residency of the parent or
caretaker, in accordance with § 21.06(a), with whom the individual
resides.
(c) For any
institutionalized individual who is neither married nor emancipated, the state
of residence is:
(1) The parent's or legal
guardian's state of residence at the time of placement (if a legal guardian has
been appointed and parental rights are terminated, the state of residence of
the guardian is used instead of the parent's); or
(2) The current state of residence of the
parent or legal guardian who files the application if the individual is
institutionalized in that state (if a legal guardian has been appointed and
parental rights are terminated, the state or residence of the guardian is used
instead of the parent's).
Section 21.09 Specific prohibitions [31]
(01/15/2017, GCR 16-096)
AHS will not:
(a)
Deny health-benefits eligibility because an individual has not resided in
Vermont for a specified period.
(b)
Deny health-benefits 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 residence in Vermont before entering the
institution.
(c) Deny or terminate
a Vermont resident's health-benefits eligibility because of that person's
temporary absence from the state, as defined in § 21.13, if the person
intends to return to Vermont when the purpose of the absence has been
accomplished, unless, for purposes of Medicaid eligibility, another state has
determined that the person is a resident there (see § 21.13(c)
).
Section 21.10
Interstate agreements [32]
(01/15/2017, GCR 16-096)
A state may have a written agreement with another state
setting forth rules and procedures resolving cases of disputed residency. These
agreements may establish criteria other than those specified in §§
21.07 and 21.08, but must not include criteria that result in loss of residency
in both states or that are prohibited by § 21.09. The agreements must
contain a procedure for providing health benefits to individuals pending
resolution of the case. States may use interstate agreements for purposes other
than cases of disputed residency to facilitate administration of the program,
and to facilitate the placement and adoption of a Title IV-E individual when
the child and his or her adoptive parent(s) move into another state.
Section 21.11 Cases of disputed
residency [33]
(01/15/2017, GCR 16-096)
If Vermont and any other state cannot resolve which state is
the individual's state of residence, the state where the individual is
physically located is the state of residence.
Section 21.12 Special rule for tax households
with members in multiple Exchange service areas [34]
(01/15/2017, GCR 16-096)
(a) Except as specified in paragraph (b) of
this subsection, if all of the members of a tax household are not within the
same Exchange service area, in accordance with the applicable standards in
§§ 21.04 through 21.08, any member of the tax household may enroll in
a QHP through any of the Exchanges for which one of the tax filers meets the
residency standard.
(b) If both
spouses in a tax household enroll in a QHP through VHC, a tax dependent may
only enroll in a QHP through VHC, or through the Exchange that services the
area in which the dependent meets a residency standard described in
§§ 21.04 through 21.08.
Section 21.13 Temporary absences from the
state [35]
(01/15/2017, GCR 16-096)
(a) In general
Temporary absences from Vermont do not interrupt or end
Vermont residence.
(b)
Definition
An absence is temporary if the individual leaves the state
with the intent to return when the purpose of the absence has been
accomplished. Examples include, but are not limited to, absences for the
purposes of:
(1) Visiting;
(2) Obtaining necessary medical
care;
(3) Obtaining education or
training under a program of Vocational Rehabilitation, Work Incentive, or
higher education program; or
(4)
Residence in a long-term care facility in another state, if arranged by an
agent of the State of Vermont, unless the individual or their parents or legal
guardian, as applicable, state intent to abandon Vermont residence and to
reside outside Vermont upon discharge from long-term care.
(c) Exception
For purposes of Medicaid eligibility, an absence is not
temporary if another state verifies that the individual meets the residency
standard of such other state [36].
Section 21.14 Vermont residence as Medicaid
payment requirement
(01/15/2017, GCR 16-096)
An individual must be a resident of Vermont at the time a
medical service is rendered in order for Vermont Medicaid to pay for that
service. The service, however, does not have to be rendered in Vermont subject
to certain restrictions. [37]
Section
22.00 Pursuit of Potential Unearned Income for Medicaid
Eligibility [38]
(01/15/2017, GCR 16-096)
(a) As a condition of eligibility for
Medicaid, an individual is required to take all necessary steps to obtain any
annuities, pensions, retirement, or disability benefits to which they may be
entitled, unless they can show good cause for not doing so. Annuities,
pensions, retirement, and disability benefits include, but are not limited to,
veterans' compensation and pensions, OASDI benefits, railroad retirement
benefits, and unemployment compensation. Application for these benefits, when
appropriate, must be verified prior to granting or continuing
Medicaid.
(b) Individuals are not
required to apply for Medicare part B or for cash assistance programs such as
SSI/AABD or Reach Up as a condition of eligibility for Medicaid.
Section 23.00 Minimum Essential
Coverage
(01/15/2017, GCR 16-096)
Section 23.01 Minimum essential coverage
(01/15/2017, GCR 16-096)
(a) In general [39]
Minimum essential coverage means coverage under any of the
following: Government-sponsored programs, eligible employer- sponsored plans,
grandfathered health plans, individual health plans and certain other
health-benefits coverage.
Individuals and their tax dependents must have minimum
essential coverage (MEC) to avoid the shared responsibility payment (penalty)
imposed by the Internal Revenue Service unless they qualify for an exemption
from this payment. See § 23.06 for details on the eligibility
determination for MEC exemptions.
In addition, individuals who are eligible to enroll in health
coverage that qualifies as MEC under this section are not eligible to receive
federal tax credits and cost-sharing reductions if they enroll in a QHP. See
§§ 23.01(b) through 23.01(e) for details on health coverage that
qualifies as MEC for purposes of considering eligibility for the federal
premium tax credit. As stated in § 23.01(c)(2), for an employer-sponsored
plan to be considered as MEC when an employee or related individual applies for
APTC, the plan must be affordable and meet minimum value criteria. See §
23.02 for details on affordability, and § 23.03 for details on minimum
value.
See §§ 55.02(c) and (d) for descriptions of the
process for verifying eligibility for MEC when determining eligibility for APTC
and CSR.
(b)
Government-sponsored MEC
(1) In general [40]
Subject to the limitation in paragraph (b)(2), an individual
is eligible for government-sponsored MEC for purpose of considering eligibility
for the federal premium tax credit if, as of the first day of the first full
month the individual may receive benefits under the program, the individual
meets the criteria for coverage under one of the following government-
sponsored programs:
(i) The Medicare
program under part A of Title XVIII of the Act, except for an individual who
must pay a premium for part A coverage and who chooses not to enroll in part A
coverage (see § 23.01(e)(1));
(ii) The Medicaid program under Title XIX of
the Act, except for the following individuals:
(A) A woman who becomes pregnant while
enrolled in a QHP and who, though eligible for Medicaid as a pregnant woman
pursuant to § 7. 03(a)(2), chooses not to enroll in Medicaid (see §
23.01(e)(5)).
(B) An individual
who becomes eligible for Medicaid coverage as medically needy only after
meeting a spenddown. Such individual may apply for a hardship exemption from
the personal responsibility payment as described in § 23.06(b)(7)
(vii).
(C) An individual who is
receiving coverage limited to family planning services as described in §
9.03(g).
(D) An individual who is
receiving coverage limited to the treatment of emergency services as described
in § 17.02(d);
(iii) The CHIP program under Title XXI of the
Act;
(iv) Medical coverage under
chapter
55 of Title 10, United States Code, including coverage under the
TRICARE program;
(v) A health care
program under chapter
17 or
18 of Title 38, United States Code, as determined
by the Secretary of Veterans Affairs, in coordination with the Secretary of HHS
and the Secretary of the Treasury;
(vi) A health plan under §
2504(e) of
Title 22, United States Code (relating to Peace Corps volunteers); or
(vii) The Nonappropriated Fund Health
Benefits Program of the Department of Defense, established under § 349 of
the National Defense Authorization Act for Fiscal Year 1995 (
Public Law
103-337;
10
USC §
1587 note).
(2) Obligation to complete administrative
requirements to obtain coverage [41]
An individual who meets the eligibility criteria for
government-sponsored MEC must complete the requirements necessary to receive
benefits. An individual who fails by the last day of the third full calendar
month following the event that establishes eligibility under (b)(1) of this
subsection to complete the requirements to obtain government- sponsored MEC
(other than a veteran's health-care program) is treated as eligible for
government-sponsored MEC as of the first day of the fourth calendar month
following the event that establishes eligibility.
(3) Special rule for coverage for veterans
and other individuals under chapter
17 or
18 of Title 38, USC § [42]
An individual is eligible for MEC under a health-care program
under chapter 17 or 18 of Title 38, USC section only if the individual is
enrolled in a health-care program under chapter 17 or 18 of Title 38, USC
section identified as MEC in regulations issued under § 5000A of the
Code.
(4) Retroactive
effect of eligibility determination [43]
If an individual receiving APTC is determined to be eligible
for government-sponsored MEC that is effective retroactively (such as
Medicaid), the individual is treated as eligible for MEC under that program no
earlier than the first day of the first calendar month beginning after the
approval.
(5) Determination
of Medicaid or CHIP ineligibility [44]
An individual is treated as not eligible for Medicaid or a
similar program for a period of coverage under a QHP if, when the individual
enrolls in the QHP, the individual is determined to be not eligible for
Medicaid.
(6) Examples [45]
The following examples illustrate the provisions of this
paragraph (b):
(i) Example 1. Delay in
coverage effectiveness
On April 10, 2015, Tax filer D applies for coverage under a
government- sponsored health-care program. D's application is approved on July
12, 2015, but her coverage is not effective until September 1, 2015. Under
paragraph (b)(1), D is eligible for government-sponsored MEC on September 1,
2015.
(ii) Example 2. Time
of eligibility
Tax filer E turns 65 on June 3, 2015, and becomes eligible
for Medicare. Under § 5000A(f)(1)(A)(i), Medicare is MEC. However, E must
enroll in Medicare to receive benefits. E enrolls in Medicare in September,
which is the last month of E's initial enrollment period. Thus, E may receive
Medicare benefits on December 1, 2015. Because E completed the requirements
necessary to receive Medicare benefits by the last day of the third full
calendar month after the event that establishes E's eligibility (E turning 65),
under paragraph (b)(1) and (b)(2) of this subsection, E is eligible for
government-sponsored MEC on December 1, 2015, the first day of the first full
month that E may receive benefits under the program.
(iii) Example 3. Time of eligibility,
individual fails to complete necessary requirements
The facts are the same as in Example 2, except that E fails
to enroll in the Medicare coverage during E's initial enrollment period. E is
treated as eligible for government-sponsored MEC under paragraph (b)(2) of this
subsection as of October 1, 2015, the first day of the fourth month following
the event that establishes E's eligibility (E turning 65).
(iv) Example 4. Retroactive effect of
eligibility
In November 2014, Tax filer F enrolls in a QHP for 2015 and
receives APTCs. F loses her part-time employment and on April 10, 2015, applies
for coverage under the Medicaid program. F's application is approved on May 15,
2015, and her Medicaid coverage is effective as of April 1, 2015. Under
paragraph (b)(4), F is eligible for government- sponsored MEC on June 1, 2015,
the first day of the first calendar month after approval.
(v) Example 5. Determination of Medicaid
ineligibility
In November 2014, Tax filer G applies to enroll in health
coverage for 2015. AHS determines that G is not eligible for Medicaid and
estimates that G's household income will be 140 percent of the FPL for G's
family size for purposes of determining APTCs. G enrolls in a QHP and begins
receiving APTCs. G experiences a reduction in household income during the year
and his household income for 2015 is 130 percent of the FPL (within the
Medicaid income threshold). However, under paragraph (b)(5), G is treated as
not eligible for Medicaid for 2015.
(vi) Example 6. Mid- year Medicaid
eligibility redetermination
The facts are the same as in Example 5, except that G returns
to the Exchange in July 2015 and AHS determines that G is eligible for
Medicaid. AHS approves G for coverage and AHS discontinues G's APTCs effective
August 1. Under paragraphs (b)(4) and (b)(5), G is treated as not eligible for
Medicaid for the months when G is covered by a QHP. G is eligible for
government-sponsored MEC for the months after G is approved for Medicaid and
can receive benefits, August through December 2015.
(c) Employer-sponsored
MEC
(1) Definition: related individual
For purposes of this subsection and §§ 23.02
through 23.04, a related individual is an individual who is not an employee of
an employer offering an eligible employer-sponsored plan, but who can enroll in
such plan because of their relationship to the employee. This definition has a
similar meaning as the definition of "dependent" for purposes of the Small
Employer Health-Benefits Program under Part Six of this rule.
(2) In general [46]
An employee and related individual who may enroll in an
eligible employer-sponsored plan are eligible for MEC under the plan for
purposes of considering eligibility for the federal premium tax credit for any
month only if the plan is affordable ( § 23.02) and provides minimum
value ( § 23.03). Government-sponsored programs described in paragraph
(b) of this subsection are not eligible employer-sponsored plans.
(3) Plan year [47]
For purposes of this paragraph, a plan year is an eligible
employer- sponsored plan's regular 12-month coverage period (or the remainder
of a 12-month coverage period for a new employee or an individual who enrolls
during a special enrollment period).
(4) Eligibility for months during a plan year
(i) Failure to enroll in plan [48]
An employee or related individual may be eligible for MEC
under an eligible employer-sponsored plan for a month during a plan year if the
employee or related individual could have enrolled in the plan for that month
during an open or special enrollment period.
(ii) Waiting periods [49]
An employee or related individual is not eligible for MEC
under an eligible employer-sponsored plan during a required waiting period
before the coverage becomes effective.
(iii) Example [50]
The following example illustrates the provisions of this
paragraph (c)(4):
(A) Tax filer B is
an employee of Employer X. X offers its employees a health insurance plan that
has a plan year (within the meaning of paragraph (c)(3)) from October 1 through
September 30. Employees may enroll during an open season from August 1 to
September 15. B does not enroll in X's plan for the plan year October 1, 2014,
to September 30, 2015. In November 2014, B enrolls in a QHP for calendar year
2015.
(B) B could have enrolled in
X's plan during the August 1 to September 15 enrollment period. Therefore,
unless X's plan is not affordable for B or does not provide minimum value, B is
eligible for MEC under X's plan for the months that B is enrolled in the QHP
during X's plan year (January through September 2015).
(5) Post-employment coverage [51]
A former employee (including a retiree), or an individual
related (within the meaning of this paragraph (c)) to a former employee, who
may enroll in eligible employer-sponsored coverage or in continuation coverage
required under federal law or a state law that provides comparable continuation
coverage is eligible for MEC under this coverage only for months that the
former employee or related individual is enrolled in the coverage.
(d) Other coverage that
qualifies as MEC
The following types of coverage are designated as MEC for
purposes of considering eligibility for the federal premium tax credit [52
]:
(1) Self-funded student health
coverage. Coverage offered to students by an institution of higher education
(as defined in the Higher Education Act of 1965), where the institution assumes
the risk for payment of claims, are designated as MEC for plan or policy years
beginning on or before December 31, 2014. For coverage beginning after December
31, 2014, sponsors of self- funded student health coverage may apply to be
recognized as MEC.
(2) Refugee
Medical Assistance supported by the Administration for Children and Families.
Coverage under Refugee Medical Assistance, authorized under § 412(e)(7)(A)
of the INA, provides up to eight months of coverage to certain noncitizens who
are considered refugees.
(3)
Medicare advantage plans. Coverage under the Medicare program pursuant to part
C of Title XVIII of the Act, which provides Medicare parts A and B benefits
through a private insurer.
(4)
State high risk pool coverage. State high risk pools are designated as MEC for
plan or policy years beginning on or before December 31, 2014. For coverage
beginning after December 31, 2014, sponsors of high risk pool coverage may
apply to be recognized as MEC.
(e) Eligibility based on enrollment [53]
An individual is eligible for MEC under the following
programs for purposes of considering eligibility for the federal premium tax
credit only if the individual is enrolled in the coverage:
(1) Medicare part A coverage requiring
payment of premiums. Coverage offered under Medicare for which the individual
must pay a premium for Medicare part A coverage under § 1818 of the
Act.
(2) State high risk pools.
Health coverage offered by a state under a qualified high risk pool as defined
in § 2744(c)(2) of the PHS Act, to the extent the program is covered by a
designation by HHS as MEC.
(3)
Student health plans. Self-funded health coverage offered by a college or
university to its students, to the extent the plan is covered by a designation
by HHS as MEC.
(4) TRICARE
programs. Coverage under the following TRICARE programs:
(i) The Continued Health Care Benefit Program
(
10 USC §
1078);
(ii) Retired Reserve (
10 USC §
1076 e);
(iii) Young Adult (
10
USC §
1110 b); and
(iv) Reserve Select (
10 USC §
1076 d).
(5) MCA coverage for a pregnant woman
enrolled in a QHP. Coverage offered under Medicaid for a pregnant woman
pursuant to the criteria described in § 7.03(a)(2) if the woman was
enrolled in a QHP when she became pregnant. [54]
Section 23.02 Affordable coverage
for employer-sponsored MEC
(01/15/2017, GCR 16-096)
An individual will not be eligible for a federal premium tax
credit if the employer-sponsored plan in which they may enroll is affordable.
The details of affordability are described in this subsection.
(a) In general
(1) Affordability for employee [55]
Except as provided in paragraph (a)(3) of this subsection, an
eligible employer-sponsored plan is affordable for an employee if the portion
of the annual premium the employee must pay, whether by salary reduction or
otherwise (required contribution), for self-only coverage does not exceed the
required contribution percentage (as defined in paragraph (c)) of the
applicable tax filer's household income for the benefit year.
(2) Affordability for related individual [56]
Except as provided in paragraph (a)(3) of this subsection, an
eligible employer-sponsored plan is affordable for a related individual if the
portion of the annual premium the employee must pay for self-only coverage does
not exceed the required contribution percentage, as described in (a)(1) of this
subsection.
(3) Employee
safe harbor [57]
An employee or a related individual who is eligible for a
safe harbor as defined in this sub clause will not be subject to repayment of
APTC based on the finding that affordable MEC was in fact available to them for
all or part of a plan year, should such fact be discovered at a time subsequent
to enrollment in a QHP.
(i) An
employer-sponsored plan is not affordable for an employee or a related
individual for a plan year if, when the employee or a related individual
enrolls in a QHP for a period coinciding with the plan year (in whole or in
part), it is determined that the eligible employer-sponsored plan is not
affordable for that plan year.
(ii)
This paragraph does not apply to a determination made as part of the
redetermination process described in § 75.00 unless the individual
receiving a redetermination notification affirmatively responds and provides
current information on affordability.
(iii) This paragraph does not apply for an
individual who, with reckless disregard for the facts, provides incorrect
information concerning the portion of the annual premium for coverage for the
employee or related individual under the plan.
(4) Wellness program incentives [58]
Nondiscriminatory wellness program incentives offered by an
eligible employer-sponsored plan that affect premiums are treated as earned in
determining an employee's required contribution for purposes of affordability
of an eligible employer-sponsored plan to the extent the incentives relate
exclusively to tobacco use. Wellness program incentives that do not relate to
tobacco use or that include a component unrelated to tobacco use are treated as
not earned for this purpose. For purposes of this subsection, the term
"wellness program incentive" has the same meaning as the term "reward" in 26
CFR § 54.9802 - 1(f)(1)(i).
(5) Employer contributions to health
reimbursement arrangements [59]
Amounts newly made available for the current plan year under
a health reimbursement arrangement that an employee may use to pay premiums, or
may use to pay cost-sharing or benefits not covered by the primary plan in
addition to premiums, reduce the employee's required contribution if the health
reimbursement arrangement would be integrated, as that term is used in IRS
Notice 2013-54 (2013-40 IRB 287), with an eligible employer-sponsored plan for
an employee enrolled in the plan. The eligible employer-sponsored plan and the
health reimbursement arrangement must be offered by the same employer. Employer
contributions to a health reimbursement arrangement reduce an employee's
required contribution only to the extent the amount of the annual contribution
is required under the terms of the plan or otherwise determinable within a
reasonable time before the employee must decide whether to enroll in the
eligible employer- sponsored plan.
(6) Employer contributions to cafeteria plans
[60]
Amounts made available for the current plan year under a
cafeteria plan, within the meaning of
26 USC §
125, reduce an employee's or a related
individual's required contribution if:
(i) The employee may not opt to receive the
amount as a taxable benefit;
(ii)
The employee may use the amount to pay for minimum essential coverage;
and
(iii) The employee may use the
amount exclusively to pay for medical care, within the meaning of
26 USC §
213.
(b) Affordability for part-year period [61]
Affordability under paragraph (a)(1) of this subsection is
determined separately for each employment period that is less than a full
calendar year or for the portions of an employer's plan year that fall in
different benefit years of an applicable tax filer (a part-year period). An
eligible employer-sponsored plan is affordable for a part-year period if the
employee's annualized required contribution for self-only coverage under the
plan for the part-year period does not exceed the required contribution
percentage of the applicable tax filer's household income for the benefit year.
The employee's annualized required contribution is the employee's required
contribution for the part-year period times a fraction, the numerator of which
is 12 and the denominator of which is the number of months in the part-year
period during the applicable tax filer's benefit year. Only full calendar
months are included in the computation under this paragraph.
(c) Required contribution percentage [62]
The required contribution percentage for 2014 is 9.5 percent.
For plan years beginning in a calendar year after 2014, the percentage will be
adjusted by the ratio of premium growth to income growth for the preceding
calendar year and may be further adjusted to reflect changes to the data used
to compute the ratio of premium growth to income growth for the 2014 calendar
year or the data sources used to compute the ratio of premium growth to income
growth. Premium growth and income growth will be determined under IRS-published
guidance. In addition, the percentage may be adjusted for plan years beginning
in a calendar year after 2018 to reflect rates of premium growth relative to
growth in the consumer price index.
(d) Examples [63]
The following examples illustrate the provisions of §
23.02. Unless stated otherwise, in each example the tax filer is single and has
no tax dependents, the employer's plan is an eligible employer-sponsored plan
and provides minimum value, the employee is not eligible for other MEC, and the
tax filer, related individual, and employer-sponsored plan have a calendar
benefit year:
(1) Example 1. Basic
determination of affordability
In 2014 Tax filer C has household income of $ 47,000. C is an
employee of Employer X, which offers its employees a health insurance plan that
requires C to contribute $ 3,450 for self-only coverage for 2014 (7.3 percent
of C's household income). Because C's required contribution for self-only
coverage does not exceed 9.5 percent of household income, under paragraph
(a)(1), X's plan is affordable for C, and C is eligible for MEC for all months
in 2014.
(2) Example 2.
Basic determination of affordability for a related individual
The facts are the same as in Example 1, except that C is
married to J and X's plan requires C to contribute $ 5,300 for coverage for C
and J for 2014 (11.3 percent of C's household income). Because C's required
contribution for self-only coverage ($ 3,450) does not exceed 9.5 percent of
household income, under paragraph (a)(2) of this subsection, X's plan is
affordable for C and J, and C and J are eligible for minimum essential coverage
for all months in 2014.
(3)
Example 3.
Determination of unaffordability at enrollment
(i) Tax filer D is an employee of Employer X.
In November 2013 AHS projects that D's 2014 household income will be $ 37,000.
It also verifies that D's required contribution for self-only coverage under
X's health insurance plan will be $ 3,700 (10 percent of household income).
Consequently, AHS determines that X's plan is unaffordable. D enrolls in a QHP
and not in X's plan. In December 2014, X pays D a $ 2,500 bonus. Thus, D's
actual 2014 household income is $ 39,500 and D's required contribution for
coverage under X's plan is 9.4 percent of D's household income.
(ii) Based on D's actual 2014 household
income, D's required contribution does not exceed 9.5 percent of household
income and X's health plan is affordable for D. However, when D enrolled in a
QHP for 2014, AHS determined that X's plan was not affordable for D for 2014.
Consequently, under paragraph (a)(3), X's plan is not affordable for D and D is
not eligible for MEC under X's plan for 2014.
(4) Example 4. Determination of
unaffordability for plan year
The facts are the same as in Example 3, except that X's
employee health insurance plan year is September 1 to August 31. AHS determines
in August 2014 that X's plan is unaffordable for D based on D's projected
household income for 2014. D enrolls in a QHP as of September 1, 2014. Under
paragraph (a)(3), X's plan is not affordable for D and D is not eligible for
MEC under X's plan for the coverage months September to December 2014 and
January through August 2015.
(5) Example 5. No affordability information
affirmatively provided for annual redetermination.
(i) The facts are the same as in Example 3,
except AHS redetermines D's eligibility for APTCs for 2015. D does not
affirmatively provide AHS with current information regarding affordability and
AHS determines that D's coverage is not affordable for 2015 and approves APTCs
based on information from the previous enrollment period. In 2015, D's required
contribution for coverage under X's plan is 9.4 percent of D's household
income.
(ii) Because D does not
respond to AHS's notification and AHS makes an affordability determination
based on information from an earlier year, the employee safe harbor in
paragraph (a)(3) does not apply. D's required contribution for 2015 does not
exceed 9.5 percent of D's household income. Thus, X's plan is affordable for D
for 2015 and D is eligible for MEC for all months in 2015.
(6) Example 6.
Determination of unaffordability for part of plan year
(part-year period)
(i) Tax filer E is
an employee of Employer X beginning in May 2015. X's employee health insurance
plan year is September 1 to August 31. E's required contribution for self-only
coverage for May through August is $ 150 per month ($ 1,800 for the full plan
year). AHS projects E's household income for purposes of eligibility for APTCs
as $ 18,000. E's actual household income for the 2015 benefit year is $
20,000.
(ii) Under paragraph (b) of
this subsection, whether coverage under X's plan is affordable for E is
determined for the remainder of X's plan year (May through August). E's
required contribution for a full plan year ($ 1,800) exceeds 9.5 percent of E's
household income (1,800/18,000 = 10 percent). Therefore, AHS determines that
X's coverage is unaffordable for May through August. Although E's actual
household income for 2015 is $ 20,000 (and E's required contribution of $ 1,800
does not exceed 9.5 percent of E's household income), under paragraph (a)(3),
X's plan is unaffordable for E for the part of the plan year May through August
2015. Consequently, E is not eligible for MEC under X's plan for the period May
through August 2015.
(7)
Example 7.
Affordability determined for part of a benefit year (part-
year period)
(i) Tax filer F is an
employee of Employer X. X's employee health insurance plan year is September 1
to August 31. F's required contribution for self-only coverage for the period
September 2014 through August 2015 is $ 150 per month or $ 1,800 for the plan
year. F does not enroll in X's plan during X's open season but enrolls in a QHP
for September through December 2014. F does not request APTCs and does not ask
AHS to determine whether X's coverage is affordable for F. F's household income
in 2014 is $ 18,000.
(ii) Because F
is a calendar year tax filer and Employer X's plan is not a calendar year plan,
F must determine the affordability of X's coverage for the part-year period in
2014 (September-December) under paragraph (b) of this subsection. F determines
the affordability of X's plan for the September through December 2014 period by
comparing the annual premiums ($ 1,800) to F's 2014 household income. F's
required contribution of $ 1,800 is 10 percent of F's 2014 household income.
Because F's required contribution exceeds 9.5 percent of F's 2014 household
income, X's plan is not affordable for F for the part-year period September
through December 2014 and F is not eligible for MEC under X's plan for that
period.
(iii) F enrolls in coverage
for 2015 and does not ask AHS to approve APTCs or determine whether X's
coverage is affordable. F's 2015 household income is $ 20,000.
(iv) F must determine if X's plan is
affordable for the part-year period January 2015 through August 2015. F's
annual required contribution ($ 1,800) is 9 percent of F's 2015 household
income. Because F's required contribution does not exceed 9.5 percent of F's
2015 household income, X's plan is affordable for F for the part-year period
January through August 2015 and F is eligible for MEC for that
period.
(8) Example 8.
Coverage unaffordable at year end
Tax filer G is employed by Employer X. In November 2014, AHS
determines that G is eligible for affordable employer-sponsored coverage for
2015. G nonetheless enrolls in a QHP for 2015 but does not receive APTC. G's
2015 household income is less than expected and G's required contribution for
employer-sponsored coverage for 2015 exceeds 9.5 percent of G's actual 2015
household income. Under paragraph (a)(1) of this subsection, G is not eligible
for MEC under X's plan for 2015.
(9) Example 9. Wellness program incentives
(i) Employer X offers an eligible
employer-sponsored plan with a nondiscriminatory wellness program that reduces
premiums by $ 300 for employees who do not use tobacco products or who complete
a smoking cessation course. Premiums are reduced by $ 200 if an employee
completes cholesterol screening within the first six months of the plan year.
Employee B does not use tobacco and the cost of his premiums is $ 3,700.
Employee C uses tobacco and the cost of her premiums is $ 4,000.
(ii) Under paragraph (a)(4) of this
subsection, only the incentives related to tobacco use are counted toward the
premium amount used to determine the affordability of X's plan. C is treated as
having earned the $ 300 incentive for attending a smoking cessation course
regardless of whether C actually attends the course. Thus, the required
contribution for determining affordability for both Employee B and Employee C
is $ 3,700. The $ 200 incentive for completing cholesterol screening is treated
as not earned and does not reduce their required contribution.
Section
23.03 Minimum value for employer-sponsored MEC [64]
(01/15/2017, GCR 16- 096)
An individual will not be eligible for a federal premium tax
credit if the employer-sponsored plan in which they may enroll provides minimum
value. An eligible employer-sponsored plan provides minimum value only if the
percentage of the total allowed costs of benefits provided under the plan is
greater than or equal to 60 percent, and the benefits under the plan include
substantial coverage of inpatient hospital services and physician
services.
Section 23.04
Enrollment in eligible employer-sponsored plan
(01/15/2017, GCR 16- 096)
(a) In general [65]
Except as provided in paragraph (b) of this subsection, the
requirements of affordability and minimum value do not apply for months that an
individual is enrolled in an eligible employer-sponsored plan.
(b) Automatic enrollment [66]
An employee or related individual is treated as not enrolled
in an eligible employer-sponsored plan for a month in a plan year or other
period for which the employee or related individual is automatically enrolled
if the employee or related individual terminates the coverage before the later
of the first day of the second full calendar month of that plan year or other
period or the last day of any permissible opt-out period provided by the
employer-sponsored plan or in regulations to be issued by the Department of
Labor, for that plan year or other period.
(c) Examples [67]
The following examples illustrate the provisions of this
subsection:
(1) Example 1. Tax filer H
is employed by Employer X in 2014.
H's required contribution for self-only employer coverage
exceeds 9.5 percent of H's 2014 household income. H enrolls in X's calendar
year plan for 2014. Under paragraph (a) of this subsection, H is eligible for
MEC for 2014 because H is enrolled in an eligible employer-sponsored plan for
2014.
(2) Example 2. The
facts are the same as in Example 1, except that H terminates plan coverage on
June 30, 2014.
Under paragraph (a) of this subsection, H is eligible for MEC
under X's plan for January through June 2014 but is not eligible for MEC under
X's plan for July through December 2014.
(3) Example 3. The facts are the same as in
Example 1, except that Employer X automatically enrolls H in the plan for
calendar year 2015.
H terminates the coverage on January 20, 2015. Under
paragraph (b) of this subsection, H is not eligible for MEC under X's plan for
January 2015.
Section 23.05 Related individual not claimed
as a personal exemption deduction [68]
(01/15/2017, GCR 16-096)
An individual who may enroll in MEC because of a relationship
to another person eligible for the coverage, but for whom the other eligible
person does not claim a personal exemption deduction, is treated as eligible
for MEC under the coverage only for months that the related individual is
enrolled in the coverage.
Section
23.06 Eligibility determinations for MEC exemptions
(01/15/2017, GCR 16-096)
(a) Definitions and general requirements [69]
Anything in § 23.06 to the contrary notwithstanding, AHS
will adopt an exemption eligibility determination made by HHS.
(1) Definitions
As used in this § 23.06, the following terms have the
following meanings:
(i) Applicant
An individual who is seeking an exemption for themselves
through an application submitted to AHS.
(ii) Application filer
An applicant, an individual who is liable for the shared
responsibility payment for an applicant, an authorized representative, or, if
the applicant is a minor or incapacitated, someone acting responsibly for an
applicant.
(iii) Exemption
An exemption from the shared responsibility payment.
(iv) Health care sharing ministry
[70]
An organization:
(A)
Which is described in §
501(c)(3)
of the Code and is exempt from taxation under §
501(a)
of the Code;
(B) Members of which
share a common set of ethical or religious beliefs and share medical expenses
among members in accordance with those beliefs and without regard to the state
in which a member resides or is employed;
(C) Members of which retain membership even
after they develop a medical condition;
(D) Which (or a predecessor of which) has
been in existence at all times since December 31, 1999, and medical expenses of
its members have been shared continuously and without interruption since at
least December 31, 1999; and
(E)
Which conducts an annual audit which is performed by an independent certified
public accounting firm in accordance with generally accepted accounting
principles and which is made available to the public upon request.
(v) Indian tribe [71]
Any Indian tribe, band, nation, pueblo, or other organized
group or community, including any Alaska Native village, or regional or village
corporation, as defined in, or established pursuant to, the Alaska Native
Claims Settlement Act (
43 USC §
1601 et seq.) which is recognized as eligible
for the special programs and services provided by the United States to Indians
because of their status as Indians.
(vi) Required contribution [72]
(A) In the case of an individual eligible to
purchase MEC consisting of coverage through an eligible-employer- sponsored
plan, the portion of the annual premium which would be paid by the individual
(without regard to whether paid through salary reduction or otherwise) for
self-only coverage; or
(B) In the
case of an individual eligible only to purchase MEC under a health plan offered
in the individual market within the state, the annual premium for the lowest
cost bronze plan available in the individual market through the Exchange in the
state in the rating area in which the individual resides (without regard to
whether the individual purchased a qualified health plan through the Exchange),
reduced by the amount of the credit allowable for the taxable year (determined
as if the individual was covered by a qualified health plan offered through the
Exchange for the entire taxable year).
(vii) Required contribution percentage
The product of eight percent and the rate of premium growth
over the rate of income growth for the calendar year, rounded to the nearest
one-hundredth of one percent.
(viii) Shared responsibility payment
The payment (penalty) imposed by the IRS with respect to a
non- exempt individual who does not maintain MEC.
(ix) Tax filer
Has the same meaning as it does in § 3.00.
(2) Attestation
For purposes of this subsection, any attestation that an
applicant is to provide under this subsection may be made by the application
filer on behalf of the applicant.
(3) Reasonably compatible
For purposes of this subsection, AHS will consider
information through electronic data sources, other information provided by the
applicant, or other information in AHS's records to be reasonably compatible
with an applicant's attestation if the difference or discrepancy does not
impact the eligibility of the applicant for the exemption or exemptions for
which they applied.
(4)
Accessibility
Information, including notices, form, and applications, must
be provided to applicants in accordance with the standards specified in §
5.01(c).
(5) Notices
Any notice required to be sent by AHS to an individual in
accordance with this subsection must be provided in accordance with the
standards specified in § 67.00(a).
(b) Eligibility standards for exemptions [73]
(1) Eligibility for an exemption
Except as specified in (7) of this paragraph (b), AHS will
determine an applicant eligible for and issue a certificate of exemption for
any month if AHS determines that the applicant meets the requirements for one
or more of the categories of exemptions described in this paragraph for at
least one day of the month.
(2) Duration of single exemption
Except as specified in (3)(ii), (6)(ii), and (7) of this
paragraph (b), AHS may provide a certificate of exemption only for the calendar
year in which an applicant submitted an application for such exemption.
(3) Religious conscience
(i) AHS will determine an applicant eligible
for an exemption for any month if the applicant is a member of a recognized
religious sect or division described in
26
USC §
1402(g)(1) and
(3)(iv) of this paragraph (b), and an
adherent of established tenets or teachings of such sect or division for such
month.
(ii) Duration of exemption
for religious conscience.
(A) AHS will grant
the certificate of exemption specified in this paragraph (b)(3) to an applicant
who meets the standards provided in (i) above for a month on a continuing
basis, until the month after the month of the individual's 21st birthday, or
until such time that an individual reports that they no longer meet those
standards.
(B) If AHS granted a
certificate of exemption in this category to an applicant prior to their
reaching the age of 21, AHS will send the applicant a notice upon reaching the
age of 21 informing the applicant that they must submit a new exemption
application to maintain the certificate of exemption.
(iii) AHS will make an exemption in this
category available prospectively or retrospectively.
(iv) For purposes of exemption in this
category, AHS must determine that:
(A) Such
sect or division thereof has the established tenets or teachings referred in
(i) of this paragraph (b)(3);
(B)
That it is the practice, and has been for a period of time which AHS deems to
be substantial, for members of such sect or division thereof to make provision
for their dependent members which, in AHS's judgment, is reasonable in view of
their general level of living; and
(C) Such sect or division thereof has been in
existence at all times since December 31, 1950.
(4) Membership in a health care sharing
ministry
(i) AHS will determine an applicant
eligible for an exemption for a month if for such month the applicant is a
member of a health care sharing ministry as defined in §
26.03(a)(1)(iv).
(ii) AHS will make
an exemption in this category available only retrospectively.
(5) Incarceration
(i) AHS will determine an applicant eligible
for an exemption for a month if the applicant is incarcerated, other than
incarceration pending the disposition of charges, for such month.
(ii) AHS will make an exemption in this
category available only retrospectively.
(6) Membership in an Indian tribe
(i) AHS will determine an applicant eligible
for an exemption for any month if they are a member of an Indian tribe, as
defined in § 26.03(a)(1)(v), for such month.
(ii) Duration of exemption for membership in
an Indian tribe. AHS will grant the exemption specified in this paragraph
(b)(6) to an applicant who meets the standards specified in (i) above for a
month on a continuing basis, until such time that the applicant reports that
they no longer meet those standards.
(iii) AHS will make an exemption available in
this category prospectively or retrospectively.
(7) Hardship
(i) General. AHS will grant a hardship
exemption to an applicant eligible for an exemption for at least the month
before, a month or months during which, and the month after, if AHS determines
that:
(A) The applicant experienced financial
or domestic circumstances, including an unexpected natural or human-caused
event, such that they had a significant, unexpected increase in essential
expenses that prevented them from obtaining coverage under a QHP;
(B) The expense of purchasing a QHP would
have caused the applicant to experience serious deprivation of food, shelter,
clothing or other necessities; or
(C) The applicant experienced other
circumstances that prevented them from obtaining coverage under a QHP,
including:
(I) They became homeless;
(II) They were evicted in the past six
months, or are facing eviction or foreclosure;
(III) They received a shut-off notice from a
utility company;
(IV) They recently
experienced domestic violence;
(V)
They recently experienced the death of a close family member;
(VI) They recently experienced a fire, flood,
or other natural or human-caused disaster that resulted in substantial damage
to their property;
(VII) They filed
for bankruptcy in the last 6 months;
(VIII) They incurred unreimbursed medical
expenses in the last 24 months that resulted in substantial debt;
(IX) They experienced unexpected increases in
essential expenses due to caring for an ill, disabled, or aging family
member;
(X) They are a child who
has been determined ineligible for Medicaid and CHIP, and for whom a party
other than the party who expects to claim them as a tax dependent is required
by court order to provide medical support. This exemption should only be
provided for the months during which the medical support order is in effect;
or
(XI) As a result of an
eligibility appeals decision, they are determined eligible for enrollment in a
QHP, APTC or CSR for a period of time during which they were not enrolled in a
QHP. This exemption should only be provided for the period of time affected by
the appeals decision.
(ii) Lack of affordable coverage based on
projected income. AHS will determine an applicant eligible for an exemption for
a month or months during which they, or another individual they attest will be
included in their household, are unable to afford coverage in accordance with
the standards specified in § 5000A(e)(1) of the Code (the individual's
required contribution for MEC for the month (determined on an annual basis)
exceeds the required contribution percentage of the individual's household
income), provided that:
(A) Eligibility for
this exemption is based on projected annual household income;
(B) An eligible employer-sponsored plan is
only considered under (ii)(C) and (ii)(D) of this paragraph (b)(7) if it meets
the minimum value standard described in § 23.03.
(C) For an individual who is eligible to
purchase coverage under an eligible employer-sponsored plan, AHS determines the
required contribution for coverage such that:
(I) An individual who uses tobacco is treated
as not earning any premium incentive related to participation in a wellness
program designed to prevent or reduce tobacco use that is offered by an
eligible employer-sponsored plan;
(II) Wellness incentives offered by an
eligible employer-sponsored plan that do not relate to tobacco use are treated
as not earned;
(III) In the case of
an employee who is eligible to purchase coverage under an eligible employer-
sponsored plan sponsored by the employee's employer, the required contribution
is the portion of the annual premium that the employee would pay (whether
through salary reduction or otherwise) for the lowest cost self-only
coverage.
(IV) In the case of an
individual who is eligible to purchase coverage under an eligible employer-
sponsored plan as a member of the employee's household, the required
contribution is the portion of the annual premium that the employee would pay
(whether through salary reduction or otherwise) for the lowest cost family
coverage that would cover the employee and all other individuals who are
included in the employee's household who have not otherwise been granted an
exemption.
(D) For an
individual who is ineligible to purchase coverage under an eligible
employer-sponsored plan, AHS will determine the required contribution for
coverage in accordance with § 23.06(a)(1)(vi)(B), inclusive of all members
of the household who have not otherwise been granted an exemption and who are
not treated as eligible to purchase coverage under an eligible
employer-sponsored plan, in accordance with (ii)(B) of this paragraph (b)(7);
and
(E) The applicant applies for
this exemption prior to the last date on which they could enroll in a QHP for
the month or months of a calendar year for which the exemption is
requested.
(F) AHS will make an
exemption in this category available prospectively, and provide it for all
remaining months in a coverage year, notwithstanding any change in an
individual's circumstances.
(iii) Ineligible for Medicaid based on a
state's decision not to expand. AHS will determine an applicant eligible for an
exemption for a calendar year if they have been determined ineligible for
Medicaid for one or more months during the benefit year solely as a result of a
state not implementing §
2001(a)
of the ACA;
(iv) Eligible for
services through an Indian health care provider.
(A) AHS will determine an applicant eligible
for an exemption for any month if they are an Indian eligible for services
through an Indian health care provider, as defined in (C) below, and not
otherwise eligible for an exemption under paragraph (b)(6) or an individual
eligible for services through the Indian Health Service in accordance with
25 USC
§§
1680 c(a), (b), or
(d)(3).
(B) AHS will grant the
exemption specified in this (7)(iv) of this paragraph (b) to an applicant who
meets the standards specified in (A) above for a month on a continuing basis,
until such time that the applicant reports that they no longer meet those
standards.
(C) For purposes of (A)
above, Indian health care provider means a health care program operated by the
Indian Health Service (IHS) or by an Indian Tribe, Tribal Organization, or
Urban Indian Organization (otherwise known as an I/T/U) as those terms are
defined in section
4 of
the Indian Health Care Improvement Act (
25
USC §
1603) [74].
(D) The IRS may allow an applicant to claim
the exemption specified in this (7)(iv) of this paragraph (b) without obtaining
an exemption certificate from AHS.
(v) Filing threshold. The IRS may allow an
applicant to claim an exemption without obtaining an exemption certificate from
AHS for a taxable year if, for such year, the applicant could not be claimed as
a dependent by another taxpayer and the applicant's gross income was less than
the applicant's applicable return filing threshold.
(vi) Self-only coverage in an eligible
employer-sponsored plan. The IRS may allow an applicant to claim an exemption
for a calendar year if they, as well as one or more employed members of their
family, has been determined eligible for affordable self-only employer-
sponsored coverage through their respective employers for one or more months
during the calendar year, but the aggregate cost of employer-sponsored coverage
for all the employed members of the family exceeds the required contribution
percentage of household income for that calendar year.
(vii) Enrolled in Medicaid coverage as
medically needy after meeting a spenddown. AHS will determine an applicant
eligible for an exemption for any month the applicant is enrolled in Medicaid
coverage as medically needy after meeting a spenddown.
(c) Eligibility process for
exemptions [75]
(1) Application
Except as specified in (2) and (3) of this paragraph (c), AHS
will use an application established by HHS to collect information necessary for
determining eligibility for and granting certificates of exemption as described
in § 23.06(b).
(2)
Alternative application
If AHS seeks to use an alternative application, such
application, as approved by HHS, must request the minimum information necessary
for the purposes identified in (1) of this paragraph (c).
(3) Exemptions through the eligibility
process for coverage
If an individual submits the application described in §
52.02 and then requests an exemption, AHS will use information collected for
purposes of the eligibility determination for enrollment in a QHP and health-
benefits programs in making the exemption eligibility determination, and will
not request duplicate information or conduct repeat verifications to the extent
that AHS finds that such information is still applicable, where the standards
for such verifications adhere to the standards specified in this
subsection.
(4) Filing the
exemption application
AHS will:
(i) Accept
the application from an application filer; and
(ii) Provide the tools to file an
application.
(5)
Collection of Social Security numbers
(i) AHS
will require an applicant who has a Social Security number to provide such
number.
(ii) AHS will not require
an individual who is not seeking an exemption for themselves to provide a
Social Security number, except as specified in (5)(iii) of this paragraph
(c).
(iii) AHS must require an
application filer to provide the Social Security number of a tax filer who is
not an applicant only if an applicant attests that the tax filer has a Social
Security number and filed a tax return for the year for which tax data would be
utilized for verification of household income and family size for an exemption
under § 23.06(b)(7)(ii) that requires such verification.
(6) Determination of eligibility;
granting of certificates
AHS will determine an applicant's eligibility for an
exemption in accordance with the standards specified in § 23.06(b), and
grant a certificate of exemption to any applicant determined eligible.
(7) Timeliness standards
(i) AHS will determine eligibility for
exemption promptly and without undue delay.
(ii) AHS will assess the timeliness of
eligibility determinations made under this subsection based on the period from
the date of application to the date AHS notifies the applicant of its
decision.
(8) Exemptions
for previous tax years
(i) Except for the
exemptions described in §§ 23.06(b)(3), (6), and (7), after December
31 of a given calendar year, AHS will not accept an application for an
exemption that is available retrospectively for months for such calendar year,
and must provide information to individuals regarding how to claim an exemption
through the tax filing process.
(ii) AHS will only accept an application for
an exemption described in § 23.06(b)(7)(i) during one of the 3 calendar
years after the month or months during which the applicant attests that the
hardship occurred.
(9)
Notification of eligibility determination for exemptions
AHS will provide timely written notice to an applicant of any
eligibility determination made in accordance with this subsection. In the case
of a determination that an applicant is eligible for an exemption, this
notification must include the exemption certificate number for the purposes of
tax administration.
(10)
Retention of records for tax compliance
(i)
AHS will notify an individual to retain the records that demonstrate receipt of
the certificate of exemption and qualification for the underlying
exemption.
(ii) In the case of any
factor of eligibility that is verified through use of the special circumstances
exception described in § 23.06(d)(8), the records that demonstrate
qualification for the underlying exemption are the information submitted to AHS
regarding the circumstances that warranted the use of the exception, as well as
records of AHS's decision to allow such exception.
(d) Verification process related
to eligibility for exemptions [76]
(1) General
rule
Unless a request for modification is granted under (9) of
this paragraph (d), AHS will verify or obtain information as provided in this
paragraph (d) in order to determine that an applicant is eligible for an
exemption.
(2) Verification
related to exemption for religious conscience
For any applicant who requests an exemption based on
religious conscience, AHS will verify that the applicant meets the standards
specified in § 23.06(b)(3) by:
(i) Except as specified in (ii) below,
accepting a form that reflects that the applicant is exempt from Social
Security and Medicare taxes under § 1402(g)(1) of the Code;
(ii) Except as specified in paragraphs (iii)
and (iv) below, accepting their attestation of membership in a religious sect
or division, and verifying that the religious sect or division to which the
applicant attests membership is recognized by the SSA as an approved religious
sect or division under § 1402(g)(1) of the Code.
(iii) If information provided by an applicant
regarding their membership in a religious sect or division is not reasonably
compatible with other information provided by the individual or in AHS's
records, AHS will follow the procedures specified in (7) of this paragraph
(d).
(iv) If an applicant attests
to membership in a religious sect or division that is not recognized by the SSA
as an approved religious sect or division under § 1402(g)(1) of the Code,
AHS will provide the applicant with information regarding how their religious
sect or division can pursue recognition under § 1402(g)(1) of the Code,
and determine the applicant ineligible for this exemption until such time as
AHS obtains information indicating that the religious sect or division has been
approved.
(3)
Verification related to exemption for membership in a health care sharing
ministry
(i) For any applicant who requests
an exemption based on membership in a health care sharing ministry, AHS will
verify that the applicant meets the standards specified in § 23.06(b)(4)
by, except as provided in (A) and (B) below, accepting their attestation; and
verifying that the health care sharing ministry to which the applicant attests
membership is known to AHS as a valid health care sharing ministry based on
data provided by HHS:
(A) If information
provided by an applicant regarding their membership in a health care sharing
ministry is not reasonably compatible with other information provided by the
individual or in AHS's records, AHS will follow the procedures specified in (7)
of this paragraph (d). AHS will not consider an applicant's prior or current
enrollment in health coverage as not reasonably compatible with an applicant's
attestation of membership in a health care sharing ministry.
(B) If an applicant attests to membership in
a health care sharing ministry that is not known to AHS as a health care
sharing ministry based on information provided by HHS, AHS will provide the
applicant with information regarding how an organization can pursue recognition
under (ii) below, and determine the applicant ineligible for this exemption
until such time as HHS notifies AHS that the health care sharing ministry meets
the standards specified in § 5000A(d)(2)(B)(ii) of the Code.
(ii) To be considered a health
care sharing ministry for the purposes of this subsection, an organization must
submit information to HHS that substantiates the organization's compliance with
the standards specified in § 5000A(d)(2)(B)(ii) of the Code. If at any
time HHS determines that an organization previously considered a health care
sharing ministry for the purposes of this subsection no longer meets the
standards specified in § 5000A(d)(2)(B)(ii) of the Code, HHS may revoke
its earlier decision regarding the status of the health care sharing
ministry.
(4)
Verification related to exemption for incarceration
(i) For any applicant who provides
information attesting that they were incarcerated for a given month in
accordance with the standards specified in § 23.06(b)(5), AHS will verify
their attestation through the same process as described in §
55.02(b).
(ii) To the extent that
AHS is unable to verify an applicant's attestation that they were incarcerated
for a given month in accordance with the standards specified in §
23.06(b)(5) through the process described in § 55.02(b), AHS will follow
the procedures specified in (7) of this paragraph (d).
(5) Verification related to exemption for
members of Indian tribes
(i) For any
applicant who provides information attesting that they are a member of an
Indian tribe, AHS will use the process outlined in § 59.03 to verify that
the applicant is a member of an Indian tribe.
(ii) To the extent that AHS is unable to
verify an applicant's status as a member of an Indian tribe through the process
described in § 59.03, AHS will follow the procedures specified in (7) of
this paragraph (d).
(6)
Verification related to exemption for hardship
(i) In general. For any applicant who
requests an exemption based on hardship, AHS will verify whether the applicant
has experienced the hardship to which they are attesting.
(ii) Lack of affordable coverage based on
projected income.
(A) For any applicant who
requests an exemption based on the hardship described in §
23.06(b)(7)(ii), AHS will verify the unavailability of affordable coverage
through the procedures used to determine eligibility for APTC, including the
procedures described in § 55.04(a), and the procedures used to verify
eligibility for qualifying coverage in an eligible employer-sponsored plan, as
specified in § 55.02(d), except as specified in (B) below.
(B) AHS will accept an application filer's
attestation for an applicant regarding eligibility for MEC other than through
an eligible employer-sponsored plan, instead of following the procedures
specified in § 55.02(c).
(iii) Eligible for services through an Indian
health care provider. For any applicant who requests an exemption based on the
hardship described in § 23.06(b)(7)(iv), AHS will verify whether the
applicant meets the standards specified in § 23.06(b)(7)(iv) through the
same process described in (5) of this paragraph (d).
(iv) To the extent that AHS is unable to
verify any of the information needed to determine an applicant's eligibility
for an exemption based on hardship, AHS will follow the procedures specified in
(7) of this paragraph (d).
(7) Inability to verify necessary information
Except as otherwise specified in this subsection, for an
applicant for whom AHS cannot verify information required to determine
eligibility for an exemption, including but not limited to when electronic data
is required in accordance with this subsection but data for individuals
relevant to the eligibility determination for an exemption are not included in
such data sources or when electronic data is required but it is not reasonably
expected that data sources will be available within the time period as
specified in § 57.00(b), AHS:
(i)
Will make a reasonable effort to identify and address the causes of such
inconsistency, including typographical or other clerical errors, by contacting
the application filer to confirm the accuracy of the information submitted by
the application filer;
(ii) If
unable to resolve the inconsistency through the process described in (i) above,
will:
(A) Provide notice to the applicant
regarding the inconsistency; and
(B) Provide the applicant with a period of 90
days from the date on which the notice described in (A) above is sent to the
applicant to either present satisfactory documentary evidence via the channels
available for the submission of an application (except for by telephone) or
otherwise to resolve the inconsistency.
(iii) May extend the period described in
(ii)(B) above for an applicant if the applicant demonstrates that a good faith
effort has been made to obtain the required documentation during the
period.
(iv) During the period
described in (i) and (ii)(B) above, must not grant a certificate of exemption
based on the information subject to (7) of paragraph (d).
(v) If, after the period described in
paragraph (ii)(B) above, AHS remains unable to verify the attestation, AHS will
determine the applicant's eligibility for an exemption based on any information
available from the data sources used in accordance with this subsection, if
applicable, unless such applicant qualifies for the exception provided under
(8) of this paragraph (d), and notify the applicant of such determination,
including notice that AHS is unable to verify the attestation.
(8) Exception for special
circumstances
For an applicant who does not have documentation with which
to resolve the inconsistency through the process described in (7)(ii) of this
paragraph (d) because such documentation does not exist or is not reasonably
available and for whom AHS is unable to otherwise resolve the inconsistency,
AHS may provide an exception, on a case-by-case basis, to accept an applicant's
attestation as to the information which cannot otherwise be verified along with
an explanation of circumstances as to why the applicant does not have
documentation.
(9)
Flexibility in information collection and verification
HHS may approve modification to the methods to be used by AHS
for collection of information and verification as set forth in this subsection,
as well as the specific information required to be collected, provided that HHS
finds that such modification would reduce the administrative costs and burdens
on individuals while maintaining accuracy and minimizing delay, and that
applicable requirements under (10) of this paragraph (d), §§ 4.08 and
4.09, and § 6103 of the Code with respect to the confidentiality,
disclosure, maintenance, or use of such information will be met.
(10) Applicant information
AHS will not require an applicant to provide information
beyond the minimum necessary to support the eligibility process for exemptions
as described in this subsection.
(11) Validation of Social Security number
(i) For any individual who provides their
Social Security number to AHS, AHS must transmit the Social Security number and
other identifying information to HHS, which will submit it to the
SSA.
(ii) To the extent that AHS is
unable to validate an individual's Social Security number through the SSA, or
the SSA indicates that the individual is deceased, AHS will follow the
procedures specified in (7) of this paragraph (d), except that AHS will provide
the individual with a period of 90 days from the date on which the notice
described in (7)(ii)(A) is received for the applicant to provide satisfactory
documentary evidence or resolve the inconsistency with the SSA. The date on
which the notice is received means 5 days after the date on the notice, unless
the individual demonstrates that they did not receive the notice within the 5
day period.
(e) Eligibility redeterminations for
exemptions during a calendar year [77]
(1)
General requirement
AHS will redetermine the eligibility of an individual with an
exemption granted by AHS if it receives and verifies new information reported
by such an individual, except for the exemption described in §
23.06(b)(7)(ii).
(2)
Requirement for individuals to report changes
(i) Except as specified in (ii) below, AHS
will require an individual who has a certificate of exemption from AHS to
report any change with respect to the eligibility standards for the exemption
as specified in § 23.06(b), except for the exemption described in §
23.06(b)(7)(ii), within 30 days of such change.
(ii) AHS will allow an individual with a
certificate of exemption to report changes via the channels available for the
submission of an application, as described in § 23.06(c)(4).
(3) Verification of reported
changes
AHS will:
(i) Verify
any information reported by an individual with a certificate of exemption in
accordance with the processes specified in § 23.06(d) prior to using such
information in an eligibility redetermination.
(ii) Notify an individual in accordance with
§ 23.06(c)(9) after redetermining their eligibility based on a reported
change.
(iii) Provide periodic
electronic notifications regarding the requirements for reporting changes and
an individual's opportunity to report any changes, to an individual who has a
certificate of exemption for which changes must be reported in accordance with
(2) of this paragraph (e) and who has elected to receive electronic
notifications, unless they have declined to receive such
notifications.
(4)
Effective date of changes
AHS will implement a change resulting from a redetermination
under this paragraph for the month or months after the month in which the
redetermination occurs, such that a certificate that was provided for the month
in which the redetermination occurs, and for prior months remains
effective.
(f)
[Reserved]
(g) Reporting [78]
(requirement to provide information related to tax administration)
If AHS grants an individual a certificate of exemption in
accordance with § 23.06(c)(9), AHS will transmit to the IRS at such time
and in such manner as the IRS may specify:
(1) The individual's name, Social Security
number, and exemption certificate number;
(2) Any other information required in
guidance published by the Secretary of the Treasury in accordance with
26 CFR §
601.601(d)(2).
(h) Right to appeal [79]
(1) For an eligibility determination made by
HHS, the individual will appeal the determination with the HHS appeals entity
if the appeal is limited to a determination of eligibility for an
exemption.80
(2) For an eligibility
determination made by AHS, AHS will include the notice of the right to appeal
and instructions regarding how to file an appeal in any notification issued in
accordance with § 23.06 (c)(9).
Part FOUR SPECIAL RULES FOR MEDICAID COVERAGE OF LONG-TERM
CARE SERVICES AND SUPPORTS - ELIGIBILITY AND POST-ELIGIBILITY
Section 24.00 Patient
Share Payment for Medicaid Coverage of Long-Term Care Services and Supports
(01/15/2017, GCR 16-097)
Section 24.01 In general
(01/15/2017, GCR 16-097)
(a) Definition: patient share [1]
Once AHS determines that an individual is eligible for
Medicaid coverage of long-term care services and supports, it computes how much
of their income must be paid to the long-term care provider each month for the
cost of their care (this is called the "patient share").
A patient share is computed for an individual who qualifies
for Medicaid coverage of long-term care services and supports under MABD in a
medical institution or in a home and community-based setting under a special
income coverage group (see § 8.05(k)) or as medically needy (see §
8.06). An individual's patient share is determined at initial eligibility,
eligibility redeterminations, and when changes in circumstances occur.
(b) Computation of patient share
(1) An individual's patient share is
determined by computing a maximum patient share and deducting allowable
expenses. § 24.03 describes how the maximum patient share is determined.
§ 24.04 describes allowable deductions from the patient share. The actual
patient share payable by the individual is the lesser of:
(i) The balance of the individual's income
remaining after computing the patient share; and
(ii) The cost of care remaining after
third-party payment.
(2)
In cases in which allowable deductions exceed the individual's income, the
patient-share payment is reduced by the deductions, sometimes resulting in no
patient-share obligation, for as many months needed to exhaust the deductions
against the individual's available income. The month when the remaining
deductions no longer exceed the individual's income, the balance is the patient
share payment for that month. When monthly income and allowable deductions are
stable, the patient-share amount remains constant. When income or allowable
deductions fluctuate, the patient-share payment is likely to vary.
(c) Patient share payment
An individual owes their patient share by the last day of the
month in which they receive the income. Payment is made either to the facility
in which the individual resided or to the highest-paid provider of long-term
care services and supports. Patient-share amounts and payments to long-term
care providers may be adjusted when a patient transitions from one setting to
another, as specified in § 24.05.
Section 24.02 Long-term care residence period
(01/15/2017, GCR 16-097)
(a) In general
A patient share obligation is assessed in the month of
admission to long-term care as long as the individual is expected to need
long-term care services and supports for at least 30 consecutive days. If
long-term care services and supports are expected to be needed for fewer than
30 consecutive days, no patient share is assessed. Instead, the individual's
services are covered through Medicaid, other than Medicaid coverage of
long-term care services and supports, if the individual meets medical necessity
criteria (see Medicaid coverage rule §
7103) and
relevant financial, nonfinancial and categorical eligibility criteria.
(b) Duration of the long-term care
residence period
(1) Beginning of long- term
care residence
(i) In a general hospital
setting
A long-term care residence period in a general hospital
setting begins with the first day that the utilization review committee finds
acute hospital care is no longer medically necessary and skilled nursing care
is medically necessary.
(ii) In other long-term care settings
A long-term care residence period in a long-term care
setting, other than a general hospital, begins with the first day that the
utilization review committee finds medical need for long-term care or the date
of admission, whichever is later.
(2) Ending of long-term care residence period
A long-term care residence period ends with the earliest
of:
(i) The individual's date of
death;
(ii) The date of the
individual's discharge from a long-term care living arrangement (as defined in
§ 30.01); or
(iii) The last
day medical need for long-term care is established by the utilization review
committee.
(3) Leave of
absence or transfer
A long-term care residence period is not ended by a leave of
absence from the current setting (see DVHA Rule 7604.
1) . A long-term care residence period also
continues despite transfer from either:
(i)
One long-term care setting to another long-term care setting;
(ii) A general hospital setting (where
skilled nursing care has been continuously authorized while awaiting transfer)
to another long-term care setting; or
(iii) A long-term care setting to a general
hospital setting followed by return to the long-term care setting without an
intervening residence period in a community living arrangement (as defined in
§ 30.01).
(4) Percentage of month in long-term care
The percentage of the month an individual is in long-term
care is determined using the appropriate table below.
Percentage of Month in Long-Term Care: All months except
February
|
Day of the month admitted to long- term care
|
Percentage of the month in long- term care
|
Day of the month admitted to long- term care
|
Percentage of the month in long- term care
|
Day of the month admitted to long- term care
|
Percentage of the month in long- term care
|
|
1
|
100%
|
11
|
67%
|
21
|
33%
|
|
2
|
97%
|
12
|
63%
|
22
|
30%
|
|
3
|
93%
|
13
|
60%
|
23
|
27%
|
|
4
|
90%
|
14
|
57%
|
24
|
23%
|
|
5
|
87%
|
15
|
53%
|
25
|
20%
|
|
6
|
83%
|
16
|
50%
|
26
|
17%
|
|
7
|
80%
|
17
|
47%
|
27
|
13%
|
|
8
|
77%
|
18
|
43%
|
28
|
10%
|
|
9
|
73%
|
19
|
40%
|
29
|
7%
|
|
10
|
70%
|
20
|
37%
|
30-31
|
3%
|
Percentage of Month in Long-Term Care: February
|
Day of the month admitted to long- term care
|
Percentage of the month in long- term care
|
Day of the month admitted to long- term care
|
Percentage of the month in long- term care
|
Day of the month admitted to long- term care
|
Percentage of the month in long-term care
|
|
1
|
100%
|
11
|
64%
|
21
|
29%
|
|
2
|
96%
|
12
|
61%
|
22
|
25%
|
|
3
|
93%
|
13
|
57%
|
23
|
21%
|
|
4
|
89%
|
14
|
54%
|
24
|
18%
|
|
5
|
86%
|
15
|
50%
|
25
|
14%
|
|
6
|
82%
|
16
|
46%
|
26
|
11%
|
|
7
|
79%
|
17
|
43%
|
27
|
7%
|
|
8
|
75%
|
18
|
39%
|
28
|
4%
|
|
9
|
71%
|
19
|
36%
|
29
|
0%
|
|
10
|
68%
|
20
|
32%
|
Section 24.03 Determining maximum patient
share
(01/15/2017, GCR 16-097)
To determine the maximum patient share, the individual's
gross income less allowable deductions as specified in § 24.04 is
considered. This is the most that an individual receiving Medicaid coverage of
long-term care services and supports is obliged to pay toward the cost of their
long-term care services and supports. If an individual was in long-term care
for less than a full month, the maximum patient share is multiplied by the
applicable percentage in the table set forth in § 24.02.
Section 24.04 Allowable deductions from
patient-share
(01/15/2017, GCR 16-097)
(a) Income deductions
When determining the actual patient share payable by an
individual, the following are deducted from the individual's gross
income:
(1) SSI/AABD, AABD only and
Reach Up benefit payments still being received when the person first enters
long-term care;
(2) SSI/AABD
payments intended to be used to maintain the community residence of an
individual temporarily (not to exceed 3 months) in an institution;
(3) Austrian Reparation Payments;
(4) German Reparation Payments;
(5) Japanese and Aleutian Restitution
Payments;
(6) Payments from the
Agent Orange Settlement Fund;
(7)
Radiation Exposure Compensation; and
(8) VA payments for aid and attendance paid
to a veteran residing in a nursing facility or to the veteran's surviving
spouse residing in a nursing facility.
(b) Other deductions
The following items are then deducted from the individual's
patient share in the following order:
(1) A personal-needs allowance (PNA) or
community-maintenance allowance (CMA) (see paragraph (c) of this
subsection);
(2) Home-upkeep
expenses, if applicable (see paragraph (d) of this subsection);
(3) Allocations to a community spouse or
maintenance needs of family members living in the community, if applicable (see
paragraph (e) of this subsection); and
(4) Reasonable medical expenses incurred, if
applicable (see §§ 30.05 and 30.06). For the purposes of this
paragraph (b)(4), "reasonable medical expenses" do not include expenses for
long-term care services and supports received during penalty periods for
Medicaid coverage of long-term care services and supports.
(5) NOTE: Unpaid patient-share obligations
may not be used to reduce a current patient share obligation.
(c) Personal-needs allowance and
community- maintenance allowance
A reasonable amount for clothing and other personal needs of
an individual is deducted from their monthly income, as follows:
(1) For an individual receiving Medicaid
coverage of long-term care services and supports in an institutional setting, a
standard personal needs deduction (PNA) is applied.
(2) For an individual receiving Medicaid
coverage of long-term care services and supports in a home and community-based
setting, a standard community maintenance deduction (CMA) is applied. (NOTE:
Unlike the individual in the institutional setting whose room and board is
covered by Medicaid, an individual receiving long-term care services and
supports in a home and community-based setting has a higher deduction to
provide a reasonable amount for food, shelter, and clothing to meet their
personal needs.)
(d)
Home-upkeep deduction
(1) Expenses from the
monthly income of an individual receiving Medicaid coverage of long-term care
services and supports in an institution or receiving enhanced residential care
(ERC) services in a residential care home are deducted to help maintain their
owned or rented home in the community. This deduction is allowed for six
months. It is available for each separate admission to long-term care, as long
as the criteria listed below are met. The home-upkeep standard deduction is
three-fourths of the SSI/AABD payment level for a single individual living in
the community.
(2) The home-upkeep
deduction is granted when the individual has income equal to or greater than
the standard home-upkeep deduction and greater than their PNA. An individual
who has less income than the standard home-upkeep deduction may deduct an
amount for home upkeep equal to the difference between the individual's income
and the PNA.
(i) The home-upkeep deduction
may be applied at any point during the individual's institutionalization or
receipt of ERC services, as the case may be, as long as both of the following
criteria for the deduction are met:
(A) No
one resides in the individual's home and receives an allocation as a community
spouse or other eligible family member; and
(B) The individual submits a doctor's
statement before the six-month deduction period, stating that the individual is
expected to be discharged from the institution or ERC setting within six months
and to return home immediately after discharge.
(ii) If the situation changes during the
period the individual is receiving the home-upkeep deduction, the individual's
eligibility for the deduction is redetermined. The deduction is denied or ended
when:
(A) The individual's home is sold or
rented;
(B) The rented quarters of
the individual are given up; or
(C)
The individual's health requires the long-term care admission period to last
longer than six months.
(e) Allocations to family members
(1) In general
An individual is allowed to allocate their income to certain
family members as described in this paragraph.
(i) Allocation to community spouse
(A) If an individual receiving Medicaid
coverage of long-term care services and supports (the institutionalized spouse)
has a spouse living in the community (the community spouse), an allocation may
be deducted from the institutionalized spouse's income for the needs of the
community spouse. The term "community spouse" applies to the spouse of the
institutionalized spouse even if the community spouse is also receiving
Medicaid coverage of long-term care services and supports in a home and
community-based setting. When one spouse is receiving Medicaid coverage of
long-term care services and supports in an institutional setting and the other
is receiving Medicaid coverage of long-term care services and supports in a
home and community-based setting, the spouse receiving home and community-based
services and supports may receive an allocation. When both spouses are
receiving home and community-based services and supports, either may allocate
to the other.
(B) "Assisted living"
is considered a community setting and not an institutional setting provided
that assisted living does not include 24- hour care, has privacy, a lockable
door, and is a homelike setting. If the spouse of an institutionalized spouse
is living in an assisted living setting, they are considered a community spouse
for purposes of the community spouse income allocation.
(C) An institutionalized spouse may allocate
less than the full amount of the allocation to their community spouse or may
allocate nothing. The allocation is reduced by the gross income, if any, of the
community spouse. A community spouse, as well as an institutionalized spouse,
has a right to request a fair hearing on the amount of the
allocation.
(D) The standard
community spouse income allocation equals 150 percent of the FPL for two. The
actual community spouse income allocation equals the standard allocation plus
any amount by which actual shelter expenses of the community spouse exceed the
standard allocation, up to a maximum amount. The maximum community spouse
income allocation equals a maximum provided by the federal government each year
by November 1st.
(E) The
presumptions set forth below are applied to the ownership interests in income
when determining a community spouse's community spouse income allocation unless
the institutionalized spouse establishes by a preponderance of the evidence
that the ownership interests are other than as presumed.
(I) Income paid in the name of one spouse is
presumed available only to the named spouse.
(II) Income paid in the name of both spouses
is presumed available in equal shares to each spouse.
(III) Income paid in the name of either
spouse and any other person is presumed available to that spouse in proportion
to their ownership interest.
(IV)
Income paid in the name of both spouses and any other person is presumed
available to each spouse in an amount of one-half of the joint
interest.
(ii) Allocation to other family members
A deduction from the individual's income is allowed for the
following family members unless the countable resources of any such family
member exceed $ 12,000:
(A) Any child
of either the individual or the individual's spouse under age 18; and
(B) Any dependent child, parent, or sibling
of either the individual or the individual's spouse, as specified in (C) or (D)
below. For the purposes of this paragraph, a family member is considered
dependent if they meet each of the following three criteria:
(I) They have been or will be a member of the
household of the individual or their spouse for at least one year;
(II) More than one half of their total
support is provided by the individual or the individual's spouse; and
(III) They have gross annual income below $
2,500 or are a child of the individual (or spouse) under age 19 or under age 24
and a full-time student during any five months of the tax year.
(C) Family members living with the
community spouse. When family members live with the community spouse of the
individual receiving Medicaid coverage of long-term care services and supports
and living in an institution, the deduction equals the maintenance income
standard reduced by the gross income of each family member and divided by
three. The resulting amount is the maximum allocation that may be made to each
family member.
(D) Family members
not living with the community spouse. When family members do not live with the
community spouse of the individual receiving Medicaid coverage of long-term
care services and supports and living in an institution, the deduction equals
the applicable PIL for the number of family members living in the same
household, reduced by the gross income, if any, of the family members in the
household.
(E) NOTE: The family
members described above may be required to apply for SSI, AABD or Reach Up, as
long as this would not disadvantage them financially.
Section
24.05 Transfer between settings
(01/15/2017, GCR 16-097)
(a) In general
An individual receiving long-term care sometimes moves from
one setting to another, such as from one nursing facility to another or from a
nursing facility to a hospital and back to the same or another nursing
facility. The patient share must be paid toward the cost of the individual's
care from income received by the individual during each month of a continuous
period of receiving Medicaid coverage of long-term care services and supports.
As a general rule, the provider giving long-term care services and supports to
the individual on the last day of the preceding month sends the individual a
bill for the individual's share of the cost for that month. Payment is made to
an institution if the individual was receiving Medicaid coverage of long-term
care services and supports in the institution on the last day of the preceding
month. Payment is made to the highest-paid provider of long-term care services
and supports if the individual was receiving Medicaid coverage of long-term
care services and supports in a home and community-based setting on the last
day of the preceding month. If payment of a patient share results in a credit
to the provider, then the provider sends the excess to AHS. Exceptions to this
rule are specified in the paragraphs below.
(b) Hospital admission from nursing facility
An individual receiving Medicaid coverage of long-term care
services and supports who is hospitalized continues to receive Medicaid
coverage of long-term care services and supports, and their patient share
amount is not redetermined. Payment of the patient share is allocated to the
providers as follows:
(1) Acute care
The patient share is paid directly to AHS when the individual
is hospitalized and receiving acute hospital care on the last day of the month
preceding the month in which income is received. Failure to pay the patient
share may result in closure of the individual's eligibility for Medicaid
coverage of long-term care services and supports.
(2) Long-term care
The patient share is paid to the hospital when the individual
is hospitalized and receiving Medicaid coverage of long-term care services and
supports in the hospital on the last day of the month preceding the month in
which income is received.
(c) Transfer from home and community-based
setting to nursing facility
(1) Respite
services
The patient share amount is not adjusted when an individual
receiving Medicaid coverage of long-term care services and supports in a home
and community- based setting enters an institution for respite services. The
patient share is paid to the highest-paid provider of the long-term care
services and supports, even if the individual is in an institution on the last
day of the month.
(2) Other
services
AHS adjusts the patient share amount when an individual
receiving Medicaid coverage of long-term care services and supports in a home
and community- based setting enters an institution for services other than
respite services and has been in the institution for a full calendar month. The
patient share is paid to the institution since the individual was receiving
Medicaid coverage of long-term care services and supports in an institution on
the last day of the month.
(d) Discharge from nursing facility to home
and community-based setting
The patient share amount is adjusted when an individual is in
an institution for more than one full calendar month and discharged to a home
and community- based setting. After the patient-share amount is redetermined
using the community maintenance allowance (see § 24.04(c)), the first
month's patient share is paid to the institution because the individual resided
in the institution on the last day of the previous month. Thereafter, the
patient share it is paid to the highest paid provider.
(e) Discharge from long-term care
All income an individual receiving Medicaid coverage of
long-term care services and supports receives during the month they are
discharged from long-term care and any month after discharge when the
individual leaves a long-term care living arrangement (see § 30.01) is
excluded. A long-term care provider must refund any patient-share payment made
by an individual when the individual pays their patient share from income
received in the month of their discharge.
(f) Termination of eligibility for long-term
care
An individual receiving Medicaid coverage of long-term care
services and supports becomes fully responsible for the total cost of any care
they receive when they remain institutionalized after a medical-review team
decision that they no longer need skilled nursing or intermediate care, or they
become ineligible for other reasons. The individual's responsibility begins
after the effective date of the review team's decision. An individual usually
must pay in advance for such care as a privately-paying patient. They incur no
patient share obligation for the calendar month that the review team's decision
takes effect. A long-term care provider must credit payment toward the cost of
private care furnished after the effective date of the review team's decision
to end Medicaid coverage of long-term care services and supports when an
individual receiving Medicaid coverage of long-term care services and supports
has already paid their patient share to the provider during the calendar month
the review team's decision takes effect.
(g) Patient share in the month of death
Income received during the calendar month of the death of an
individual receiving Medicaid coverage of long-term care services and supports
is counted and applied to the cost of the care the individual received during
the prior month. For example, if the individual dies on June 26th, the
patient-share payment from income they received during June is due for care
provided in May. If the individual dies on July 1st, the patient-share payment
from income they received during July is due for care provided in June.
Section 25.00 Income or
Resource Transfers and Eligibility for Medicaid Coverage of Long-Term Care
Services and Supports
(01/15/2017, GCR 16-097)
Section 25.01 In general
(01/15/2017, GCR 16-097)
(a) AHS determines whether transfers of
income or resources made by an individual requesting Medicaid coverage of
long-term care services and supports are allowable transfers under the rules
set forth in this section.
(1) This section
applies to an individual:
(i) Who is
requesting Medicaid coverage of long-term care services and supports in a
medical institution under MABD or MCA.
(ii) Who is requesting Medicaid coverage of
long-term care services and supports in a home and community-based setting
under MCA.
(iii) Who is requesting
Medicaid coverage of long-term care services and supports in a home and
community-based setting under MABD and is in a special income coverage group
under § 8.05(k)) or is medically needy ( § 8.06).
(2) This section also applies to
the spouse of an individual described in (1) above.
If AHS determines that a transfer is not allowable, the
individual requesting
Medicaid coverage of long-term care services and supports
will not be eligible for such coverage until a penalty period has expired. The
start date of the penalty period is based on when the individual would, but for
the disallowed transfer, be otherwise eligible for Medicaid coverage of
long-term care services and supports, as explained in more detail in this
section. The duration of the penalty period is based on the value of the
disallowed transfer.
(b) AHS makes determinations concerning
transfers occurring before the individual requests Medicaid coverage of
long-term care services and supports as part of its determination of the
individual's initial eligibility. Once AHS has determined that a transfer is
disallowed and has established a penalty period that transfer is not
reconsidered unless AHS obtains new information about the transfer. If, after
the initial determination, AHS discovers that the individual made an additional
transfer (or transfers), AHS also determines whether the additional transfer
(or transfers) is allowable, whether the date of the additional transfer (or
transfers) is before or after the initial determination, and establishes a
penalty period (or periods) as required. If the individual requesting Medicaid
coverage of long-term care services and supports has a spouse (community
spouse), after the month in which the individual is determined eligible for
Medicaid coverage of long-term care services and supports, no resources of the
community spouse shall be determined available to the individual (the
institutionalized spouse). Accordingly, no transfers by the community spouse
after the initial month of the institutionalized spouse's eligibility are
considered for purposes of the institutionalized spouse's ongoing
eligibility.
(c)
§ 25.03
specifies the criteria for allowable transfers, to which no penalty period
applies, effective for all initial determinations of eligibility for Medicaid
coverage of long-term care services and supports and all redeterminations. No
other transfers are allowable.
Section 25.02 Definitions
(01/15/2017, GCR 16-097)
(a) Transfer of income or resources
For the purposes of this section, a transfer of income or
resources is any action taken by the individual requesting Medicaid coverage of
long-term care services and supports, by the spouse of such individual, or by
any other person with lawful access to the income or resources of the
individual or such individual's spouse that disposes of the income or
resources. The date of the transfer is the date the action was taken. It also
applies to certain income and resources to which the individual or such
individual's spouse is entitled but does not have access because of an action
taken by:
(1) The individual or such
individual's spouse;
(2) A person,
including a court or administrative body, with legal authority to act in place
of or on behalf of the individual or such individual's spouse; or
(3) A person, including a court or
administrative body, acting at the direction or upon the request of the
individual or such individual's spouse.
(b) Fair market value
Unless otherwise specified, fair market value is an amount
equal to the price of an item on the open market in the individual's locality
at the time of a transfer, or contract for sale, if earlier.
Section 25.03 Allowable transfers
(01/15/2017, GCR 16-097)
(a) Transfers for fair-market value - in
general
No penalty period is applied to income or resources
transferred for fair market value.
AHS determines whether the individual requesting Medicaid
coverage of long- term care services and supports, or the spouse of such
individual, as the case may be, received fair market value for a transfer of
income or resources by determining the difference, if any, between the fair
market value of the income or resource reduced by any applicable deductions at
the time of the transfer and the amount received for the income or resource.
Any of the following deductions may be used to reduce fair market value:
(1) The amount of any legally enforceable
liens or debts against the transferred income or resource at the time of
transfer that reduced the transferor's equity in the income or
resource;
(2) The reasonable and
necessary costs of making the sale or transfer;
(3) The value of income or resources received
by the transferor in exchange for the transferred income or
resources;
(4) The value of income
or resources returned to the transferor; and
(5) The following verified payments or
in-kind support given to or on behalf of the transferor as compensation for
receipt of the income or resources by the person who received the income or
resources:
(i) Personal services;
(ii) Payments for medical care;
(iii) Funeral expenses of the individual's
deceased spouse;
(iv) Taxes,
mortgage payments, property insurance, or normal repairs, maintenance and
upkeep on the transferred property; or
(v) Support and maintenance ( e.g., food,
clothing, incidentals, fuel and utilities) provided in the transferor's own
home or in the home of the person who received the income or resources from the
transferor.
(b) Receipt of fair market value after the
date of the transfer
If the value of a transferred resource is scheduled for
receipt after the date of transfer, it is considered a transfer for fair market
value only if the transferor can expect to receive the full fair-market value
of the resource within their expected lifetime. Expected lifetime is determined
as follows:
(1) When institutionalized
individual is transferor
Expected lifetime of the institutionalized individual is
measured at the time of the transfer as determined in accordance with actuarial
publications of the Office of the Chief Actuary of the SSA (http://soci a l
security.gov/OACT/STATS/table4c6.html) and set forth in Vermont's Medicaid
Procedures Manual.
(2) When
spouse of institutionalized individual is transferor
Expected lifetime of the spouse of the institutionalized
individual is measured at the time of the transfer as determined in accordance
with actuarial publications of the Office of the Chief Actuary of the SSA)
(http://soci a lsecurity.gov/OACT/STATS/table4c6.html) and set forth in
Vermont's Medicaid Procedures Manual.
(3) Pursuant to the authority granted in
Vermont Act 71 §
303(7)(2005),
AHS may develop alternate actuarial tables that will be consistent with federal
law and adopted by rule.
(c) Transfers for less than fair- market
value - in general
A penalty period is not imposed for a transfer for less than
fair market value that meets one or more of the following criteria:
(1) Time of transfer - beyond look-back
period
The date of the transfer was more than 60 calendar months
prior to the first month in which the individual both requests eligibility for
Medicaid coverage of long-term care services and supports and meets all other
requirements for eligibility.
(2) Transferred income or resources are
returned
The transferred income or resources have been returned or
otherwise remain available to the individual or the individual's spouse.
(3) Property transferred of a
person other than the individual or their spouse
The action that constituted the transfer was the removal of
the individual's (or spouse's) name from a joint account in a financial
institution, and the individual (or spouse) has demonstrated, to AHS's
satisfaction, that the funds in the account accumulated from the income and
resources of another owner who is not the individual (or their spouse).
(4) Transfer of resource for a
purpose other than creation or maintenance of eligibility for Medicaid coverage
of long-term care services and supports
The transferor has documented to AHS's satisfaction
convincing evidence that the resources were transferred exclusively for a
purpose other than for the individual to become or remain eligible for Medicaid
coverage of long-term care services and supports. A signed statement by the
transferor is not, by itself, convincing evidence. Examples of convincing
evidence are documents showing that:
(i) The transfer was not within the
transferor's control (e.g., was ordered by a court);
(ii) The transferor could not have
anticipated the individual's eligibility for Medicaid coverage of long-term
care services and supports on the date of the transfer (e.g., the individual
became disabled due to a traumatic accident after the date of transfer);
or
(iii) A diagnosis of a
previously undetected disabling condition leading to the individual's
eligibility for Medicaid coverage of long-term care services and supports was
made after the date of the transfer.
(5) Transfers of specified property for the
benefit of certain family members
The transfer meets the criteria specified below for transfers
involving trusts (see paragraph (d)), transfers of homes (see paragraph (e)),
and transfers for the benefit of certain family members (see paragraph
(g)).
(6) Intent to
transfer for fair market value
The transferor has demonstrated to AHS's satisfaction that
they intended to dispose of the income or resources either at fair market
value, or for other valuable consideration.
(7) Transfer of excluded income or resources
(i) The transferor transferred excluded
income or resources.
(ii) Penalties
are imposed for the transfer for less than fair market value of any asset
considered by the SSA's SSI program to be countable or excluded. For example,
transfer of a home or of the proceeds of a loan are both subject to
penalty.
(d)
Allowable transfers involving trusts
A penalty period is not imposed for transfers involving
trusts that meet one or more of the following criteria:
(1) The action that constituted the transfer
was the establishment of an irrevocable trust that does not under any
circumstances allow disbursements to or for the benefit of the individual, and
the date of the transfer was more than 60 calendar months prior to the first
month in which the individual requests Medicaid coverage of long-term care
services and supports.
(2) The
action that constituted the transfer was the establishment of a trust solely
for the benefit of the individual if the individual was under age 65 when the
trust was established and the trust meets all of the criteria at §
29.08(e)(1)(F).
(3) The action that
constituted the transfer was the establishment of a pooled trust, as specified
at § 29.08(e)(1)(G), unless the individual was age 65 or older when they
established the trust. If so, the transfer is not exempted from the imposition
of a transfer penalty period.
(4)
The action that constituted the transfer was the establishment of a revocable
trust. However, AHS considers any payment from the revocable trust to anyone
other than the individual a transfer for less than fair-market value subject to
penalty unless the payment is for their benefit.
(e) Allowable transfers of homes to family
members
A penalty period is not imposed for the transfer of a home
that meets the definition at § 29.08(a)(1) provided that title was
transferred to one or more of the following persons:
(1) The spouse of the individual requesting
Medicaid coverage of long- term care services and supports;
(2) The individual's child who was under age
21 on the date of the transfer;
(3)
The individual's son or daughter who is blind or permanently and totally
disabled, regardless of age;
(4)
The brother or sister of the individual when:
(i) The brother or sister had an equity
interest in the home on the date of the transfer; and
(ii) Was residing in the home continuously
for at least one year immediately prior to the date the individualbegan to
receive Medicaid coverage of long-term care services and supports, including
services in a home and community-based setting; or
(5) The son or daughter of the individual
provided that the son or daughter:
(i) Was
residing in the home continuously for at least two years immediately prior to
the date the individual (parent) began receiving Medicaid coverage of long-term
care services and supports, including services in a home and community-based
setting; and
(ii) Provided care to
the individual during part or all of this period that allowed the individual to
postpone receipt of Medicaid coverage of long-term care services and
supports.
(f)
Allowable transfers involving life-estate interests in another individual's
home
A penalty period is not imposed for the purchase of a
life-estate interest in another person's home when:
(1) It is the purchaser's residence;
and
(2) The purchaser resides in
the home for a period of at least one year after the purchase.
(g) Other allowable transfers
A penalty period is not imposed for transfers that meet any
of the following criteria:
(1) The
transfer was for the sole benefit of the individual requesting Medicaid
coverage of long-term care services and supports.
(2) The income or resource was transferred by
the institutionalized spouse to their community spouse before the initial
determination of the institutionalized spouse's eligibility for Medicaid
coverage of long- term care services and supports. This also applies to a
transfer made to a third party for the sole benefit of the community
spouse.
(3) The income or resource
was transferred to the individual's son or daughter who is blind or permanently
and totally disabled or to a trust for the sole benefit of such son or daughter
regardless of their age.
(4) The
income or resource was transferred to a trust, including a trust described in
§ 29.08(e)(1)(F) or § 29.08(e)(1)(G), established solely for the
benefit of an individual under the age of 65 years who is disabled.
(h) Transfers involving annuities
(1) In general
(i) Purchases. Any annuity purchased by an
individual requesting Medicaid coverage of long-term care services and
supports, or, if married, their community spouse on or after February 8, 2006,
must name Vermont Medicaid as the first remainder beneficiary of the annuity up
to the amount of Medicaid payments, including payments for Medicaid coverage of
long-term-care services and supports, made by the state on behalf of the
individual. In cases where a minor or disabled child or a community spouse is
named as a remainder beneficiary ahead of the state, Vermont Medicaid must be
named as the secondary remainder beneficiary. If Vermont Medicaid is not named
as a remainder beneficiary in the correct position, the purchase of the annuity
is considered a transfer for less than fair market value. When Vermont Medicaid
is a remainder beneficiary of an annuity, the issuer of the annuity is required
to notify Vermont Medicaid of any changes in the disbursement of income or
principal from the annuity as well as any changes to the state's position as
remainder beneficiary.
(ii)
Annuity-related transactions other than purchases. In addition to the purchase
of an annuity, certain transactions with respect to an annuity that occur on or
after February 8, 2006, make an annuity, including one purchased before that
date, subject to the provisions of this paragraph. Such transactions include
any action taken by the individual requesting Medicaid coverage of long-term
care services and supports or, if married, their community spouse that changes
the course of payments to be made by the annuity or the treatment of the income
or principal of the annuity. Routine changes and automatic events that do not
require any action or decision are not considered transactions that would
subject the annuity to this treatment.
(2) Additional requirements
(i) In addition to the requirement under
paragraph (h)(1) that Vermont Medicaid be named as a remainder beneficiary in
the correct position in order for the purchase of an annuity by an individual
requesting Medicaid coverage of long-term care services and supports or, if
married, their community spouse to not be considered a transfer for less than
fair market value, if the purchase of the annuity is by the individual
requesting Medicaid coverage of long-term care services and supports, the
purchase must also meet one or more of the four alternatives described below in
order for it to not be subject to a transfer penalty. To determine that an
annuity is established under any of the various provisions of the Code that are
referenced in (C) and (D) below, AHS relies on verification from the financial
institution, employer or employer association that issued the annuity. The
burden of proof is on the individual to produce this documentation. Absent such
documentation, AHS considers the purchase of the annuity a transfer for less
than fair-market value and, as such, subject to a penalty.
(ii) The four alternatives are as follows:
(A) The annuity meets the provisions of
§§ 29.08(d)(1) or 29.09(d)(1).
(B) The annuity is:
(I) Irrevocable and nonassignable;
(II) Provides for payments to the individual
in equal intervals and equal amounts with no deferral and no balloon payments
made;
(III) Is actuarially sound
because it does not exceed the life expectancy of the individual, as determined
using the actuarial publications of the Office of the Chief Actuary of the SSA
(http://soci a lsecurity.gov/OACT/STATS/table4c6.html) and set forth in
Vermont's Medicaid Procedures Manual; and
(IV) Returns to the individual at least the
amount used to establish the contract and any additional payments plus
earnings, as specified in the contract.
(C) The annuity is considered either:
(I) An individual retirement annuity
(according to § 408(b) of the Code), or
(II) A deemed Individual Retirement Account
(IRA) under a qualified employer plan (according to § 408(q) of the
Code).
(D) The annuity
is purchased with proceeds from one of the following:
(I) A traditional IRA ( § 408(a) of the
Code);
(II) Certain accounts or
trusts which are treated as traditional IRAs ( § 408(c) of the
Code);
(III) A simplified
retirement account ( § 408(p) of the Code);
(IV) A simplified employee pension ( §
408(k) of the Code); or
(V) A Roth
IRA ( § 408A of the Code).
(3) Impermissible transfers
An annuity that does not meet the above criteria is assessed
a transfer penalty based on its fair market value. The fair market value of an
annuity equals the amount of money used to establish the annuity and any
additional amounts used to fund the annuity, plus any earnings and minus any
early withdrawals and surrender fees.
(i) Allowable transfers involving promissory
notes and other income- producing resources
(1) Promissory notes or similar
income-producing resources (contracts) are assessed a transfer penalty based on
their fair market value unless they:
(i) Have
a repayment term that is actuarially-sound as determined in accordance with
actuarial publications of the Office of the Chief Actuary of the SSA
(http://soci a lsecurity.gov/OACT/STATS/table4c6.html) and set forth in
Vermont's Medicaid Procedures Manual;
(ii) Provide for payments to be made in equal
amounts during the term of the loan, with no deferral and no balloon payments
made; and
(iii) Prohibit the
cancellation of the balance upon the death of the lender.
(2) Fair market value equals the amount of
money used to establish the contract and any additional payments used to fund
it, plus any earnings and minus any payments already received as of the date of
the application for Medicaid coverage of long-term care services and
supports.
(j) Transfers
involving jointly- owned income or resources
(1) Joint-ownership established on or after
January 1, 1994
For any joint-ownership established on or after January 1,
1994, the portion of the jointly-owned asset subject to the imposition of a
penalty period is evaluated based on the specific circumstances of the
situation. A n individual is presumed to own a jointly-owned resource using the
rules in § 29.09. In the case of a jointly-owned account in a financial
institution, for example, since the account is presumed to be owned entirely by
the individual (see § 29.09(c)(5)(ii)), a transfer penalty is imposed
against the individual for any amount withdrawn from the account by another
joint owner on the account. The individual may rebut the presumption of
ownership by establishing to AHS's satisfaction that the amount withdrawn was,
in fact, the sole property of and contributed to the account by the other joint
owner (or owners), and thus did not belong to the individual.
(2) Joint-ownership established before
January 1, 1994
For a joint ownership established before January 1, 1994, the
date of the transfer is the date the other person (or persons) became a joint
owner. The value of the transfer equals the amount that the resource available
to the individual or, if married, the individual's spouse was reduced in value
when the other person (or persons) became a joint owner.
Section 25.04 Penalty
period for disallowed transfers
(01/15/2017, GCR 16-097)
(a) Definition: Otherwise eligible
(1) For purposes of determining the start
date of the penalty period because of disallowed transfers, an individual is
considered "otherwise eligible" for Medicaid coverage of long-term care
services and supports as of the earliest date they pass all eligibility
criteria in the sequence listed below. They must also meet each of these
criteria in any month for which they request retroactive eligibility:
(i) Clinical criteria (see definition of
long-term care in § 3.00).
(ii) Citizenship and identity criteria (
§ 17.00).
(iii) Category (
§ 7.03 (MCA), §§ 8.05 and 8.06 (MABD)).
(iv) Residency ( § 21.00).
(v) Living arrangements ( § 20.00
).
(vi) Resources ( § 29.07),
if applicable.
(vii) Income (
§§ 28.03 and 28.04 (MCA), § 29.11 (MABD) - for anyone with
excess income, see explanation in (2) below).
(2) When an individual's income exceeds the
income requirement for their applicable coverage group, the individual must
spend down to the applicable PIL in the month of application or the next month.
An individual with a penalty is subject to the penalty period start date
beginning on the date the spenddown is met. If the spenddown is not met in the
month of application or the next month, the individual is denied Medicaid
coverage of long-term care services and supports. AHS then determines whether
the person is eligible for Medicaid (other than Medicaid coverage of long-term
care services and supports). If so, it assesses a 6-month spend down.
Examples:
(i) The
individual applies in June for Medicaid coverage of long-term care services and
supports under MABD and requests retroactive coverage as of April. The
individual meets all eligibility criteria but their gross countable income
exceeds the IIS and they have transfers that will result in a 38 day penalty
period. The spenddown period is April - September. The individual meets their
spenddown on April 23rd. April 23rd is the date the individual is considered to
be "otherwise eligible." Their penalty period would be April 23rd - May
30th.
(ii) Same case as in (i), but
no retroactive coverage is requested. The spenddown period is June-November.
The spenddown is met June 23rd. June 23rd is the date the individual is
considered to be "otherwise eligible." The penalty period is June 23rd - July
30th.
(b)
Penalty period - in general
If a transfer is disallowed, a penalty period of restricted
Medicaid coverage to an otherwise eligible individual is imposed. During this
period, no Medicaid payments are made for the individual's long-term care
services and supports. Payments are made for all other covered Medicaid
services provided to the individual during the period of restricted
coverage.
(c) Penalty date
(1) Transfers made in a single month
The penalty date is the beginning date of each penalty period
imposed for a disallowed transfer. The penalty date starts on the first day in
which the individual would have been otherwise eligible for Medicaid coverage
of long-term care services and supports (see paragraph (a) of this subsection
for explanation of "otherwise eligible").
(2) Transfers occurring in different months
Penalty periods run consecutively rather than concurrently,
in the order in which the transfers occurred. If, after establishing a penalty
period for disallowed transfers, it is determined that additional disallowed
transfers were made in a subsequent month but before the end of the first
penalty period, the first day following the end of the first penalty period
will be designated as the penalty date for the subsequent penalty
period.
(d)
Penalty period
(1) Calculation of penalty
The number of days in a penalty period are equal to the total
value of all disallowed transfers made during a given calendar month divided by
the average daily cost to a privately-paying patient of nursing facility
services in the state as of the date of application or the date of discovery,
if additional disallowed transfers are discovered after the initial
determination of eligibility for Medicaid coverage of long-term care services
and supports.
(2) Transfers
in different calendar months
Penalty periods for transfers in different calendar months
are consecutive and established in the order in which the disallowed transfers
occurred.
(3) Continuous
nature of penalty period
A penalty period runs continuously from the first date of the
penalty period, even if the individual stops receiving long-term care services
and supports.
(e) Penalty when both spouses request
Medicaid coverage of long-term care services and supports
(1) In general
The following rules are applied to the assignment of penalty
periods when both members of a couple are requesting or receiving Medicaid
coverage of long-term care services and supports.
(2) Spouses eligible at same time
For spouses determined otherwise eligible for Medicaid
coverage of long-term care services and supports at the same time, the value of
the disallowed transfer is divided by two to determine the number of days of
restricted coverage for each member of the couple.
(3) Penalty period for one spouse is running
at the time the other requests Medicaid coverage of long-term care services and
supports
If the penalty period established for one member of the
couple has not yet expired when the other member of the couple requests and is
determined otherwise eligible for Medicaid coverage of long-term care services
and supports, the number of days remaining in the penalty period is divided by
two to determine the number of days of restricted coverage for each member of
the couple.
(4) Death of a
spouse during penalty period
When the member of the couple for whom a penalty period has
been established dies, the days remaining in that member's penalty period are
not reassigned to their spouse if the spouse requests and is determined
otherwise eligible for Medicaid coverage of long-term care services and
supports.
(5) Penalty
periods for transfer by second spouse to request Medicaid coverage of long-term
care services and supports
When a penalty period is established for a disallowed
transfer by the second member of the couple to request and be determined
otherwise eligible for Medicaid coverage of long-term care services and
supports, that penalty period is assigned to the spouse who made the transfer
provided that it was made after the determination of disallowed transfers for
the first spouse.
Section 25.05 Undue Hardship
(01/15/2017, GCR 16-097)
(a) In general
AHS does not establish a penalty period resulting from a
disallowed transfer when it determines that restricted coverage will result in
an undue hardship. Undue hardship is considered only in cases where AHS has
first determined that a transfer has been made for less than fair market value
and that no transfer exception applies (see § 25.03).
(b) Definition: Undue hardship
(1) For purposes of this subsection, undue
hardship means depriving the individual of:
(i) Medical care, such that the individual's
health or life would be endangered; or
(ii) Food, clothing, shelter, or other
necessities of life.
(2)
Undue hardship does not exist when the application of a transfer penalty merely
causes an individual or the individual's family member(s) inconvenience or
restricts their lifestyle. Undue hardship does not exist when the individual
transferred the assets to their community spouse and the community spouse has
countable or excluded resources in excess of the community spouse resource
allocation (CSRA) standard ( § 29.10(e)).
(c) Undue hardship reasons
In determining the existence of undue hardship, all
circumstances involving the transfer and the situation of the individual are
considered. Undue hardship is established when one or more of the following
circumstances, or any other comparable reasons, exist:
(1) Whether imposition of the transfer
penalty would result in the individual's immediate family qualifying for SSI;
Reach Up; AABD; General Assistance; 3SquaresVTs; or another public assistance
program requiring a comparable showing of financial need.
(2) Whether funds can be made available for
the cost of the individual's long-term care services and supports only if
assets such as a family farm or other family business are sold, and the assets
are the primary source of income for the individual's spouse, parents, children
or siblings.
(3) Whether an agent
under a power of attorney (POA) or a guardian of the individual transferred the
asset, and the POA or guardian was not acting in the best interest of the
individual when t
Part FIVE FINANCIAL METHODOLOGIES
Section 28.00 Financial
Eligibility Standards - Application of Modified Adjusted Gross Income (MAGI)
(01/15/2017, GCR 16-098)
Section 28.01 Basis, scope, and
implementation [1]
(01/15/2017, GCR 16-098)
(a) This section implements §
1902(e)(14)
of the Act.
(b) Effective January
1, 2014, the financial methodologies set forth in this section will be applied
in determining the financial eligibility of all individuals for health
benefits, except for individuals identified in paragraph (i) of § 28.03
and as provided in paragraph (c) of this subsection.
(c) In the case of determining ongoing
eligibility for an individual determined eligible for Medicaid coverage to
begin on or before December 31, 2013, application of the financial
methodologies set forth in this section will not be applied until March 31,
2014, or the next regularly-scheduled renewal of eligibility for such
individual under § 75.00, whichever is later.
Section 28.02 Definitions
(01/15/2017, GCR 16-098)
For purposes of this section:
(a) Family size [2]
(1) The number of persons counted as members
of the individual's household. Family size may include individuals who are not
subject to or are exempt from penalty for failing to maintain MEC.
(2) Special counting rule for Medicaid: In
the case of determining the family size of a pregnant woman, or the family size
of other individuals who have a pregnant woman in their household, the pregnant
woman is counted as herself plus the number of children she is expected to
deliver.
(b) Modified
Adjusted Gross Income (MAGI) [3]
Adjusted gross income (within the meaning of § 62 of the
Code) increased by:
(1) Amounts
excluded from gross income for citizens or residents of the United States
living abroad;
(2) Tax-exempt
interest the tax filer receives or accrues during the benefit year;
and
(3) Social Security benefits
not already included in adjusted gross income.
Section 28.03 MAGI-Based Medicaid
(01/15/2017, GCR 16-098)
(a) Definition: Tax dependent
For purposes of MAGI-based Medicaid, the term "tax dependent"
has the same meaning as the term "dependent" under § 152 of the Code, and
also includes an individual for whom another individual claims a deduction for
a personal exemption under § 151 of the Code for the benefit year.4
(b) Basic rule [5]
Except as specified in paragraphs (h), (i), and (j) of this
subsection, financial eligibility for MAGI-based Medicaid is determined based
on household income, as defined in paragraph (c) of this subsection. Household
composition is determined separately for each individual; see paragraph (e) of
this subsection for details on household composition.
(c) Household income [6]
(1) General rule
Except as provided in paragraphs (c)(2) through (c)(4) of
this subsection, household income for MAGI-based Medicaid is the sum of the
MAGI-based income, as defined in paragraph (d) of this subsection, of every
person included in the individual's household, as defined in paragraph (e) of
this subsection.
(2) Income
of children and tax dependents
(i) 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 return7 for the benefit year in which eligibility for Medicaid is
being determined, is not included in household income whether or not such
person files a federal tax return.
(ii) The MAGI-based income of a tax dependent
described in paragraph (e)(3)(i) of this subsection (individual other than a
spouse or child who expects to be claimed as a tax dependent by another tax
filer) who is not expected to be required to file a federal tax return [8] for
the benefit year in which eligibility for Medicaid is being determined, is not
included in the household income of the tax filer whether or not such tax
dependent files a federal tax return.
(3) Available cash support not included
In the case of an individual described in paragraph (e)(3)(i)
of this subsection (individual other than a spouse or child who expects to be
claimed as a tax dependent by another tax filer), household income does not
include cash support provided by the person claiming such individual as a tax
dependent.
(4) Five-percent
disregard
Effective January 1, 2014, in determining the eligibility of
an individual for Medicaid under the eligibility group with the highest income
standard under which the individual may be determined eligible using MAGI-based
methodologies, an amount equivalent to 5 percentage points of the FPL for the
applicable family size is deducted from household income.
(5) Sponsored noncitizens
(i) In determining the financial eligibility
of a noncitizen who is admitted to the United States on or after August 22,
1996, based on a sponsorship under § 204 of the INA, the income of the
sponsor and the sponsor's spouse, if living with the sponsor, must be counted
as available to the noncitizen when all four of the conditions set forth in (A)
through (D) below are met. The responsibility of a sponsor continues until the
noncitizen is naturalized or credited with 40 qualifying quarters of coverage
by the SSA (as described in (ii) below). Children and pregnant women who are
exempt from the five- year bar pursuant to § 17.03(c)(6) are not subject
to these provisions. The four conditions are as follows:
(A) The sponsor has signed an affidavit of
support on a form developed by the United States Attorney General as required
by PRWORA to conform to the requirements of § 213A(b) of INA;
(B) The noncitizen is lawfully admitted for
permanent residence, and a five-year period of ineligibility for Medicaid
following entry to the United States has ended;
(C) The noncitizen is not battered;
and
(D) The noncitizen is not
indigent, defined as unable to obtain food and shelter without assistance,
because his or her sponsor is not providing adequate support.
(ii) Qualifying quarters of
coverage.
(A) A noncitizen is credited with
the following qualifying quarters of coverage (as defined under Title II of the
Act);
(I) All of the qualifying quarters of
coverage worked by the noncitizen;
(II) All of the qualifying quarters of
coverage worked by a parent of such noncitizen while the noncitizen was under
age 18; and
(III) All of the
qualifying quarters of coverage worked by a spouse of such noncitizen during
their marriage as long as the noncitizen remains married to such spouse or such
spouse is deceased.
(B)
No qualifying quarter of coverage for any period beginning after December 31,
1996 may be credited to a noncitizen under (II) or (III) above if the parent or
spouse, as the case may be, of such noncitizen received any federal means-
tested public benefit during the period for which the qualifying quarter of
coverage is credited. Federal means- tested benefits for this purpose do not
include:
(I) Emergency medical
assistance;
(II) Short-term,
non-cash, in-kind emergency disaster relief;
(III) Assistance under the National School
Lunch Act or the Child Nutrition Act of 1966:
(IV) Public health assistance for
immunizations or testing and treatment of symptoms of communicable diseases not
paid by Medicaid;
(V) Payments for
foster care and adoption assistance under parts B and E of Title IV of the Act,
under certain conditions;
(VI)
Programs, services or assistance specified by the Attorney General;
(VII) Programs of student assistance under
Titles IV, V, IX and X of the Higher Education Act of 1965, and Titles III, VII
and VIII of the PHS Act;
(VIII)
Means-tested programs under the Elementary and Secondary Education Act of
1965;
(IX) Benefits under the Head
Start Act; or
(X) Benefits under
the Job Training Partnership Act.
(d) MAGI-based income [9]
For the purposes of this subsection, MAGI-based income 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.
(2) Scholarships, awards, or fellowship
grants used for education purposes and not for living expenses are excluded
from income.
(3) American
Indian/Alaska Native exceptions. The following are excluded from income:
(i) Distributions from Alaska Native
Corporations and Settlement Trusts;
(ii) Distributions from any property held in
trust, subject to federal restrictions, located within the most recent
boundaries of a prior federal reservation, or otherwise under the supervision
of the Secretary of the Interior;
(iii) Distributions and payments from rents,
leases, rights of way, royalties, usage rights, or natural resource extraction
and harvest from:
(A) Rights of ownership or
possession in any lands described in paragraph (d)(3)(ii) of this subsection;
or
(B) Federally protected rights
regarding off-reservation hunting, fishing, gathering, or usage of natural
resources;
(iv)
Distributions resulting from real property ownership interests related to
natural resources and improvements:
(A)
Located on or near a reservation or within the most recent boundaries of a
prior federal reservation; or
(B)
Resulting from the exercise of federally-protected rights relating to such real
property ownership interests;
(v) Payments resulting from ownership
interests in or usage rights to items that have unique religious, spiritual,
traditional, or cultural significance or rights that support subsistence or a
traditional lifestyle according to applicable tribal law or custom;
(vi) Student financial assistance provided
under the Bureau of Indian Affairs education programs.
(e) Household
(1) In general
For purposes of household composition:
(i) "Child" includes a natural or biological,
adopted or step-child.
(ii)
"Parent" includes a natural or biological, adopted or step-parent.
(iii) "Sibling" includes a natural or
biological, adopted or step- sibling.
(2) Basic rule for tax filers not claimed as
a tax dependent
In the case of an individual who expects to file a federal
tax return for the benefit year in which an initial determination or renewal of
eligibility is being made, and who does not expect to be claimed as a tax
dependent by another tax filer, the household consists of the tax filer and,
subject to paragraph (e)(6) of this subsection, all persons whom such
individual expects to claim as a tax dependent.
(3) Basic rule for individuals claimed as a
tax dependent
In the case of an individual who expects to be claimed as a
tax dependent by another tax filer for the benefit year in which an initial
determination or renewal of eligibility is being made, the household is the
household of the tax filer claiming such individual as a tax dependent, except
that the household must be determined in accordance with paragraph (e)(4) of
this subsection in the case of:
(i)
Individuals who expect to be claimed as a tax dependent by a tax filer who is
not the individual's spouse or parent;
(ii) Individuals under the age specified
under paragraph (e)(4)(iv) of this subsection who expect to be claimed by one
parent as a tax dependent and are living with both parents but whose parents do
not expect to file a joint federal tax return; and
(iii) Individuals under the age specified
under paragraph (e)(4)(iv) of this subsection who expect to be claimed as a tax
dependent by a non-custodial parent. For purposes of this paragraph:
(A) The custodial parent is the parent so
named in a court order or binding separation, divorce, or custody agreement
establishing physical custody; or
(B) If there is no such order or agreement,
or in the event of a shared custody agreement, the custodial parent is the
parent with whom the child spends most nights.
(4) Rules for individuals who neither file a
tax return nor are claimed as a tax dependent
In the case of an individual who does not expect to file a
federal tax return and does not expect to be claimed as a tax dependent for the
benefit year in which an initial determination or renewal of eligibility is
being made, or who is described in paragraph (e)(3)(i), (e)(3)(ii), or
(e)(3)(iii) of this subsection, the household consists of the individual and,
if living with the individual:
(i) The
individual's spouse;
(ii) The
individual's children under the age specified in (iv) of this paragraph (e)(4);
and
(iii) In the case of an
individual under the age specified in (iv) of this paragraph (e)(4), the
individual's parents and siblings under the age specified in (iv) of this
paragraph (e)(4).
(iv) The age
specified in this paragraph (e)(4) is age 19 or, in the case of a full-time
student, age 21.
(5)
Couples
In the case of a couple living together, each spouse is
included in the household of the other spouse, regardless of whether they
expect to file a joint federal tax return [10] or whether one spouse expects to
be claimed as a tax dependent by the other spouse.
(6) Households of individuals whom tax filer
cannot establish as a dependent
For purposes of paragraph (e)(2) of this subsection, if,
consistent with the procedures adopted by the state in accordance with §
56.00, a tax filer cannot reasonably establish that another person is a tax
dependent of the tax filer for the benefit year in which Medicaid is sought,
the inclusion of such person in the household of the tax filer is determined in
accordance with paragraph (e)(4) of this subsection.
(f) No resource test or income
disregards [11]
In the case of an individual whose financial eligibility for
Medicaid is determined in accordance with this subsection, AHS will not:
(1) Apply any resources test; or
(2) Apply any income or expense disregards
under §§
1902(r)(2)
or
1931(b)(2)(C),
or otherwise under Title XIX of the Act, except as provided in paragraph (c)(4)
of this subsection.
(g)
Budget period [12]
(1) Applicants and new
enrollees
Financial eligibility for Medicaid for applicants, and other
individuals not receiving Medicaid benefits at the point at which eligibility
for Medicaid is being determined, must be based on current monthly household
income and family size.
(2)
Current beneficiaries
For an individual who has been determined financially
eligible for Medicaid using the MAGI-based methods 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.
(h) Alternative methodology to
avoid eligibility gap [13]
If an individual who meets the non-financial eligibility
requirements for Medicaid is determined to be financially ineligible for
Medicaid using the MAGI-based Medicaid methodologies set forth in this
subsection, but their household income is determined to be less than 100
percent of the FPL using the MAGI methodologies for determining eligibility for
APTC and CSR, as set forth in § 28.05, the individual's eligibility for
Medicaid will be determined using the MAGI methodologies set forth in §
28.05.
(i) Eligibility
groups for which MAGI-based methods do not apply [14]
The financial methodologies described in this subsection are
not applied in determining the Medicaid eligibility of individuals described in
this paragraph. Except for the individuals described in (1) of this paragraph
(i), the financial methods described in § 29.00 (MABD financial
eligibility standards) will be used to determine Medicaid eligibility for such
individuals.
(1) Individuals whose
eligibility for Medicaid does not require a determination of income, including,
but not limited to, individuals receiving SSI eligible for Medicaid under
§ 8.05(a) and individuals deemed to be receiving SSI and eligible for
Medicaid under §
§ 8.05(c), (f) and (h).
(2) Individuals who are age 65 or older when
age is a condition of eligibility.
(3) Individuals whose eligibility is being
determined on the basis of being blind or disabled, or on the basis of being
treated as being blind or disabled, including, but not limited to, individuals
under § 8.05(k)(6) (Katie Beckett) and individuals receiving state
supplements, but only for the purpose of determining eligibility on such
basis.
(4) Individuals who request
that the financial methods described in § 29.00 be used to determine their
eligibility for Medicaid coverage of long-term care services and
supports.
(5) Individuals who are
being evaluated for eligibility for Medicare cost-sharing assistance under
§ 8.07, but only for purposes of determining eligibility for such
assistance.
(j) Special
rule: family planning services [15]
In the case of an individual whose eligibility is being
determined under § 9.03(g) (family planning services), AHS will:
(1) Consider the household to consist of only
the individual for purposes of paragraph (e) of this subsection;
(2) Count only the MAGI-based income of the
individual for purposes of paragraph (c) of this subsection; and
(3) Increase the family size of the
individual, as defined in § 28.02, by one.
Section 28.04 Medically-needy MCA - income
eligibility
(01/15/2017, GCR 16-098)
(a) In general
Income eligibility of an individual requesting
medically-needy MCA is determined by calculating the individual's MAGI-based
income as described in § 28.03(d). The individual's MAGI-based income is
then adjusted, if applicable, by apportioning the income of financially
responsible family members according to the requirements set forth in paragraph
(b) of this subsection.
For the individuals who may qualify for medically-needy MCA,
see § 7.03(a)(8).
(b)
Financial responsibility of relatives and other individuals [16]
(1) Financial responsibility of relatives and
other persons for the individual is limited to the following:
(i) A spouse for their spouse when both are
living in the same household; and
(ii) A parent, step-parent, or adoptive
parent for their unmarried child under the age of 21 living in the same
household unless the child is pregnant or a parent whose own child is living in
the household and they make a monthly (or more frequent) room or board payment
to their parents.
(2)
Except for a spouse of an individual or a parent for a child who is under age
21, no income or resources of any other relative will be considered as
available to the individual.
(3)
When a couple ceases to live together, only the income of the individual spouse
will be counted in determining their eligibility, beginning the first month
following the month the couple ceases to live together.
(c) Spenddown
The income spenddown provisions set forth in § 30.00
apply to an individual requesting medically-needy MCA. For purposes of the
spenddown provisions at § 30.00, anyone identified in paragraph (b) above
as financially responsible for the individual is considered a member of the
individual's financial responsibility group as that term is used throughout
§ 30.00.
Section
28.05 APTC and CSR
(01/15/2017, GCR 16-098)
(a) Definition: Tax dependent
For purposes of APTC and CSR, the term "tax dependent" has
the same meaning as the term "dependent" under § 152 of the Code.
(b) Basic rule
Financial eligibility for APTC and CSR is determined based on
household income as defined in paragraph (c) of this subsection.
(c) Household income [17]
Household income is the sum of:
(1) A tax filer's MAGI; plus
(2) The aggregate MAGI of all other
individuals who:
(i) Are included in the tax
filer's household (as defined in paragraph (d) of this subsection);
and
(ii) Are required to file a
federal income tax return for the benefit year.
(d) Household
The household consists of the tax filer, the tax filer's
spouse (if married within the meaning of
26 CFR §
1.7703-1) , and all individuals claimed as
the tax filer's tax dependents. As described in § 58.02(b)(2), married
couples must file joint federal tax returns in order to be considered for APTC
and CSR, unless the tax filer meets the exception criteria defined in §
12.03(b) (victim of domestic abuse or spousal abandonment). Parties to a civil
union may qualify for APTC and CSR by filing separate tax returns.
Section 29.00 Financial
Eligibility Standards - Medicaid for the Aged, Blind, and Disabled (MABD)
(01/15/2017, GCR 16-098)
Section 29.01 Introduction
(01/15/2017, GCR 16-098)
An individual who meets the nonfinancial and categorical
requirements for MABD must also meet the financial requirements specified in
this section. AHS determines financial eligibility for MABD, including Medicaid
coverage of long-term care services and supports under MABD.
To determine an individual's financial eligibility for MABD,
AHS calculates the countable income and countable resources of the individual's
financial responsibility group and compares those amounts to standards based on
the size of the individual's Medicaid group. The first step in determining
financial eligibility is to identify the members of the individual's financial
responsibility group and the members of the individual's Medicaid group. An
aged, blind, or disabled individual requesting MABD is always a member of both
groups.
The rules for forming the financial responsibility group are
specified in § 29.03.
The rules for forming the Medicaid group are specified in
§ 29.04. The rules on resources are specified in §§ 29.07
through 29.10.
The rules on income are specified in §§ 29.11
through 29.15.
Section
29.02 Definitions
(01/15/2017, GCR 16-098)
As used in this § 29.00, the following terms have the
following meanings:
(a) Child
(1) An individual who:
(i) Is under age 18 or is a student under age
22;
(ii) Has always been single;
and
(iii) Lives with a parent.
(A) A child is not considered living with a
parent when:
(I) The parent has relinquished
control to a school or vocational facility;
(II) The child is confined to a public
institution or is in the custody of a public agency;
(III) The child is a member of the armed
forces;
(IV) The child lives in a
private nonmedical facility; or
(V)
The child has been admitted to long-term care.
(B) A child away at school who returns to a
parent's home for vacations, holidays, or some weekends is considered living
with that parent.
(2) An individual who qualifies for the Katie
Beckett coverage group (see § 8.05(k)(6)) is not considered a child for
the purposes of determining their financial eligibility for MABD.
(3) An individual is no longer considered a
child on the first day of the month following the calendar month in which they
no longer meet the definition of child.
(b) Adult
An individual who is not a child.
(c) Eligible child
For purposes of deeming, as described in § 29.05, a
child who is a natural or adopted child under the age of 18, who lives in a
household with one or both parents, is not married, and meets the non-financial
eligibility requirements for MABD.
(d) Ineligible child
For deeming purposes, a child, as defined in (a) of this
subsection, who does not meet the non-financial criteria for MABD, lives in the
same household as the individual requesting MABD, and is:
(1) The natural child or adopted child of the
individual;
(2) The natural or
adopted child of the individual's spouse, or
(3) The natural or adopted child of the
individual's parent or of the spouse of the individual's parent.
(e) Ineligible parent
For deeming purposes, a person who does not meet the non-
financial criteria for MABD, lives with an eligible child, and is:
(1) A natural or adoptive parent of the
child; or
(2) The spouse of a
natural or adoptive parent of the child.
(f) Ineligible spouse
For deeming purposes, the spouse who lives with the
individual requesting MABD and does not meet the nonfinancial eligibility
criteria for MABD.
Section
29.03 Formation of the financial responsibility group
(01/15/2017, GCR 16- 098)
(a) In general
The financial responsibility group for MABD consists of the
individuals whose income and resources are considered available to the Medicaid
group in the eligibility determination. With some exceptions, spouses are
considered financially responsible for each other, and parents are considered
financially responsible for their children. The following paragraphs set forth
the rules for determining membership in the financial responsibility group and
the portion of the group's income considered available to the Medicaid
group.
(b) Financial
responsibility group for an adult
The financial responsibility group for an adult requesting
MABD, including Medicaid coverage of long-term care services and supports under
MABD, is the same as the adult's Medicaid group.
(c) Financial responsibility group for a
child
The financial responsibility group for a child requesting
MABD includes the child and any parents living with the child until the child
reaches the age of 18.
(d)
Financial responsibility group for a sponsored noncitizen
(1) The financial responsibility group for a
noncitizen admitted to the United States on or after August 22, 1996, based on
a sponsorship under § 204 of the INA, includes the income and resources of
the sponsor and the sponsor's spouse, if living with the sponsor, when all four
of the conditions set forth in (i) through (iv) below are met. Children and
pregnant women who are exempt from the five-year bar pursuant to §
17.03(c)(6) are not subject to these provisions. The four conditions are as
follows:
(i) The sponsor has signed an
affidavit of support on a form developed by the United States Attorney General
as required by the Personal Responsibility and Work Opportunity Reconciliation
Act of 1996 (PRWORA) to conform to the requirements of § 213A(b) of the
INA;
(ii) The noncitizen is
lawfully admitted for permanent residence, and a five-year period of
ineligibility for MABD following entry to the United States has
ended;
(iii) The noncitizen is not
battered; and
(iv) The noncitizen
is not indigent, defined as unable to obtain food and shelter without
assistance, because their sponsor is not providing adequate support.
(2) The financial responsibility
of a sponsor continues until the noncitizen is naturalized or credited with 40
qualifying quarters of coverage by the SSA (see (3) below for crediting of
qualifying quarters).
(3) A
non-citizen is credited with the following qualifying quarters of coverage as
defined under Title II of the Act:
(i) Those
worked by the non-citizen;
(ii)
Those worked by a parent of such non-citizen while the non-citizen was under
age 18 unless the parent received any federal means-tested public benefit
during the period for which the qualifying quarter of coverage is credited
after December 31, 1996;
(iii)
Those worked by a spouse of the non-citizen while they were spouses, as long as
the non-citizen remains the spouse or the spouse is deceased and the spouse did
not receive any federal means-tested public benefit during the period for which
the qualifying quarter of cover is credited after December 31, 1996;
(iv) For this purpose, federal means-tested
benefits do not include:
(A) Emergency
medical assistance;
(B) Short-term,
non-cash, in-kind emergency disaster relief;
(C) Assistance under the National School
Lunch Act or the Child Nutrition Act of 1966;
(D) Public health assistance for
immunizations or testing and treatment of symptoms of communicable diseases not
paid by Medicaid;
(E) Payments for
foster care and adoption assistance under parts B and E of Title IV of the Act,
under certain conditions;
(F)
Programs, services or assistance specified by the Attorney General;
(G) Programs for student assistance under
Titles IV, V, IX, and X of the Higher Education Act of 1965, and Titles III,
VII, and VIII of the Public Health Service Act;
(H) Means-tested programs under the
Elementary and Secondary Education Act of 1965;
(I) Benefits under the Head Start Act;
or
(J) Benefits under the
WIA.
Section 29.04 Formation of the Medicaid group
(01/15/2017, GCR 16-098)
(a) In general
The Medicaid group consists of individuals whose needs are
included in the financial eligibility determination for MABD. The following
paragraphs set forth the rules for determining membership in the Medicaid
group. AHS compares countable income and resources of the financial
responsibility group to maximums based on the size of the Medicaid
group.
(b) Medicaid group
for a single adult
A single adult requesting MABD, including Medicaid coverage
of long-term care services and supports under MABD, is treated as a Medicaid
group of one.
(c) Medicaid
group for an adult with a spouse
(1) When
spouses are living together, both the individual requesting MABD and the
individual's spouse are considered members of the individual's Medicaid group,
a Medicaid group of two, unless one of the exceptions specified in paragraph
(d) of this subsection applies. This is true whether or not the individual's
spouse is also requesting MABD.
(2)
Spouses are considered living together in any of the following circumstances:
(i) Until the first day of the month
following the calendar month of death or separation, when one spouse dies or
the couple separates.
(ii) When one
spouse is likely to need long-term care for fewer than 30 consecutive
days.
(iii) When the resources of
the couple are assessed and allocated as of the date of initial application for
Medicaid coverage of long-term care services and supports under MABD.
(d) Exceptions for an
adult with a spouse
An adult requesting MABD with a spouse is treated as a
Medicaid group of one in the following circumstances:
(1) When one spouse is applying for Medicaid
coverage of long-term care services and supports under MABD, they are
considered a Medicaid group of one for:
(i)
The determination of their initial and ongoing income eligibility;
and
(ii) Resource reviews of their
eligibility.
(iii) AHS considers
the spouses to be no longer living together as of the first day of the calendar
month one spouse begins receiving Medicaid coverage of long-term care services
and supports under MABD. This remains true even if the other spouse begins
receiving Medicaid coverage of long-term care services and supports in a
subsequent month.
(2)
When AHS determines the eligibility of one spouse for MABD when the other
spouse already receives Medicaid coverage of long-term care services and
supports in a home and community-based setting.
(3) When both spouses are admitted to the
same residential care home, each spouse is considered a Medicaid group of one
if the residential care home is designed for four or more residents.
(4) When both spouses have been admitted to
the same institution for long-term care in the same month and have lived there
at least six months beginning with the first month following the month of their
admission, for purposes of determining each spouse's eligibility for Medicaid
coverage of long-term care services and supports under MABD, each spouse is
considered a Medicaid group of one for the determination of their initial and
ongoing income eligibility and resource reviews of their eligibility. However,
if it works to their advantage, they may be considered a Medicaid group of
two.
(5) When one spouse is
receiving custodial care in their home, as defined in AABD Rule 2766, they are
considered a Medicaid group of one.
(e) Medicaid group for a child
(1) A child requesting MABD is treated as a
Medicaid group of one.
(2) When a
parent and child living together are both requesting MABD, they are treated as
two Medicaid groups of one, if the parent is not living with a spouse. If the
parent is living with a spouse, the parent and their spouse are treated as a
Medicaid group of two and the child as a Medicaid group of one.
Section 29.05 Deeming
(01/15/2017, GCR 16-098)
(a) In general
MABD financial eligibility is based on the financial
eligibility rules for the SSA's SSI program. Like SSI, the term "deeming" is
used to identify countable resources and income from other people as belonging
to the individual requesting MABD. When the deeming rules apply, it does not
matter whether the resources or income of the other person are actually
available to the individual.
(b) Categories of people whose income and
resources are counted
(1) Resources and
income from two categories of people may be counted as belonging to the
individual. These people are members of the individual's financial
responsibility group. AHS considers:
(i)
Spousal resources and income to decide whether it must deem some of it to the
Medicaid group; and
(ii) Parental
resources and income for an eligible child to decide whether it must deem some
of it to the Medicaid group.
(2)
§ 29.10 specifies the resources
counted when determining MABD financial eligibility.
(3)
§ 29.14 specifies the income counted
when determining MABD financial eligibility.
Section 29.06 Temporary absences and deeming
rules
(01/15/2017, GCR 16-098)
(a) Effect of temporary absence
For purposes of deeming, during a temporary absence, the
absent person continues to be considered a member of the individual's
household.
(b) Definition
of temporary absence
A temporary absence occurs when the individual or their
ineligible spouse, parent, or an ineligible child leaves the household but
intends to and does return in the same month or the next month.
(c) Treatment of absences due to
schooling
An eligible child is considered temporarily absent from their
parent's (or parents') household if they are away at school but come home on
some weekends or lengthy holidays and are subject to the control of their
parent(s).
(d) Absences
related to active duty assignment
If the individual's ineligible spouse or parent is absent
from the household due solely to a duty assignment as a member of the armed
forces on active duty, that person is considered to be living in the same
household as the individual, unless evidence indicates that the individual's
spouse or parent should no longer be considered to be living in the same
household. When such evidence exists, AHS stops deeming their resources and
income beginning with the month after the spouse or parent no longer lived in
the same household.
Section
29.07 Resources
(01/15/2017, GCR 16-098)
(a) In general
(1) Resources are cash and other property,
real or personal, that an individual (or their spouse, if any):
(i) Owns;
(ii) Has the right, authority or power to
convert to cash (if not already cash); and
(iii) Is available for their support and
maintenance.
(2)
Resources are treated in different ways depending on the rules of the coverage
group involved and the type and liquidity of the resource.
(3) Resources are counted based upon their
availability and the ease with which they can be converted into cash.
Availability is often affected when more than one person has an ownership
interest in the same resource.
(4)
Resource limits vary depending on the type of category and services, and the
size of the Medicaid group. Resource eligibility for each coverage group is
determined by comparing the resources of the financial responsibility group to
the resource limit based on the size of the Medicaid group. Resource maximums
are specified in Vermont's Medicaid Procedures Manual.
(5) All resources of the members of the
financial responsibility group must be counted except those specifically
excluded. See § 29.08 for the resource exclusion rules.
(6) Equity value as well as availability is
considered when determining the amount of a resource that counts. In general,
equity value means the price an item can be reasonably expected to sell for on
the local open market minus any encumbrances. See § 29.09 for the general
rules on valuing countable resources.
(b) Types of resources
This paragraph describes some of the kinds of resources the
availability of which are considered in determining MABD eligibility. The
descriptions are divided into two categories - nonliquid resources and liquid
resources. Except for cash, any kind of property may be either liquid or
nonliquid. The liquidity (or nonliquidity) of a resource has no effect on the
resource's countability for MABD eligibility purposes.
(1) Definition: Nonliquid resources
A nonliquid resource means property that is not cash,
including real and personal property that cannot be converted to cash within 20
work days. Real property, life estates, life insurance and burial funds,
described below, are some of the more common kinds of nonliquid resources.
Certain other noncash resources, though they may occasionally be liquid, are
nearly always nonliquid. These include, but are not limited to, household goods
and personal effects, vehicles, livestock, and machinery.
(i) Real property
Land and generally whatever is erected, growing on, or
affixed to land. See § 29.08(a) for information on the resource exclusion
of real property.
(ii) Life
estates
Life estate means a legal arrangement entitling the owner of
the life estate (sometimes referred to as the "life tenant") to possess, rent,
and otherwise profit from real or personal property during their lifetime. The
owner of a life estate sometimes may have the right to sell the life estate,
but does not normally have future rights to the property. Ownership of a life
estate may be conditioned upon other circumstances, such as a new spouse. The
document granting the life estate includes the conditions for the life estate
and the right of the owner of the life estate to sell or bequeath it, if these
property rights were retained. See § 29.08(a)(6) for information on the
resource exclusion of life estates.
(iii) Life insurance
A contract that provides for its purchaser to pay premiums to
the insurer, who agrees to pay a specific sum to a designated beneficiary upon
the death of the insured. Life insurance is usually sold by an insurance
company but may also be sold by other financial institutions, such as brokerage
firms. See § 29.08(b) for information on the resource exclusion of life
insurance.
The following are terms related to life insurance:
(A) Face value
The amount the life insurance policy pays the designated
beneficiary upon the death of the insured.
(B) Term life insurance
A life insurance policy that does not accumulate any cash
value as premiums are paid.
(C) Whole life insurance (sometimes called
ordinary life, limited payment or endowment insurance)
A life insurance policy that accumulates cash value as
premiums are paid. It may also pay periodic dividends on this value when all
premiums have been paid. These dividends may be paid to the owner, or they may
be added to the cash surrender value (defined below) of the policy.
(D) Cash surrender value (CSV) of
whole life insurance
The amount the owner would receive if the life insurance
policy were terminated before the insured dies. It is a form of equity that
accumulates over time as life insurance premiums are paid. The owner may borrow
against the CSV according to the terms of the policy. A loan against a policy
reduces its CSV.
(E) Group
policy
A life insurance policy that is usually issued through a
company or organization insuring the participating employees or members and,
perhaps, their families. The group policy may be paid partially by the
employer. A group insurance policy generally has no CSV.
(iv) Burial Funds
(A) Any separately-identifiable fund clearly
designated for burial expenses (which includes expenses for burial spaces,
items related to burial spaces and services related to burial spaces) through
the title to the fund or by a sworn statement provided. Burial funds include
contracts, trusts, or other agreements, accounts, or instruments with a cash
value. Some burial funds include accumulated interest, and the value of some
burial funds may change through time (e.g., when the fund consists of bonds).
See § 29.08(c) for information on the resource exclusion of burial
funds.
(B) The cash value of life
insurance policies may also be treated as a burial fund if owned by a person
whose income and resources are considered in determining an individual's MABD
eligibility and if designated as specified above.
(C) For the purposes of determining MABD
eligibility, burial spaces, if not fully paid, are considered burial funds and
include burial plots, gravesites, crypts, mausoleums, caskets, urns, and other
repositories customarily and traditionally used for the deceased's bodily
remains. Items related to burial spaces include, but are not limited to,
vaults, headstones, markers, plaques, and burial containers for caskets.
Services related to burial include, but are not limited to, embalming, opening
and closing of the gravesite, and care and maintenance of the gravesite,
sometimes called an endowment or perpetual care.
(2) Definition: Liquid resources
A liquid resource means cash or other property that can be
converted to cash within 20 work days. Accounts in financial institutions;
retirement funds; stocks, bonds, mutual funds, and money market funds;
annuities; mortgages and promissory notes; and home equity conversion plans,
described below, are some of the more common kinds of liquid resources.
(i) Accounts in financial institutions
(A) Accounts in depository financial
institutions such as banks and credit unions include, but are not limited to,
savings accounts, checking accounts, joint fiduciary accounts, and certificates
of deposit. Depository institutions may also manage mutual fund and money
market fund accounts for depositors.
(B) Nondepository financial institutions,
such as brokerage firms, investment firms, and finance companies, also offer
certificates of deposits as well as accounts and services related to the
purchase and sale of stocks, bonds, mutual funds, money market funds, and other
investments.
(ii)
Stocks, bonds, and funds
(A) Legal instruments
authenticating an investment, such as stocks, bonds, mutual funds, and money
market funds pay interest at specified intervals, sometimes pay dividends, and
are convertible into cash either on demand or at maturity.
(B) U. S. savings bonds are obligations of
the federal government. Unlike other government bonds, they are not tradable in
the usual sense through brokers and security traders and, as described below,
the value of the bond depends on its type. See § 29.08(i)(11) for
information on the resource exclusion of U.S. savings bonds.
(I) Series E and EE bonds are sold at one
half of their face value and increase in redemption value as interest
accrues.
(II) Series I bonds are
sold at their full face value and increase in redemption value as interest
accrues.
(III) Series H and HH
bonds are sold at their full face value and do not increase in value. Instead,
they pay interest to the owner each six months.
(iii) Annuities
A contract reflecting payment to an insurance company, bank,
charitable organization, or other registered or licensed entity; it may also be
a private contract between two parties. There are two phases to an annuity: An
accumulation phase and a pay- out phase, and their countability as a resource
for MABD eligibility purposes is impacted by the phase the annuity is in (see
below). Annuities vary in how they accumulate and pay out money. Annuities may
accumulate money by payment of a single lump sum or by payments on a schedule,
which accumulate interest over time. Once an annuity has reached its pay-out
phase (often referred to as "matured"), money is paid to the beneficiary
according to the terms of the annuity contract.
(A) Parties to an annuity
(I) There are always two parties to an
annuity: The writer of the annuity, usually an insurance carrier or charitable
organization, and the purchaser who owns the annuity (sometimes referred to as
the annuitant). There may also be a third party to the annuity if someone other
than the owner is the annuitant.
(II) In addition, annuities also name a
beneficiary. The beneficiary is the person who will be paid a regular stream of
income from the annuity in equal payments. Anyone can be a beneficiary,
including but not limited to, the owner of the annuity, a spouse, dependent,
trust, estate, commercial entity, proprietorship, or charitable
organization.
(III) Beneficiaries
may be revocable or irrevocable. A revocable beneficiary can be changed by the
owner of the annuity at any time. An irrevocable beneficiary can be changed
only by the written permission of that beneficiary.
(IV) In addition to the beneficiary described
in (II) above, annuities can also provide for a contingent beneficiary or
residual beneficiary. A contingent or residual beneficiary will receive annuity
payments upon the occurrence of a specified condition.
(B) Types of annuities
There are many types of annuities. For MABD purposes, AHS
considers whether annuities of any type are available as a liquid resource.
Since annuities are trust-like instruments, terminology similar to trusts is
used when it describes the availability of cash from annuities.
(I) Annuity naming revocable beneficiaries
An annuity that names revocable beneficiaries is available to
the owner because the owner can change the beneficiary. This type of an annuity
is considered a countable resource for purposes of the owner's MABD
eligibility. See subsection 29.09(d)(1) for information on how to value an
annuity when it is a countable resource.
(II) Annuity that can be surrendered, cashed
in or assigned
An annuity that can be surrendered, cashed in or assigned by
the owner is presumed to be a revocable annuity. A revocable annuity is
considered a countable resource for purposes of the owner's MABD eligibility.
An annuity is presumed to be revocable when the annuity contract is silent on
revocability. See § 29.09(d)(1) for information on how to value an annuity
when it is a countable resource.
(III) Annuity owned by someone other than the
applicant or spouse
An annuity is an unavailable resource for purposes of MABD
eligibility when the owner of the annuity is not the individual requesting MABD
or the individual's spouse, or the individual or their spouse has abandoned all
rights of ownership. However, if payments from the annuity are being made to
the individual (or spouse), those payments may be counted as income to the
individual (or spouse).
(C) Standard of review
(I) For the purposes of MABD eligibility:
(i) An annuity in its accumulation phase is
considered a countable resource of the owner because it can be liquidated or
sold by the owner. See § 29.09(d)(1) for information on how to value an
annuity when it is a countable resource.
(ii) An annuity in its pay-out phase may be
excluded as a resource of the owner if certain criteria are met. See §
29.08(d)(1) for information on the resource exclusion of an annuity.
(II) For purposes of MABD for
long-term care, an annuity purchased, or subjected to certain transactions, by
an individual or their spouse on or after February 6, 2006, is subject to
transfer review. See § 25.03(h) for information on transfer analysis of
annuities.
(iv) Mortgages
(A) The pledging of real estate or conveyance
of an interest in land to a creditor as security for repayment of a
debt.
(B) A mortgage owned by an
individual, as the creditor, may be excluded as a resource if certain criteria
are met. See § 29.08(d)(2) for information on the resource exclusion of a
mortgage. If a mortgage is a countable resource of the individual, see §
29.09(d)(5) for information about the valuation of the mortgage.
(v) Promissory notes
(A) Written promises to pay a certain sum of
money to a certain person, the bearer, upon demand or on a specified
date.
(B) A promissory note owned
by an individual, as the bearer, may be excluded as a resource if certain
criteria are met. See § 29.08(d)(2) for information on the resource
exclusion of a promissory note. If a promissory note is a countable resource of
the individual, see § 29.09(d)(5) for information about the valuation of
the promissory note.
(vi) Retirement funds
Any resource set aside by a member of the individual's
financial responsibility group to be used for self-support upon their
withdrawal from active life, service, or business.
Retirement funds include but are not limited to IRAs, Keogh
plans, 401K plans, pensions, mutual funds, stocks, bonds, securities, money
market accounts, whole life insurance, and annuities. The value of a retirement
fund is the amount of money that can currently be withdrawn from the fund. See
§ 29.08(i)(5) for information on the resource exclusion of retirement
funds. See § 29.08(f) for information on the exclusion of early withdrawal
and surrender penalties.
(vii) Health savings accounts (HSAs)
Accounts used to set aside funds to meet medical expenses.
Unless the individual can demonstrate that the funds in their HSA are not
available to them, the HSA is a countable resource.
(c) Resources managed
by a third party
Resources, liquid and nonliquid, managed by a third party
include, but are not limited to, trusts, guardianship accounts, and retirement
funds. Resources of a member of the financial responsibility group managed by a
third party (e.g., trustee, guardian, conservator, or agent under a power of
attorney) are considered available to the member as long as the member can
direct the third party to dispose of the resource or the third party has the
legal authority to dispose of the resource on the member's behalf without the
member's direction.
(1) Definitions
(i) Guardian
A person or institution appointed by a court in any state to
act as a legal representative for another person, such as a minor or a person
with disabilities. Guardianship funds are presumed to be available for the
support and maintenance of the protected person. That person may rebut the
presumption of the availability of guardianship funds by presenting evidence to
the contrary, including, but not limited to, restrictive language in the court
order establishing the account or in a subsequent court order regarding
withdrawal of funds.
(ii)
Power of attorney
A written document signed by a person giving another person
authority to make decisions on behalf of the person signing it, according to
the terms of the document. Vermont law requires a power of attorney to be
executed according to certain formalities, such as being signed, witnessed, and
acknowledged. Funds managed by an agent under a power of attorney are not
property of the agent and cannot be counted as resources of the agent.
(iii) Representative payee
An individual, agency, or institution selected by a court or
the SSA to receive and manage benefits on behalf of another person. A
representative payee has responsibilities to use these payments only for the
use and benefit of that person, to notify the payer of any event that will
affect the amount of benefits the person receives or circumstances that would
affect the performance of the representative payee's responsibilities, and
account periodically for the benefits received. Funds managed by a
representative payee are not property of the representative payee and cannot be
counted as resources of the representative payee.
(iv) Trust
A trust is a property interest where property is held by an
individual or an entity (called a "trustee") subject to a fiduciary duty to use
the property for the benefit of another person (the "trust beneficiary"). A
trust includes a legal instrument or device that is similar to a trust but may
not be called a trust. See § 29.08(e) for information on resource
exclusion of trusts. The following are terms related to trusts:
(A) Grantor (also known as settler or
trustor)
(I) The person who transfers liquid
or nonliquid property to another person or entity (the "trustee"), with the
intention that it be held, managed, or administered by the trustee for the
benefit of one or more persons (the "grantees") In some cases, the grantor is
named as a grantee.
(II) A person
is considered the grantor of a trust if:
(i)
The assets of the person were used to form all or part of the principal of the
trust; and
(ii) One of the
following established the trust:
(A) The
person;
(B) Another person, court,
or administrative body, with legal authority to act in place of or on behalf of
the person; or
(C) Another person,
court, or administrative body, acting at the direction of or upon the request
of the person.
(B) Trustee
The person or entity (such as a bank or insurance company)
that holds, manages, or administers trust property for the benefit of the
trust's grantee(s). In most cases, a trustee does not have the legal right to
use the trust property for their own benefit. Some, but not all, trusts grant
discretion to the trustee to use judgment as to when or how to handle trust
principal or trust income. A trust may provide reasonable compensation to the
trustee for managing the trust as well as reimbursement for reasonable costs
associated with managing the trust property.
(C) Grantee (also known as beneficiary)
The person or entity that receives the benefit of a trust. A
trust can have more than one grantee at the same time; it can also have
different grantees under different circumstances.
(D) Trust income (also known as trust
earnings)
Monies earned by the trust property. It may take various
forms, such as interest, dividends, or rental payments. These amounts may be
countable unearned income to any person legally able to use them for their
support and maintenance.
(E) Trust principal (also known as trust
corpus)
The property that the grantor transfers to the trustee for
the benefit of the grantee(s).
(F) Trust property
The sum of the trust principal and the trust income.
(G) Residual beneficiary
The person or entity named in the trust to receive the trust
property upon termination of the trust.
Section 29.08 Excluded
resources
(01/15/2017, GCR 16-098)
This subsection specifies the resources whose value is
excluded in determining MABD eligibility.
(a) Real property
(1) Home and contiguous land
(i) Definition
Home means the property in which an individual resides and
has an ownership interest and which serves as the individual's principal place
of residence. This property includes the shelter in which the individual
resides, the land on which the shelter is located, related outbuildings, and
surrounding property not separated from the home by intervening property owned
by others. Public rights of way, such as roads that run through the surrounding
property and separate it from the home, will not affect the exemption of the
property. The home includes contiguous land and any other nonresidential
buildings located on the contiguous land that are related to the home.
(ii) Exclusion
(A) Except when determining an individual's
eligibility for Medicaid coverage of long-term care services and supports, a
home is excluded as a resource, regardless of its value.
(B) For Medicaid coverage of long-term care
services and supports, the home is considered a resource when the equity in the
home is substantial. See Vermont's Medicaid Procedures Manual for the current
substantial home equity limit; see § 29.09(d)(6) for information on
exceptions to the application of the substantial home equity limit. The home
may also be considered as a resource when determining whether the home has been
transferred and should be subject to a penalty period (see § 25.00
)
(C) The home exclusion applies
even if the owner is making an effort to sell the home.
(D) The home exclusion also applies if the
owner is absent from the home due to institutionalization, provided they have
not placed the home in a revocable trust, and any one of the following three
conditions is satisfied:
(I) The owner
intends to return to the home even if the likelihood of return is apparently
nil.
(II) The owner has a spouse or
dependent relative residing in the home. Dependent relative in this context
applies to:
(i) Any kind of dependency
(medical, financial, etc.); and
(ii) A relationship to the owner that is one
of the following: child, step-child, or grandchild; parent, step-parent, or
grandparent; aunt, uncle, niece, or nephew; brother or sister, step-brother or
step-sister, half brother or half sister; cousin; or in-law.
(III) The owner has a medical
condition that prevented them from residing in the home before
institutionalization.
(E) Unless one of the exceptions listed in
(D) applies, the home becomes a countable resource when the owner moves out of
the home without the intent to return, because it is no longer their principal
place of residence.
(F) Temporary
absences, such as for hospitalization or convalescence with a relative, do not
affect the determination of the owner's principal place of residence.
(2) Proceeds from the
sale of an excluded home
(i) Proceeds from
the sale of a home is excluded to the extent that the owner intends to use the
proceeds and, in fact, uses or obligates them to purchase or construct another
home within three months of the date the proceeds are received.
(ii) Use of proceeds from the sale of a home
to pay costs of another home will be excluded only if the other costs are paid
within three months of the sale of the home. Such costs are limited to the down
payment, settlement costs, loan processing fees and points, moving expenses,
necessary repairs to or replacements of the new home's structure or fixtures
(e.g., roof, furnace, plumbing, built-in appliances) identified and documented
prior to occupancy, and mortgage payments for the new home.
(iii) The value of a promissory note or
similar installment sales contract constitutes a "proceed." Other proceeds
consist of the down payment and the portion of any installment amount
constituting payment against the principal. These are also excluded if used
within 3 months to make payment on the replacement home.
(iv) When all of the proceeds are not timely
reinvested as specified above, the portion of the proceeds retained by the
owner are combined with the value of the promissory note or installment sales
contract and counted as a resource beginning with the month following the month
the note or contract is executed. If the entire proceeds are fully reinvested
in a replacement home at a later date, the value of the note or contract and
reinvested proceeds are excluded beginning with the month after the month in
which they are reinvested, but any proceeds not reinvested as specified above
remain a countable resource until fully reinvested.
(3) Real property up-for-sale
(i) Real property is excluded from being a
countable resource as long as the owner verifies that they are making
reasonable efforts to sell it. Reasonable efforts to sell property means taking
all necessary steps to sell it for fair market value in the geographic area
covered by the media serving the area in which property is located, unless the
owner is prevented by circumstances beyond their control from taking these
steps.
(ii) The steps considered
necessary to sell the property depend on the method of sale. An owner may
choose to list the real property with a real estate agent or undertake to sell
it themselves.
(iii) If the owner
chooses to list the property with a real estate agency, they must take the
necessary step of listing it and cooperating with the real estate agent's
efforts to sell it.
(iv) If the
owner chooses to sell the property without an agent, they must take all of the
following necessary steps:
(A) Advertise the
property in at least one of the appropriate local media continuously;
(B) Place a "For Sale" sign on the property
continuously, unless prohibited by zoning regulations;
(C) Conduct open houses or otherwise show the
property to prospective buyers; and
(D) Attempt any other appropriate methods of
sale.
(v) If any
prospective buyer makes a reasonable offer for the property, the owner must
accept it or demonstrate why it was not a reasonable offer. Any offer of at
least two-thirds of the most recent estimate of the property's fair market
value is considered a reasonable offer.
(vi) Fair market value means:
(A) A certified appraisal; or
(B) An amount equal to the price of the
property on the open market in its locality at the time of the transfer or
contract for sale, if earlier.
(4) Home equity conversion plans
(i) Definition
Home equity conversion plans are financial instruments used
to secure loans with real property as collateral. Home equity conversion plans
include reverse mortgages, reverse annuity mortgages, sale-leaseback
arrangements, time-sale agreements, and deferred payment loans.
(ii) Exclusion as a resource in
month received
In the month of receipt, funds an owner of the real property
receives from any home equity conversion arrangements on their real property
are excluded as a resource. Any funds received from a home equity conversion
plan that are retained after the month of receipt are counted as a resource
beginning the month after receipt.
For information on the treatment of the funds for purposes of
income eligibility, see § 29.13(b)(30).
(5) Jointly-owned real property
(i) Exclusion due to joint owner's refusal to
sell
(A) An owner's interest in jointly-owned
real property is excluded as a resource as long as:
(I) At least one of the other joint owners
refuses to sell the property; and
(II) The joint ownership was created more
than 60 months before the date of the MABD application.
(B) The addition of a new joint owner (or
joint owners) to a property is considered as the creation of a new joint
ownership. The new joint ownership will be evaluated as a countable resource
under § 29.09(d)(3) if the addition of the new joint owner was made within
60 months of the date of the MABD application.
(ii) Exclusion due to undue hardship
An owner's interest in jointly-owned real property is
excluded as a resource if the sale of the property would cause the other joint
owner (or owners) undue hardship due to loss of housing.
Undue hardship would result when:
(A) The property serves as the principal
place of residence for one or more of the other joint owners;
(B) Sale of the property would result in loss
of that residence; and
(C) No other
housing would be readily available for the displaced other owner.
(6) Life estates
(i) Treatment of life estate interest created
on or after July 1, 2002
For a life estate ownership in real property created on or
after July 1, 2002:
(A) The value of
the life estate is excluded as a resource when the life estate owner does not
retain the power to sell or mortgage the real property. For purposes of
eligibility for Medicaid coverage of long term care services and supports,
however, the life estate may be considered as a resource when determining
whether it has been transferred and should be subject to a penalty period (see
§ 25.00).
(B) When the life
estate owner retains the power to sell or mortgage the real property, including
any remainder interest, the value of the life estate is excluded only if the
life estate is an interest in the life estate owner's home ( § 29.08(a)(1)
). Otherwise, the value of the life estate is counted. For this purpose, the
value of the life estate includes the value of the remainder
interest.
(C) When an individual
transfers their home and retains a life estate with the power to sell or
mortgage the property, the transfer is not subject to a transfer penalty
analysis under § 25.00. In this situation, no transfer has occurred
because the individual's ownership interest in the home has not been reduced or
eliminated.
(ii)
Treatment of life estate interest created before July 1, 2002
For a life estate ownership created before July 1,
2002:
(A) When the life estate owner
retains the power to sell the real property, including any remainder interest,
the value of the life estate is excluded only if the life estate is excludable
on another basis, such as because it is real property producing significant
income. Otherwise, the value of the life estate is counted. For this purpose,
the value of the life estate includes the value of the remainder
interest.
(B) The life estate
ownership is excluded as a resource when the life estate owner does not retain
the power to sell the real property.
(7) Income-producing real property
(i) Non-business real property. Non-business
real property is excluded as a resource if the property produces significant
income to the owner. Real property is considered to produce significant income
if it generates at least 6 percent of its fair market value in net annual
income after allowable expenses related to producing the income are
deducted.
(ii) Real property used
in a trade or business. Real property is excluded as a resource if the real
property is essential to the owner's self-support and used by the owner in a
trade or business. For purposes of this exclusion, the property must be in
current use in the type of activity that qualifies it as essential.
(8) Goods for home consumption
Non-business real property is excluded as a resource of the
owner when used by the owner to produce goods for only home consumption (e.g.,
a garden plot used to raise vegetables to be eaten at home or a wood lot used
to provide fuel to heat the home). When real property is used to produce goods
for both home consumption and income production, only the part used to produce
goods for home consumption is excluded. The part of the property used for
income production is evaluated for exclusion under (7) above.
(b) Insurance
(1) Exclusion of life insurance
(i) Whole life insurance
(A) If the combined face values of the whole
life insurance policies owned by any one member of the financial responsibility
group do not exceed $ 1500, the cash surrender values of the policies are
excluded.
(B) If the combined face
values exceed $ 1500, the cash surrender values, excluding any amounts up to $
1500, and all dividend additions are a countable resource.
(ii) Term life insurance
Regardless of its face value, a term life insurance policy is
not a countable resource.
(2) Long-term care insurance partnership
(i) Definition: Qualified State Long-Term
Care Insurance Partnership
A state plan amendment that provides for the disregard of any
assets or resources in an amount equal to the insurance benefit payments that
are made under a long-term care insurance policy (including a certificate
issued under a group insurance contract), but only if:
(A) The policy covers an insured who, at the
time coverage under the policy first becomes effective, is a resident of such
State or of a State that maintains a Qualified Long-Term Care Insurance
Partnership;
(B) The policy is a
qualified long-term care insurance contract within the meaning of §
7702B(b) of the Code;
(C) The
policy provides some level of inflation protection as set forth in regulations
promulgated by the Department of Financial Regulations (DFR);
(D) The policy satisfies any requirements of
State or other applicable law that apply to a long-term care insurance policy
as certified by the DFR; and
(E)
The issuer of the policy reports:
(I) To the
Secretary of HHS such information or data as the Secretary may require;
and
(II) To the State, the
information or data reported to the Secretary of HHS (if any), the information
or data required under the minimum reporting requirements developed under
§
2(c)(1)
of the State Long-Term Care Partnership Act of 2005, and such additional
information or data as the State may require.
(ii) Exclusion
(A) Subject to approval by CMS, assets or
resources 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 are excluded.
(B) This section is further contingent on the
passage of changes to
33 VSA §
1908a necessary to bring the Vermont statute
on Long-Term Care Partnership Insurance into conformance with the requirements
of § 6021 of the federal Deficit Reduction Act of 2005.
(c) Burial
Funds Exclusion
(1) For any person whose
income and resources are considered in determining MABD eligibility, up to $
10,000 of burial funds are excluded, as long as the person shows that the funds
are designated for burial expenses through the title to the funds or by a sworn
statement provided. The funds must be separately identifiable and not
commingled with other funds.
(2)
Burial funds may be excluded as of the first day of the month in which the
person whose income and resources are considered in determining MABD
eligibility established it. Interest and appreciation accrued on burial funds
are excluded if the funds have been left to accumulate.
(3) The value of certain burial spaces may
also be excluded under the allowable limit of $ 10,000 for each person whose
income and resources are considered in determining MABD eligibility. Such
spaces must be held for the burial of a member of the individual's immediate
family. For this purpose, the immediate family includes the individual's
spouse, children, brothers, sisters, and parents.
(4) Irrevocable burial trusts established
prior to July 1, 2002 and funded in excess of $ 10,000 are excluded up to the
value of the trust as of June 30, 2002.
(d) Other income-producing resources
(1) Annuities
(i) An annuity is excluded as a resource of
an individual requesting MABD or of their spouse if the annuity is in its
pay-out phase and meets all of the following conditions:
(A) Has no beneficiary (or payee) other than
the individual requesting MABD or their spouse;
(B) Provides for payments to the beneficiary
in equal intervals and equal amounts;
(C) Does not exceed the life expectancy of
the beneficiary as determined by using the annuity tables published by the
Office of the Chief Actuary of the SSA (
http://socialsecurity.gov/OACT/STATS/table4c6.ht ml) and set forth in Vermont's
Medicaid Procedures Manual;
(D)
Returns to the beneficiary at least the amount used to establish the annuity
contract and any additional payments plus any earnings, as specified in the
contract; and
(E) Except as
provided in (ii) below, does not pay anyone else, as residual beneficiary, in
the event the beneficiary dies before the payment period ends.
(ii) An annuity will also be
considered to meet the requirements of (A) and (E) of (i) above if the
individual or their spouse, as the owner of the annuity, elects to designate
Vermont Medicaid as the primary residual beneficiary up to the amount of
Medicaid payments made on behalf of the individual (or their spouse), and names
a contingent residual beneficiary other than the individual or their spouse to
receive any surplus after Vermont Medicaid is paid.
(2) Promissory notes and other
income-producing resources
(i) A promissory
note or similar resource that produces income is excluded as a resource of an
individual requesting MABD eligibility or of their spouse if:
(A) It meets the requirements in paragraph
(1)(A) through (E) above; or
(B)
The owner owned a nonnegotiable or nonassignable promissory note executed
before September 1, 2005 and they can expect to receive the full fair market
value of the resource within their expected lifetime, as determined by using
the annuity tables published by the Office of the Chief Actuary of the SSA (
http://socialsecurity.gov/OACT/STATS/table4c6.ht ml) and set forth in Vermont's
Medicaid Procedures Manual.
(ii) All other promissory notes and similar
resources that produce income are evaluated for whether they are a countable
resource as specified in § 29.09(d)(5) or, for purposes of Medicaid
coverage of long-term care services and supports, subject to a transfer penalty
as specified in § 25.00.
(e) Excluded trusts
(1) In general
(i) A trust is excluded as a resource if the
member of the financial responsibility group is the grantor or grantee of the
trust and cannot revoke the trust or receive trust property, whether or not the
trustee exercises their full discretion. Trust property is also excluded as a
resource when the grantor is a member of the financial responsibility group and
establishes a trust by will (often referred to as a "testamentary
trust").
(ii) The following trust
property is excluded as a resource when either the grantor or the grantee is a
member of the financial responsibility group:
(A) Trust property in a trust established
prior to April 7, 1986, for the sole benefit of a person who is developmentally
disabled residing in an ICF-DD.
(B)
Trust property in a trust for which the grantee is a disabled child under the
decision in Sullivan v. Zebley, 493 U. S.
521 (1990).
(C) Trust property or any portion of trust
property that cannot be made available to the member of the financial
responsibility group, either through full exercise of the trustee's discretion
under the terms of the trust or through revocation of the trust by a member of
the financial responsibility group.
(D) Trust property in a trust established by
persons other than the individual or the individual's spouse (known as a
third-party trust) unless the terms of the trust permit the individual (or
their spouse) to revoke the trust or to have access to it without trustee
intervention.
(E) Trust property in
an irrevocable trust, including a home placed in an irrevocable trust by an
institutionalized individual who intends to return to it, from which no payment
under any circumstances could be made to the individual.
(F) A special needs trust that contains the
assets of an individual under the age of 65 who does or would meet the SSI
criteria for disability, and meets all of the criteria below:
(I) Was established through the actions of a
parent, grandparent, or legal guardian of the disabled individual, or by a
court;
(II) Was established for the
sole benefit of the disabled individual which means that no person or entity
except the disabled individual can benefit from the trust in any way, until
after the death of the disabled individual and then not before Vermont Medicaid
receives sums owed under the payback provision under (III) below; and
(III) Includes a payback provision which
requires that, upon the death of the disabled individual, any amounts remaining
in the trust will first be paid to Vermont Medicaid in an amount equal to the
total Medicaid payments made on behalf of the disabled individual.
(G) A pooled trust that contains
the assets of an individual who does or would meet the SSI criteria for
disability, and meets all of the criteria below:
(I) Was established and administered by a
non- profit association;
(II)
Maintains a separate account for the disabled individual, but assets are pooled
for investing and management purposes;
(III) The separate account was established
for the sole benefit of the disabled individual;
(IV) The account was established through the
actions of the disabled individual, their parent, grandparent or legal
guardian, or by a court; and
(V)
The trust contains a pay-back provision which requires that to the extent any
amounts in the separate account for the disabled individual upon their death
are not retained by the trust, such amounts will first be paid to Vermont
Medicaid in an amount equal to the total Medicaid payments made on behalf of
the disabled individual.
(VI) Any
asset of the disabled individual that is added to the trust after the disabled
individual reaches the age of 65 may be subject to transfer penalty (see §
25.00) for purposes of the disabled individual's eligibility for Medicaid
coverage of long-term care services and supports.
(iii) In the case of a trust with
more than one grantor, these exclusions apply only to that portion of the trust
attributable to the income or resources of a member of the financial
responsibility group. In the case of a trust with more than one grantee, the
exclusions apply only to that portion of the trust available for the benefit of
a member of the financial responsibility group.
(2) Trusts excluded due to hardship
(i) Trust property that has not been
distributed may be excluded if counting it as a resource would cause undue
hardship to a grantor or grantee who is a member of the financial
responsibility group.
(ii) Undue
hardship includes situations in which a member of the financial responsibility
group or someone in the member's immediate family would be forced to go without
life-sustaining services because the trust property could not be made available
to pay for the services. For this purpose, the immediate family includes the
member's spouse, children, brothers, sisters, and parents.
(iii) The following situations also would
cause undue hardship:
(A) Funds can be made
available for medical care only if trust property is sold, and this property is
the sole source of income for the member or someone in the member's immediate
family; and
(B) Funds can be made
available for medical care only if income-producing trust property is sold and,
as a result of this sale, the member or someone in the member's immediate
family would qualify for SSI, Reach Up, AABD, General Assistance, 3SquaresVT,
or another public assistance program requiring a comparable showing of
financial need.
(iv)
Undue hardship does not exist when application of the trust regulations does
not cause risk of serious deprivation to the member of someone in the member's
immediate family.
(v) An individual
claiming undue hardship must submit a written request and any supporting
documentation. Required documentation from the individual can include, but is
not limited to, the following:
(A) A
statement from the individual's attorney, if one was involved;
(B) Verification of medical insurance
coverage and statements from medical providers relative to usage not covered by
the insurance; or
(C) A statement
from the trustee of the trust.
(vi) When application of trust provisions are
waived because they would cause the individual undue hardship, only amounts
actually distributed from the trust and held for more than a month are counted
as a resource.
(vii) Request for
consideration of undue hardship does not limit an individual's right to appeal
denial of eligibility for any reason, including the determination of undue
hardship.
(f)
Early withdrawal and surrender penalties
(1)
Early withdrawal penalties and surrender fees assessed by a financial
institution are excluded to the extent that they reduce the value of a
countable resource that has been liquidated. Examples of resources to which
this exclusion applies are retirement funds, annuities, bonds, and certificates
of deposit.
(2) Income tax
withholding and tax penalties for early withdrawal are not excluded.
(g) Jointly-owned accounts
A jointly-owned account in a financial institution is
excluded as a resource only if the owner rebuts the presumption of availability
by:
(1) Submitting a statement, along
with a corroborating statement (or statements) from the other joint owner (or
owners) of the account, regarding who owns the funds in the joint account, why
there is a joint account, who has made deposits to and withdrawals from the
account, and how withdrawals have been spent;
(2) Submitting account records showing
deposits, withdrawals, and interest, if any, in the months for which ownership
of funds is at issue; and
(3)
Taking one of the following two actions:
(i)
If the member of the financial responsibility group owns none of the funds in
the account, correcting the account title to show that the member is no longer
a co-owner of the account; or
(ii)
If the member owns only a portion of the funds in the account, separating the
funds owned by other account owners from the member's funds and correcting the
account title on the member's funds to show they are solely owned by the
member.
(h)
Fiduciary for a joint fiduciary account [18]
(1) Definition: Joint fiduciary account
A deposit in a financial institution in the name of an owner
naming one or more fiduciaries. The owner makes a clear statement about how the
money can be used, and the fiduciary is required to follow those instructions
and keep track of how the money is spent.
(2) Exclusion
When an individual owns a joint fiduciary account, it is
counted as a resource. When an individual is designated a fiduciary of a joint
fiduciary account, the joint fiduciary account is an excluded resource for the
fiduciary.
(i)
Other excluded resources
(1) Household goods,
personal effects and other personal property
(i) Except as provided in (ii), home
furnishings, apparel, personal effects, and household goods are excluded as
resources. Tools, equipment, uniforms and other nonliquid property required by
the owner's employer or essential to the owner's self-support are also excluded
as resources.
(ii) Items an owner
acquires or holds because of their value or as an investment are not
excluded.
(2) Vehicles
(i) Except as provided in (ii), all
automobiles are excluded as resources. Other vehicles, such as trucks, boats,
and snowmobiles, are excluded only if they are used to provide necessary
transportation (i.e., an automobile is unavailable or cannot be used to
transport the aged, blind or disabled individual).
(ii) Automobiles or other vehicles an owner
acquires or holds because of their value or as an investment are not
excluded.
(3)
Independent living contracts
(i) Definitions
(A) Contracts for medical care, assistive
technology devices, and home modifications
Any written agreement, contract, or accord (including
modifications) for reasonable and necessary medical care, assistive technology
devices, or home modifications not covered by Medicare, private insurance, or
Medicaid and determined by AHS to be needed to keep an individual at home and
out of a skilled nursing facility.
(B) Medical care
Care not covered under AHS's Choices for Care program,
including but not limited to, general supervision when required by the
cognitive impairment of the individual and/or unstable medical condition that
requires monitoring of the individual.
(C) Assistive technology devices
Any item, piece of equipment or product system whether
acquired commercially off the shelf, modified, or customized, to increase,
maintain, or improve the individual's functional capabilities.
(D) Home modifications
Physical adaptations to the individual's home that ensure the
health and welfare of the individual, or that improve the individual's ability
to perform activities of daily living or instrumental activities of daily
living.
(ii)
Exclusion
Resources set aside under a contract or contracts for medical
care, assistive technology devices, or home modifications are considered to be
available resources unless all of the following criteria are met:
(A) The contract is in writing and signed
before any services are provided;
(B) The funds, not to exceed a total of $
30,000, are held in a separate bank account from other resources in the sole
name of the individual applying for MABD;
(C) Any amounts due are paid after the
services are rendered;
(D) The
payments for:
(I) Medical care or assistive
technology services do not exceed $ 500 per month; and
(II) Home modifications do not exceed a
one-time expenditure of $ 7,500;
(E) The payments to nonlicensed individuals
or providers do not exceed the fair market value of such services being
provided by similarly situated and trained nonlicensed individuals, not to
exceed the amount paid under AHS's Choices for Care program (see
http://www.ddas.vermont.gov/ddas-
publications/publications-ddas/service-codes-rates- sfy-03-06-13).
(F) Periodic accountings, as requested by
AHS, must be provided specifying the amount of each expenditure, who was paid,
the service given, and the number of hours and dates of service
covered;
(G) The individual has the
power to modify, revoke or terminate the contract for care;
(H) The contract ceases upon the death of the
individual. It also ceases upon the individual's admission to an institution
for long term care for more than 45 days if not eligible for the home upkeep
deduction under § 24.04(d), or
6 months if
eligible for the deduction. In addition, revocation or termination of the
contract ceases the agreement.
(I)
Upon cessation of the contract as specified above, any remaining balance of
funds shall be treated as
(I) An asset of the
individual's estate, if the individual is deceased;
(II) An available resource that may not be
converted to an excluded resource and must be applied at the Medicaid pay rate
toward long term care services and supports if the individual is admitted to an
institution for long- term care for more than 6 months. In cases where the
individual dies before the resource is fully expended, the remainder shall
become an asset of the individual's estate; or
(III) An excluded resource, if the individual
revokes or terminates the contract and continues to receive services under
AHS's Choices for Care program.
(4) Cash/liquid resources
(i) Income is excluded as a resource in the
month of receipt, such as an automatic deposit of a social security check into
a checking account.
(ii) Liquid
resources used in the operation of the owner's trade or business as property
essential to self-support are excluded.
(5) Exclusion of retirement funds
(i) Any retirement fund owned by a member of
the financial responsibility group is excluded when:
(A) The member must terminate employment in
order to obtain any payment from the fund;
(B) The member is not eligible for periodic
payments from the fund and does not have the option of withdrawing a lump sum
from the fund; or
(C) The member is
drawing on the retirement fund at a rate consistent with their life expectancy,
as specified in § 25.03(b).
(ii) If the member is eligible for periodic
payments or a lump sum, the member must choose the periodic payments. If the
member receives a denial on a claim for periodic retirement benefits, but can
withdraw the funds in a lump sum, the lump sum value is counted in the
resources determination for the month following that in which the member
receives the denial notice.
(iii)
When a member of the financial responsibility group is seeking Medicaid
coverage of long-term care services and supports under MABD and has a spouse,
any retirement fund held by the member in an individual retirement account
(IRA) or in a work- related pension plan (including Keogh plans) as defined by
the Code, does not require a change in the title of ownership in order for the
fund to be treated as an excluded resource for the benefit of the
spouse.
(6) Tax refunds
Tax refunds on real property, income, and food are excluded
as resources.
(7) Student
benefits
Any portion of any grant, scholarship, or fellowship used to
pay fees, tuition, or other expenses necessary to securing an education is
excluded. Portions used to defray costs of food or shelter must be
counted.
(8) Savings from
excluded income
Savings from excluded income and resources are excluded as
resources. This includes, but is not limited to, the following:
(i) Liquid resources, including interest
earned by the resources accumulated from earnings by a person working with
disabilities (see § 8.05(d)) on or after January 1, 2000, and kept in a
separate bank account from other liquid resources, unless no bank within a
reasonable distance from the person's residence or place of work permits the
person working with disabilities to establish a separate account without
charging fees; and
(ii) Nonliquid
resources purchased by a person working with disabilities on or after January
1, 2000, with savings from earnings or with a combination of savings from
earnings and other excluded income or resources.
(9) Resources excluded by federal law
The following are excluded by federal law from both income
and resources:
(i) The value of meals
and food commodities distributed under the National School Lunch Act and the
Child Nutrition Act.
(ii) The value
of 3SquaresVT or 3SquaresVT cash-out checks.
(iii) The value of food or vouchers received
through the WIC Program.
(iv) The
value of food or meals received under the Older Americans Act.
(v) Compensation or remuneration received for
volunteer work in ACTION programs including foster grandparents, RSVP, SCORE,
ACV, ACE, VISTA, Senior Companion Program and UYA.
(vi) The value of assistance received under
the U. S. Housing Act, U. S. Housing Authorization Act and the Housing and
Urban Development Act.
(vii) The
value of relocation assistance to displaced persons under the Uniform
Relocation and Real Property Acquisition Policies Act.
(viii) Per capita distributions to certain
Indian Tribes and receipts from lands held in trust for certain Indian
Tribes.
(ix) Payments received
under the Alaskan Native Claims Settlement Act.
(x) Grants or loans received for educational
purposes under any U. S. Department of Education program.
(xi) Any assistance received under the
Emergency Energy Conservation or Energy Crisis Program.
(xii) Any assistance received under the
Low-Income Home Energy Assistance Act, either in cash or through vendor
payments.
(xiii) Compensation paid
to Americans of Japanese or Aleut ancestry as restitution for their
incarceration during World War II.
(xiv) Agent Orange Settlement
payments.
(xv) German reparations
to concentration camp survivors, slave laborers, partisans, and other victims
of the Holocaust. Settlement payments to victims of Nazi persecution or their
legal heirs resulting from the confiscation of assets during World War
II.
(xvi) War reparations paid
under the Austrian government's pension system.
(xvii) Radiation Exposure Compensation Trust
Fund payments.
(xviii) Assistance
received under the Disaster Relief and Emergency Assistance Act or other
assistance provided under a Federal statute because of a catastrophe which is
declared to be a major disaster by the President of the United States.
Comparable assistance received from a State or local government, or from a
disaster assistance organization is also excluded. Interest earned on the
assistance is also excluded.
(xix)
Netherlands' Act on Benefits for Victims of Persecution 1940-1945
payments.
(xx) Any account,
including interest or other earnings on the account, established and maintained
in accordance with § 1631(a)(2)(F) of the Act. These accounts are
established with retroactive SSI payments made to a child under age 18 and used
in ways specified in the Act. The exclusion continues after the child has
reached age 18.
(xxi) Earnings
deposited in a special savings account under the Tangible Assets project
managed by the Central Vermont Community Action Council and authorized by
PRWORA.
(xxii) Payments as the
result of a settlement in the case of Susan Walker v. Bayer Corporation, et al.
made to hemophiliacs who contracted the HIV virus from contaminated blood
products.
(xxiii) Any resource of a
blind or disabled individual that is necessary for them to carry out their
approved Plan for Achieving Self-Support (PASS). The plan must be approved by
the SSA.
(10) Exclusions
for limited periods
The following resources are excluded for specific
periods:
(i) Retroactive Social
Security and SSI/AABD
Retroactive payments of SSI, the AABD supplement to SSI, or
Social Security benefits for nine months beginning with the month after the
month of receipt. These payments are also excluded as resources during the
month of receipt.
(ii)
Funds for replacing excluded resources
Cash and interest earned on that cash received from any
source, including casualty insurance, for the purpose of repairing or replacing
an excluded resource that is lost, stolen, or damaged, if used to replace or
repair that resource. The exclusion is allowed for nine months from the month
of receipt. An extension of an additional nine months can be granted for good
cause.
(iii) Earned income
tax credit
State and federal earned income tax credit refunds and
advance payments for nine months beginning with the month after the month of
receipt.
(iv) Medical or
Social Services payments
Cash received for medical or social services for the calendar
month following the month of receipt. In the month following the month of
receipt, it is counted as a resource if it has been retained.
(v) Victim's compensation payments
State-administered victims' compensation payments for nine
months after the month of receipt.
(vi) Relocation payments
State and local government relocation payments for nine
months after the month of receipt.
(vii) Expenses from last illness and burial
Payments, gifts, and inheritances occasioned by the death of
another person provided that they are spent on costs resulting from the last
illness and burial of the deceased by the end of the calendar month following
the month of receipt.
(11) Exclusion of U. S. savings bonds
(i) A U. S. savings bond is excluded as a
resource during its minimum retention period if the owner of the savings bond
requested a hardship waiver based on financial need due to medical expenses and
received a denial from the United States Department of the Treasury, Bureau of
Public Debt, Accrual Services Division in Parkersburg, P. O. Box 1328,
Parkersburg, West Virginia 26106-1328.
(ii) Upon verification of a denial of a
hardship waiver, as described above, a U. S. savings bond is considered an
available resource of the owner following the expiration of the minimum
retention period. Once the minimum retention period expires, the denial of a
hardship waiver is not a basis for exclusion of new bond purchases or other
excluded assets purchased with the proceeds.
(iii) A U. S. savings bond purchased before
June 15, 2004, that has its minimum retention period expire after that date,
continues to be an excluded resource if it is not redeemed, exchanged,
surrendered, reissued, used to purchase or fund other excluded assets, or
otherwise becomes available.
(12) Home-based long-term care disregard
An additional resource disregard of $ 3,000 to the standard $
2,000 resource disregard is allowed for an aged or disabled individual without
a spouse who resides in and has an ownership interest in their principal place
of residence and chooses Medicaid coverage of long-term care services and
supports under MABD to be provided in their residence provided all other
eligibility criteria are met. This additional resource disregard remains
available until the individual begins receiving Medicaid coverage of long term
care services and supports under MABD in an institution or in a residential
care home that provides enhanced residential care services. Thereafter, if the
individual meets the requirements for a home upkeep deduction (see §
24.04(d)), they are eligible to continue this resource disregard for up to 6
months.
Section
29.09 Value of resources counted toward the Medicaid resource
limit
(01/15/2017, GCR 16-098)
(a) In general
Unless an exception under paragraph (d) below applies, the
ownership interests of resources of the members of the financial responsibility
group are valued according to these general rules.
(1) Resources not excluded under § 29.08
are valued at their equity value (see (b) below for definition of equity
value).
(2) The portion of
jointly-owned resources not excluded and countable toward the MABD resource
limit is determined according to the rules in paragraph (c) below.
(3) The equity value of any resource owned
entirely by members of the financial responsibility group and not excluded
under § 29.08 is counted toward the MABD resource limit.
(b) Definition: Equity value
(1) The fair market value of the resource
minus the total amount owed on it in mortgages, liens, or other
encumbrances.
(2) The original
estimate of the equity value of a resource is used unless the owner submits
evidence from a disinterested, knowledgeable source that, in AHS's judgment,
establishes a reasonable lower value.
(c) Counting jointly-owned resources
(1) In general
(i) This paragraph defines each type of joint
ownership and the amount of the resource that is counted when ownership is
shared.
(ii) When two or more
parties share rights to sell, transfer, or dispose of part or all of personal
or real property, the ownership share held by members of the financial
responsibility group is counted as prescribed by state law. Shared ownership or
control occurs in different forms, including tenancy- in-common, joint tenancy,
and tenancy-by-the- entirety. The type of shared ownership involved is
determined and used to compute the countable value of the resource. If an
individual submits evidence supporting another type of shared ownership, AHS
will make a decision about which type applies. If AHS decides not to use the
type submitted by the individual, it will provide the individual with a written
notice stating the basis for its decision.
(iii) Under Vermont law, a co-owner may
demand partition, the dividing of lands held by more than one person. For this
reason, AHS counts the individual's proportionate share of the lands as an
available resource, unless excluded as a home or property up for
sale.
(2) Definition:
Tenancy-in- common
(i) In tenancy-in-common,
two or more parties each have an undivided fractional interest in the whole
property. These interests are not necessarily equal. One owner may sell,
transfer or otherwise dispose of their share of the property without permission
of the other owner(s) but cannot take these actions with respect to the entire
property.
(ii) When a
tenant-in-common dies, the surviving tenant(s) has no automatic survivorship
rights to the deceased's ownership interest in the property. Upon a tenant's
death, their interest passes to their estate or heirs.
(iii) Tenancy-in-common applies to all
jointly-owned resources when title to the resource does not specify joint
tenancy or tenancy-by-the-entirety.
(iv) See (c)(5) below for how a resource
owned by a member of the financial responsibility group as a tenant-in-common
is counted.
(3)
Definition: Joint tenancy
(i) In joint
tenancy, each of two or more parties has an undivided ownership interest in the
whole property. In effect, each joint tenant owns all of the property. When the
property is personal property, the interests of the joint tenants are equal.
When the property is real property, the interests of the joint tenants can be
equal or unequal (unless the instrument creating the joint tenancy contains
language indicating a contrary intent, the joint tenants' interests are
presumed to be equal19).
(ii) Upon
the death of only one of two joint tenants, the survivor becomes the sole
owner. Upon the death of one of three or more joint tenants, the survivors
become joint tenants of the entire interest. For real property, the deceased
joint tenant's interest is allocated among the surviving joint tenants in
proportion to their respective interests at the time of the deceased joint
tenant's death unless the instrument creating the joint tenancy contains
language indicating a contrary intent. 20
(iii) See (c)(5) below for how a resource
owned by a member of the financial responsibility group as a joint tenant is
counted.
(4) Definition:
Tenancy-by-the- entirety
(i)
Tenancy-by-the-entirety can only exist between members of a married couple,
including parties to a civil union.
(ii) The couple, as a unit, owns the entire
property which can be sold only with the consent of both parties.
(iii) Upon the death of one
tenant-by-the-entirety, the survivor takes the whole. Upon legal dissolution,
the former couple become tenants-in-common (see (c)(2) above), and one can sell
their share without the consent of the other.
(iv) When a member of the financial
responsibility group owns a resource as a tenant-by-the-entirety, the entire
equity value of the resource is counted as available to the member.
(5) Countability
(i) General rule for tenancy-in- common and
joint tenancy
With the exception noted in (ii) below and subject to the
presumption under § 29.09(d)(3) regarding real property joint ownerships
created within 60 months prior to the date of the MABD application, AHS
assumes, absent evidence to the contrary, that each owner of shared property
owns only their fractional interest in the property. The total value of the
property is divided among all of the owners in direct proportion to the
ownership share held by each.
(ii) Exception: Accounts in financial
institutions
For an account in a financial institution, AHS assumes that
all of the funds in the account belong to the individual. If another member (or
members) of the individual's financial responsibility group is on the account,
AHS assumes the funds in the account belong to those account owners in equal
shares.
(d) Exceptions to general valuation rule
The following paragraphs describe exceptions to the general
valuation rules described in paragraph (a) above.
(1) Annuities
Unless an annuity is excluded as a resource under §
29.08(d)(1) or, for purposes of Medicaid coverage of long term care services
and supports, treated as a transfer under § 25.03(h), the fair market
value of an annuity is counted. The fair market value is equal to the amount of
money used to establish the annuity and any additional payments used to fund
the annuity, plus any earnings and minus any early withdrawals and surrender
fees. If evidence is furnished from a reliable source showing that the annuity
is worth a lesser amount, AHS will consider a lower value. Reliable sources
include banks, other financial institutions, insurance companies, and brokers,
as well as any other source AHS considers, in its discretion, to be
reliable.
(2) Life estates
Unless a life estate interest in property is excluded under
§ 29.08(a)(6) or the fair market value of the entire property (the life
estate and the remainder) is counted as a resource, the fair market value of a
life estate interest in property is established by multiplying the fair market
value of the property at the time the life estate interest was created by the
number in the life expectancy table that corresponds with the individual's age
at that time. The life estate table is found in the SSA's POMS at SI 01140.120
( https://secure.ssa.gov/apps10/poms.nsf/lnx/0501140120). If an individual
submits evidence supporting another method of establishing the fair market
value of a life estate, AHS will make a decision about what method to use. If
AHS decides not to use the method submitted, it will provide the individual
with a written notice stating the basis for its decision.
(3) Jointly-owned real property
Regardless of a co-owner's refusal to sell jointly-owned real
property pursuant to the resource exclusion under § 29.08(a)(5)(i), AHS
presumes that a member of the financial responsibility group that owns real
property jointly with another person (or persons) owns the entire equity value
of the real property if the joint ownership was created less than 60 months
prior to the date of the MABD application. This presumption may be rebutted by
a showing, through reliable sources, that the other joint owner (or owners)
purchased shares of the property at fair market value. Reliable sources include
cancelled checks or property transfer tax returns. When it has been established
that one or more other co-owners purchased their shares of the property, the
proportional interest owned by the member is counted.
(4) U. S. savings bonds
Unless a U. S. savings bond is excluded under §
29.08(i)(11), it is counted as a resource beginning on the date of purchase. To
establish the value of the bond, the Savings Bond Calculator or the
Comprehensive Savings Bond Value Table on the U. S. Bureau of Public Debt's
internet website at www.publicdebt.treas.gov/sav/savcalc.htm is used.
Alternately, AHS obtains the value by telephone from a local bank. The
following general rules apply to valuation:
(i) Series E and EE bonds are valued at their
purchase price.
(ii) Series I bonds
are valued at their face value.
(iii) Service HH bonds are valued at their
face value.
(5)
Income-producing promissory notes and contracts
(i) Unless the promissory note or other
income- producing resource (contract) is excluded under § 29.08(d)(2) or,
for purposes of Medicaid coverage of long-term care services and supports,
treated as a transfer under § 25.03(i), the fair market value of a
promissory note or contract is counted. Regardless of negotiability, fair
market value equals the amount of money used to establish the note or contract
and any additional payments used to fund it, plus any earnings and minus any
payments already received. If evidence is furnished to AHS of a good faith
effort to sell the note or contract by obtaining three independent appraisals
by reliable sources which reflect that the value of the note or contract is
less than fair market value, AHS will consider the note or contract available
to its owner only in the amount of this discounted value. Reliable sources
include banks, other financial institutions, insurance companies, and brokers,
as well as any other source AHS considers, in its discretion, to be
reliable.
(ii) For an individual
requesting Medicaid coverage of long-term care services and supports under
MABD, a note or contract valued at a discount will be treated as an available
resource at the discounted amount and may also be subject to a transfer penalty
to the extent of the amount discounted from the fair market value, in the
discretion of AHS. Where the note or contract is determined to have no value on
the open market, a transfer penalty will be applied for the full value used to
establish the note or contract and any additional payments used to fund it,
plus any earnings and minus any payments already received.
(6) Substantial home equity
(i) Definition: Home equity
The value of a home based on the town's assessment adjusted
by the common level of appraisal (CLA), minus the total amount owed on it in
mortgages, liens, or other encumbrances. When an individual requesting Medicaid
owns their home in a joint ownership with someone other than their spouse,
absent evidence to the contrary, the individual's equity interest in the home
is reduced by the amount of the other joint owner's equity interest when the
other joint owner resides in the home.
(ii) Counting rule
(A) A home is considered a resource, for
purposes of eligibility for Medicaid coverage of long term care services and
supports, when the owner's equity in the home is substantial. See Vermont's
Medicaid Procedures Manual for the current substantial home equity limit. The
substantial home equity limit increases from calendar year to year based on the
percentage increase in the consumer price index for all urban consumers (all
items; United States city average) rounded to the nearest $ 1,000.
(B) Substantial home equity precludes payment
for Medicaid coverage of long-term care services and supports unless one of the
following individuals lawfully resides in the home:
(I) The owner's spouse;
(II) The owner's child who is under age 21;
or
(III) The owner's child who is
blind or permanently and totally disabled, regardless of age.
(C) A individual with excess
equity in their home who is found ineligible for Medicaid coverage of long-term
care services and supports may receive other Medicaid services besides
long-term care services and supports if they meet the eligibility criteria for
a coverage group that covers services other than long-term care services and
supports.
(iii) Hardship
waivers
An individual who is ineligible for Medicaid coverage of
long- term care services and supports due to excess equity in their home may
request an undue hardship waiver based on the criteria specified at §
25.05.
(iv) Home equity
conversion plans (reverse mortgages) and home equity loans
An individual is permitted to use a home equity conversion
plan (reverse mortgage) or a home equity loan to reduce their equity interest
in their home. In such circumstances, the funds are valued as follows:
(A) The existence of a line of credit is not
considered to diminish the equity value except in amounts from the line of
credit actually paid to the borrower.
(B) In the month of receipt, lump-sum
payments from a home equity conversion plan or from a home equity loan are
excluded as a resource and proceeds paid in a stream of income are excludable
income.
(C) Lump sum payments from
home equity loans retained for more than a month continue to be an excluded
resource.
Lump sum payments and streams of income are subject to
transfer penalties if given away in the month of receipt or thereafter.
Section 29.10 Determination of countable
resources
(01/15/2017, GCR 16-098)
(a) In general
Countable resources are determined by combining the resources
of the members of the financial responsibility group, as described in §
29.03, and comparing them to the resource standard of the Medicaid group, as
described in § 29.04. Countable resources are determined for different
types of Medicaid groups: adults without spouses, adults with spouses,
children, and individuals requesting Medicaid coverage of long- term care
services and supports. If the resources of the Medicaid group fall below or are
equal to the applicable resource standard, the resource test is passed. If an
excess resource amount remains after all exclusions have been applied (see
§ 29.08), the individual has not passed the resource test. An individual
may become eligible for MABD by spending down or giving away excess resources
as provided in § 30.00 subject to transfer of resource rules (see §
25.00) for those seeking Medicaid coverage of long-term care services and
supports.
(b) Determining
countable resources for individuals other than children
The general rule in paragraph (a) above is followed to
determine whether total resources, after exclusions, of an individual other
than a child falls below the resource maximum for one.
(c) Determining countable resources for
individuals with spouses and not in long-term care
The general rule in paragraph (a) above is followed to
determine whether the total resources, after exclusions, of an individual
living with their spouse and requesting MABD, other than Medicaid coverage of
long-term care services and supports under MABD, falls below the resource
maximum for two.
(d)
Determining countable resources for children
(1) Unless otherwise specified in the
coverage group rules at §§ 8.05 and 8.06, the countable resources of
an eligible child are determined by:
(i)
Combining the resources of the parents living with the child with the child's
resources, until the child reaches the age of 18;
(ii) Subtracting the resource maximum for
one, if one parent, or two, if two parents, from the parent's countable
resources; and
(iii) Deeming and
adding the remainder to the child's own countable resources.
(2) If the child's total countable
resources fall below the resource maximum for one, the resource test is
passed.
(e) Determining
countable resources for individuals requesting Medicaid coverage of long term
care services and supports under MABD who have spouses
For an individual requesting Medicaid coverage of long-term
care services and supports under MABD who has a spouse, the resource evaluation
process of assessment and allocation is performed as set forth in this
paragraph at the beginning of the first continuous period of long-term care. An
individual discharged from long-term care and readmitted later does not undergo
these steps again; only the resources of, and any new transfers by, the
readmitted individual are counted. An institutionalized spouse (sometimes
referred to in this rule as the "IS") who receives additional resources after
allocating less than the community spouse resource allocation (CSRA) maximum to
their community spouse (sometimes referred to in this rule as the "CS") and
being found eligible for Medicaid coverage of long-term care services and
supports under MABD, may, until the first annual review of their eligibility,
continue to transfer resources to the CS up to a combined total transfer of no
more than the CSRA maximum. After the IS's first regularly- scheduled annual
redetermination of eligibility, no further transfers are allowed even if the
CSRA maximum has not been allocated to the CS; the rules regarding transfers
apply after the IS's first regularly-scheduled annual redetermination (see
§ 25.00).
(1) Assessment of
resources for individuals with community spouses
At the time of admission to long-term care and application
for Medicaid coverage of long-term care services and supports under MABD,
including long-term care services and supports in a home and community-based
setting, AHS completes an assessment of resources. An individual or their
spouse may also request a resource assessment prior to admission to long- term
care. AHS provides a copy of the assessment to each spouse and retains a copy.
The assessment must include at least:
(i) The total value of countable resources in
which either spouse has an ownership interest;
(ii) The basis for determining total
value;
(iii) The spousal share or
one-half the total;
(iv) Conclusion
as to whether the IS would be eligible for MABD based on resources;
(v) The highest amount of resources the IS
and CS may retain and still permit the IS to be eligible;
(vi) Information regarding the transfer of
assets policy; and
(vii) The right
of the IS or the CS to a fair hearing at the time of application for
MABD.
(2) Allocation of
resources for individuals with community spouses
(i) An allocation of resources is completed
at the time of the IS's application for Medicaid coverage of long- term care
services and supports under MABD, as follows:
(A) The total countable resources of the
couple are determined at the time of the application for Medicaid coverage of
long-term care services and supports under MABD, regardless of which spouse has
an ownership interest in the resource;
(B) The greatest of the following is
deducted:
(I) CSRA maximum;
(II) Amount set by a fair hearing,
or
(III) Amount transferred from
the IS to the CS under a court order.
(ii) The remaining resources allocated to the
IS are compared to the resource maximum for one to determine whether or not the
IS passes the MABD resource test. If the IS does not pass the resource test,
see the spenddown provisions at § 30.00.
(iii) The resources of the CS are considered
available to the IS until the month after the month in which the IS becomes
eligible for Medicaid coverage of long-term care services and supports under
MABD. If the CS fails to make the resources accessible to the IS, after AHS has
determined that they are available, AHS may still grant the IS Medicaid
coverage of long-term care services and supports under MABD if:
(A) The IS assigns any rights to support from
the CS to AHS; or
(B) Denial of
Medicaid coverage of long-term care services and supports would work an undue
hardship, as specified in § 25.05.
(iv) The CS is provided with the amount
determined to be the share of the CS (or to someone else for the sole benefit
of the CS). Any transfer of resources from the IS to the CS must be completed
by the next review of eligibility of the IS. The transfer will be verified at
the next regularly scheduled redetermination of the IS's eligibility.
(v) For purposes of allocation, an "assisted
living" facility is considered a community setting and not an institution for
long term care provided that the assisted living facility does not include
24-hour care, has privacy, a lockable door, and is a homelike setting. An IS is
permitted to allocate income and resources to a CS when the CS resides in an
assisted living facility.
Section 29.11 Overview of income requirements
(01/15/2017, GCR 16-098)
(a) Definition: Income
Any form of cash payment from any source received by an
individual or by a member of the individual's financial responsibility group.
Income is considered available and counted in the month it is received or
credited to the individual with the exception of a lump sum receipt of earnings
such as sale of crops or livestock. These receipts are only counted if received
during the six-month accounting period and are averaged over the six-month
period.
(b) Counting rules
(1) All earned and unearned income of an
individual who is aged, blind or disabled and of the members of the
individual's financial responsibility group is counted except income that is
specifically excluded (see § 29.13) or deducted (see § 29.15). All
countable income is verified.
(2)
Countable income depends on the coverage group for which an individual is
eligible. It is determined according to the rules at § 29.14 and compared
to the highest applicable income standard. If total countable income for the
Medicaid group exceeds the income standard for every coverage group in
§§ 8.05 and 8.06, the individual is denied eligibility and given a
spenddown (see § 30.00).
Section 29.12 Types of income
(01/15/2017, GCR 16-098)
(a) In general
This subsection describes the kinds of income considered when
determining MABD eligibility.
(b) Earned income
Earned income includes the following:
(1) Gross salary, wages, commissions,
bonuses, severance pay received as a result of employment.
(2) Income from self-employment (see (c)
below for more information about self-employment income).
(3) Payments from Economic Opportunity Act of
1964 programs as recipients or employees, such as:
(i) Youth Employment Demonstration Act
Programs;
(ii) Job Corps Program
(Title I, Part A);
(iii) Work
Training Programs (Title I, Part B);
(iv) Work Study Programs (Title I, Part
C);
(v) Community Action Programs
(Title II); and
(vi) Voluntary
Assistance Program for Needy Children (Title II); and
(4) Income from:
(i) Employment under Title I of the
Elementary and Secondary Education Act (e.g., as a teacher's aide, lunch room
worker, etc.);
(ii) Wages from
participation in the Limited Work Experience Program under the Workforce
Investment Act of 1998 (29 U. S. C. §
794d); and
(iii) Earnings from the Senior Community
Service Employment (SCSE) program.
(c) Self-employment income
(1) Net earnings from self-employment are
counted. Net earnings means gross income from any trade or business less the
allowable deductions specified in § 29.15(a)(1).
(2) Tax forms are used to determine countable
income from self-employment. An individual who states that the income on their
tax forms is no longer reflective of their situation may submit alternate
documentation.
(3) When the
individual's business has been the same for several years, income reported on
tax forms from the last year is used.
(4) When the individual's business was new in
the previous or current year and the individual has business records, income
reported on tax forms and other available business records is divided by the
number of months the individual has had the business.
(5) When the individual's business has no
records, is seasonal or has unusual income peaks, income reported on the
individual's signed statement estimating annual income is included.
(d) Unearned income
(1) Any payment other than earned income from
any source received by an individual or by a member of the individual's
financial responsibility group. It is the gross payment, less allowable
deductions at § 29.15(b). Periodic benefits received by an individual as
unearned income are counted.
(2)
Unearned income includes income from capital investments in which the
individual is not actively engaged in managerial effort. This includes rent
received for the use of real or personal property. Ordinary and necessary
expenses of rental property such as interest on debts, state and local taxes,
the expenses of managing or maintaining the property, etc. are deducted in
determining the countable unearned income from this source. The deduction is
permitted as of the date the expense is paid. Depreciation or depletion of
property is not a deductible expense.
(3) Unearned income also includes, but is not
limited to, the following:
(i) Social
Security retirement, disability, SSI, or survivor benefits for surviving
spouses, children of a decedent, and dependent parents;
(ii) Railroad Retirement;
(iii) Unemployment compensation;
(iv) Private pension plans;
(v) Annuities;
(vi) Interest earned on life insurance
dividends;
(vii) Regular and
predictable voluntary cash contributions received from friends or
relatives;
(viii) Cash prizes or
awards;
(ix) Withheld overpayments
of unearned income, unless the overpayment was counted as income in determining
Medicaid eligibility in the month received;
(x) Royalty payments to holders of patents or
copyrights for which no past or present work was or is involved;
(xi) Retroactive Retirement, Survivors and
Disability Insurance (RSDI) benefits for an individual with drug addiction or
alcoholism (such benefits are treated as if they had all been received in a
lump sum payment, even if paid in installments);
(xii) Veteran's Administration (VA) pension,
compensation and educational payments that are not part of a VA program of
vocational rehabilitation and do not include any funds which the veteran
contributed;
(xiii) Interest
payments received by the individual on an income-producing promissory note or
contract (such as a property agreement or loan agreement) when the individual
is the lender and the note or contract is excluded as a resource under §
29.08(d)(2).
(xiv) Alimony and
support payments received; and
(xv)
Death benefits received by an individual to the extent the benefits exceed what
was paid by the individual for the expenses of the deceased person's last
illness and burial.
Section 29.13 Income exclusions
(01/15/2017, GCR 16-098)
(a) Earned income exclusions
The following are excluded from earned income:
(1) Support service payments made directly to
the providers of services in the Limited Work Experience Program under the
Workforce Investment Act of 1998 (
29 USC §
794 d) or needs-based payments of $ 10 per
day made to participants in the program.
(2) The earned income of an individual under
the age of 22 who is a student regularly attending school. This applies to
wages received from regular employment, self-employment, or payments from the
Neighborhood Youth Corps, Work Study and similar programs.
(3) Infrequent or irregular earned income
received, not to exceed $ 30 per calendar quarter.
(4) Any in-kind assistance received from
others.
(5) Earned Income Tax
Credit payments (both refunds and advance payments).
(6) Earned income of a working disabled
individual when performing the second step of the categorically-needy
eligibility test redetermining net income, set forth in §
8.05(d).
(7) Earned income of a
child under the age of 18.
(8)
Wages paid by the Census Bureau for temporary employment.
(b) Unearned income exclusions
Unearned income exclusions are limited to the
following:
(1) Expenses incurred as a
condition of receiving the unearned income. For example, guardianship fees may
be deducted from unearned income if having a guardian is a requirement for
receiving the income, or attorney fees and court costs may be deducted from
unearned income if they were incurred in order to establish a right to the
income.
(2) The following VA
payments:
(i) Portion of pension or
compensation payment for aid and attendance and housebound allowances, even
when the provider is a spouse or a parent of the veteran;
(ii) Augmented portion of pensions,
compensation or other benefits for a dependent of a veteran or a veteran's
spouse;
(iii) $ 20 from educational
benefits to the veteran funded by the government;
(iv) Educational benefits paid as either part
of a plan of vocational rehabilitation or by withdrawals from the veteran's own
educational fund;
(v) Clothing
allowance; and
(vi) Payment
adjustments for unusual medical expenses.
(3) Ordinary and necessary expenses of rental
property and other capital investments except depreciation or depletion of
property. This includes, but is not limited to, interest on debts, state and
local taxes. The expenses of managing or maintaining the property, as of the
date the expense is paid, are deductible.
(4) The first $ 20 per month of any unearned
income unless all of the unearned income is from a source that gives assistance
based on financial need.
(5) Any
public agency's refund of taxes on food or real property.
(6) Infrequent or irregular unearned income
received, not to exceed $ 60 per calendar quarter.
(7) Bills paid directly to vendors by a third
party.
(8) Replacement of lost,
stolen or destroyed income.
(9)
Weatherization assistance.
(10)
Receipts from the sale, exchange or replacement of a resource.
(11) Any assistance based on need which is
funded wholly by the state, such as General Assistance.
(12) Public assistance benefits of any person
who is living with the individual, as well as any income that was used to
determine the amount of those benefits.
(13) Any portion of a grant, scholarship or
fellowship used to pay tuition, fees or other necessary educational
expenses.
(14) Home produce used
for personal consumption.
(15)
Assistance and interest earned on assistance for a catastrophe from the
Disaster Relief and Emergency Assistance Act or other comparable assistance
provided by the federal, state or local government.
(16) Irregular and unpredictable voluntary
cash contributions or gifts received from friends or relatives.
(17) Payments for providing foster care for
children or adults placed in the individual's home by a public or private
non-profit placement agency.
(18)
One-third of child support payments received for a child in the household of
the individual. The remaining two-thirds of the support payments are considered
the unearned income of the child received from the absent parent.
(19) Income paid for chore, attendant or
homemaker services under a government program, such as Title XX personal
services payments or the $ 90 VA Aid and Attendance payments to veterans in
nursing homes.
(20) Any "in-kind"
assistance received from others.
(21) Assistance provided in cash or in kind
(including food, clothing, or shelter) under a government program that provides
medical care or services (including vocational rehabilitation).
(22) That portion of a benefit intended to
cover the financial need of other individuals, such as AABD-EP
grants.
(23) Retroactive payments
of SSI, AABD or OASDI benefits if the payments were included in determining
financial eligibility for Medicaid in the month it was actually owed to the
individual.
(24) Home energy
assistance provided by a private nonprofit organization or a regulated supplier
of home energy.
(25)
State-administered victims' compensation payments.
(26) State or local government relocation
payments.
(27) Payments occasioned
by the death of another person to the extent that they are used to pay for the
deceased person's last illness and burial, including gifts and
inheritances.
(28) Earned Income
Tax Credit payments (both refunds and advance payments).
(29) Social security disability insurance
benefits (SSDI) and veterans disability benefits provided to working disabled
persons when determining categorically- needy eligibility, specified in §
8.05(d).
(30) Income from a home
equity conversion plan in the month received.
(31) Dividends paid on life insurance
policies.
(32) Payments made by
someone other than the individual to a third-party trust for the benefit of the
individual.
(33) Interest and
dividend income from a countable resource or from a resource excluded under a
federal statute other than § 1613 of the SSA.
(34) Any interest on an excluded burial space
purchase agreement if left to accumulate as part of the value of the
agreement.
(35) Any amount refunded
on income taxes that the individual has already paid.
(36) Proceeds of a loan in the month received
when the individual is the borrower because of the borrower's obligation to
repay.
(37) Exclusions based on
federal law as set forth in § 29.08(i)(9).
Section 29.14 Determination of countable
income
(01/15/2017, GCR 16-098)
(a) In general
(1) The earned and unearned income of the
members of the financial responsibility group is counted. Income is considered
available and counted in the month it is received or credited to the
member.
(2) The general approach
AHS follows when it determines countable income for MABD is set forth below.
These general rules apply to all individuals.
(i) Determine income of the financial
responsibility group.
(ii) The
income of all members of the financial responsibility group is combined, and
the appropriate exclusions (see § 29.13) and standard deductions applied
(see § 29.14).
(iii) Compare
countable income to the applicable income standard.
(iv) An individual passes the income test
when their Medicaid group's income does not exceed the appropriate PIL, or the
applicable income maximum, whichever is higher. An individual with income
greater than the applicable income standard may establish financial eligibility
by incurring eligible medical expenses that at least equal the difference
between their countable income and the applicable PIL.
(3) The following subsections specify how
income is allocated and deemed based on the type of coverage sought and the
size of the financial responsibility group.
(b) Financial responsibility group of one
individual seeking MABD other than Medicaid coverage of long-term care services
and supports under MABD
Common financial responsibility groups of one include a
single adult, an individual residing in a residential care home, and a child
seeking Katie Beckett coverage. AHS determines countable income for an
individual seeking MABD, other than Medicaid coverage of long-term care
services and supports under MABD, with a financial responsibility group of one
as follows:
(1) Determine and combine
the total countable unearned income of the individual.
(2) Subtract a $ 20 disregard (pursuant to
§ 29.13(b)(4)), if applicable.
(3) Deduct an allocation for each ineligible
child in the household for whom the individual is financially responsible. The
amount of each allocation is equal to the maximum allocation amount minus any
countable income of the child. If the unearned income is not at least equal to
the applicable allocation amount, any remaining allocation may be deducted from
earned income.
(4) Deduct from
unearned income amounts used to comply with the terms of court-ordered support
or Title IV-D support payments (pursuant to § 29.15(b)), if applicable.
If unearned income is insufficient, any remaining amounts may be deducted from
earned income.
(5) Determine and
combine the individual's countable earned income.
(6) Deduct any remaining amount of the $ 20
disregard, allocations for children and child support payments from the earned
income.
(7) Deduct $ 65 from the
remaining earned income.
(8) Deduct
allowable work expenses for the disabled ( § 29.15(a)(3)).
(9) Deduct one-half of the remaining earned
income.
(10) Deduct any allowable
work expenses for the blind ( § 29.15(a)(2)).
(11) Combine the remaining earned income with
any remaining unearned income.
(12)
Deduct the amount of any income of a blind or disabled individual that is
necessary for them to carry out a Plan to Achieve Self-Support (PASS), if
applicable.
(13) The result is the
individual's countable income for the month. For a child seeking Katie Beckett
coverage, compare it to the institutional income standard (IIS). For all
others, compare it to the protected income level (PIL) or the SSI/AABD payment
standard for one, whichever is higher.
(c) Financial responsibility group of two
seeking MABD other than Medicaid coverage of long-term care services and
supports under MABD
Countable income for MABD for any individual with a financial
responsibility group of two is determined according to the rules under
paragraph (b) above, as well as the following additional rules:
(1) Deem income at step (1). Earned and
unearned income is deemed to the individual at step (1) from their ineligible
spouse or ineligible parent, except no income is deemed to an individual from
their ineligible children.
(2)
Allocate income at step (3). Income is allocated from the financial
responsibility group to each member of the financial responsibility group who
is not applying for MABD at step (3) in the following amounts:
(i) For a child, the difference between the
SSI federal payment rate for one and the SSI federal payment rate for a couple
is allocated. The allocation is reduced for ineligible children if they have
income, unless the ineligible children are students with earned income. No
allocation is made to children receiving public assistance.
(ii) For a parent in a one-parent financial
responsibility group, the SSI federal payment for one is allocated.
(iii) For parents in two-parent financial
responsibility groups, the SSI federal payment for two is allocated.
(3) Count income at step (13) for
an individual requesting MABD who has a spouse. Countable income for an
individual whose spouse is not requesting MABD is determined, according to the
rules under paragraph (b) above, except at step (13) the countable income of
the Medicaid group is compared to the PIL or the SSI/AABD payment standard for
two, whichever is higher.
(d) Parent and child living together seeking
MABD, other than Medicaid coverage of long-term care services and supports
under MABD
These groups include a parent who is aged, blind, or disabled
and a child who is blind or disabled. When a parent and a child in the same
household both request MABD, countable income is determined as a financial
responsibility group of two as follows:
(1) Determine the net income available to the
parent following the steps under paragraph (b) if the parent is single, or
under paragraph (c) if the parent has a spouse, except do not allocate any
income to the eligible child. Compare the parent's income to the PIL for one
or, if married, the SSI/AABD payment standard for two. If the parent's
countable income is below the highest applicable income standard, the parent
has passed the income test for eligibility. If the parent's income exceeds the
highest applicable income standard, deem the amount of income in excess of the
highest applicable income standard to the eligible child as unearned
income.
(2) Determine the child's
countable income by deeming any income from (1) above and then following the
steps in paragraphs (e)(3)(iv) through (xiv). If the child's income is less
than the PIL, both the parent and the child pass the income test for MABD
eligibility.
(3) When both a parent
and child have a spenddown requirement, the parent and child will pass the
income test once the child's spenddown requirement has been met because the
parent's excess income was deemed to the child. If the parent's spenddown
requirement is less than the child's and the parent meets their spenddown
requirement, the parent will become eligible. The child, however, will remain
ineligible until the remainder of the child's spenddown is met. The parent's
incurred eligible medical expenses are deducted from the spenddown requirements
of both the parent and child because the parent's income was included in both
income computations.
(e)
Children seeking MABD, other than Medicaid coverage of long- term care services
and supports under MABD (excluding Katie Beckett)
(1) The provisions of this paragraph
generally apply when countable income for an eligible child is determined as a
financial responsibility group of one. They do not apply in the following
contexts:
(i) Katie Beckett (see paragraph (b)
above);
(ii) A child whose parent
also requests Medicaid (see paragraph (d) above); or
(iii) Medicaid coverage of long-term care
services and supports under MABD (see paragraph (f) below).
(2) Since parents are financially
responsible for their children, their income must be considered available to
their child requesting MABD, until the child reaches the age of 18.
(3) AHS determines countable income in
applicable cases as follows:
(i) Determine the
total countable income, both earned and unearned, of the parents living with
the child.
(ii) Deduct an
allocation specified in paragraph (c)(2)(ii)(B) of (C) for the needs of the
parents living in the household from the total countable income of the
parents.
(iii) Deem the remaining
amount to the child. If there is more than one blind or disabled child in the
household, divide the remainder by the number of blind or disabled children and
deem an equal portion to each. Do not deem more income to a child than the
amount which, when combined with the child's own income, would bring their
countable income to the PIL. If the share of parental income that would be
deemed to a child makes that child ineligible because that child has other
countable income, deem parental income to other blind and disabled children
under age 18 in the household and no portion to the child.
(iv) Add the child's own unearned income.
This is the total unearned income.
(v) Deduct the $ 20 disregard. This is the
total countable unearned income.
(vi) Determine the earned income of the
child.
(vii) Deduct the balance of
the $ 20 disregard.
(viii) Deduct
the $ 65 earned income exclusion from any earned income.
(ix) Deduct any allowable work expenses of a
disabled child ( § 29.15(a)(3).
(x) Deduct one-half of the remaining earned
income.
(xi) Deduct any allowable
work expenses of a blind child ( § 29.15(a)(2).
(xii) Combine the remaining earned and
unearned income.
(xiii) Deduct the
amount of any income that is necessary to carry out a Plan to Achieve
Self-Support (PASS), if applicable.
(xiv) The result is the child's countable
income. Compare it to the PIL for one. A child with income below the PIL passes
the income test.
(f) Individuals seeking Medicaid coverage of
long-term care services and supports under MABD
Countable income for an individual requesting Medicaid
coverage of long-term care services and supports under MABD is determined as
follows:
(1) The countable income of
the individual is compared to the applicable income standard for their coverage
group beginning with the date of admission to long- term care.
(2) The institutional income standard (IIS)
for an individual equals 300 percent of the maximum SSI federal payment to an
individual living independently in the community. The IIS for a couple equals
twice the IIS for an individual.
(3) When an individual is in a nursing
facility and AHS has an indication that they will need long-term care for fewer
than 30 days, AHS uses the PIL for the month of admission, and applies the
rules for MABD other than the rules for Medicaid coverage of long- term care
services and supports under MABD.
(g) Long-term care individuals in an
institution
(1) Countable income for an
individual seeking Medicaid coverage of long-term care services and supports
under MABD in an institution is determined according to the rules under
paragraph (b) above, except AHS:
(i)
Allocates income to the individual's community spouse, dependent children and
for home upkeep, according to the rules in § 24.04;
(ii) Allocates a personal needs allowance to
the individual; and
(iii) Compares
the countable income of the Medicaid group to the IIS beginning with the date
of admission to long-term care.
(2) For an individual whose gross income
exceeds the IIS, AHS determines whether they may spend down their excess income
to the PIL to establish their financial eligibility as medically needy,
according to the rules at § 30.00. AHS determines whether the individual
has incurred eligible medical expenses that equal the difference between their
countable income and the PIL.
(h) Long-term care individuals seeking
services in a home and community-based setting
(1) Countable income for an individual
seeking Medicaid coverage of long-term care services and supports under MABD in
a home and community-based setting is determined according to the rules under
paragraph (b) above, except AHS:
(i) Allocates
income to the individual's community spouse and dependent children according to
the rules in § 24.04; and
(ii)
Allocates a community maintenance allowance to the individual; and
(iii) Approves income eligibility if the
individual:
(A) Has gross income that does not
exceed the IIS; or
(B) Passes the
net income test for an individual working with disabilities (see § 8.05(d)
).
(2) For an
individual whose gross income exceeds the IIS, AHS determines whether they may
spend down their excess income to the PIL to establish their income eligibility
as medically needy using the rules at § 30.00. AHS determines whether the
individual has incurred eligible medical expenses that equal the difference
between their countable income and the PIL.
Section 29.15 Income deductions
(01/15/2017, GCR 16-098)
Deductions from earned income, including self employment, and
from unearned income are allowed.
(a)
Earned income deductions
A deduction of $ 65.00 and one-half of the remainder applies
to all determinations of earned income.
(1) Business expenses
Deductions of business expenses from self-employment income
are limited to the following:
(i)
Operating costs necessary to produce cash receipts, such as office or shop
rental; taxes on farm or business property; hired help; interest on business
loans; cost of materials, livestock and equipment required for the production
of income; and any business depreciation.
(ii) The cost of any meals provided to
children for whom an individual provides day care in their own home, at the
currently allowed rate per meal.
(iii) The actual operating expenses necessary
to produce cash receipts for commercial boarding houses: an establishment
licensed as a commercial enterprise that offers meals and lodging for
compensation, or, in areas without licensing requirements, a commercial
establishment that offers meals and lodging with the intention of making a
profit.
(iv) Room and board, alone
or as part of custodial care, provided that the amount shall not exceed the
payment the household receives for room and board.
(v) Foster care payments made by AHS to
licensed foster homes, including room and board of children in the custody of
and placed by AHS when the Medicaid group includes a foster parent.
(vi) Ordinary and necessary expenses for
active management of capital investments, like rental property. These may
include fire insurance, water and sewer charges, property taxes, minor repairs
which do not increase the value of the property, lawn care, snow removal,
advertising for tenants and the interest portion of a mortgage
payment.
(2) Work
expenses of blind individuals
In addition to other allowable deductions, work expenses from
income of a blind individual include the following [21]:
(i) Cost of purchasing and caring for a guide
dog;
(ii) Work-related fees such as
licenses, professional association dues or union fees;
(iii) Transportation to and from work
including vehicle modifications;
(iv) Training to use an impairment-related
item such as Braille or a work-related item such as a computer;
(v) Federal, state and local income
taxes;
(vi) Social Security taxes
and mandatory pension contributions;
(vii) Meals consumed during work
hours;
(viii) Attendant care
services;
(ix) Structural
modifications to the home; and
(x)
Medical devices such as wheelchairs.
(3) Work expenses of disabled individuals
In addition to other allowable deductions, work expenses from
income of a disabled individual include the following [22]:
(i) Transportation to and from work,
including vehicle modifications;
(ii) Impairment-related training;
(iii) Attendant care;
(iv) Structural modifications to the home;
and
(v) Medical devices such as
wheelchairs.
(b) Unearned income deduction
Amounts used to comply with the terms of court-ordered
support or Title IV-D support payments are deducted from unearned
income.
Section
30.00 Spenddowns
(01/15/2017, GCR 16-098)
(a) When the total countable income or, if
applicable, resources of an individual exceeds the applicable income or
resource standard for eligibility after allocations are made, and exclusions
and disregards, if applicable, are applied, an individual requesting Medicaid,
including Medicaid coverage of long-term care services and supports, may use
the spenddown provisions set forth in this section to attain financial
eligibility.
As stated in § 28.04(c), the income spenddown provisions
under this section apply to an individual requesting MCA, including Medicaid
coverage of long-term care services and supports under MCA, whose income
exceeds the applicable income standard for eligibility for MCA and who is
seeking MCA eligibility as medically needy and is subject to an income
spenddown in order to be eligible. For this purpose, all references to
"countable income" in this section shall mean the individual's MAGI-based
income as described in § 28.03(d) adjusted, if applicable, by apportioning
the income of financially responsible family members according to the
requirements set forth in § 28.04(b). Since there is no resource test for
MCA eligibility, none of the resource spenddown provisions under this section
apply.
See § 7.03(a)(8)(i) for the individuals who may qualify
for MCA as medically needy.
(b) Spending down is the process by which an
individual incurs allowable expenses to be deducted from their income or spends
resources to meet financial eligibility requirements.
(c) Spenddown is calculated using an
accounting period of either one or six months, depending on the type of
Medicaid services requested (see § 30.02). For purposes of calculating
the spenddown for an individual requesting MCA eligibility as medically needy,
other than Medicaid coverage of long-term care services and supports under MCA,
a six month accounting period is used
Section 30.01 Definitions
(01/15/2017, GCR 16-098)
(a) Accounting period
The one-month or six-month span of time used to budget the
income of an individual requesting Medicaid.
(b) Community living arrangement
(1) A community living arrangement includes
any residence, such as a house, apartment, residential care home, assisted
living facility, boarding house, or rooming house. In a community living
arrangement, the individual requesting Medicaid obtains and pays for basic
maintenance items, such as food, shelter, clothing, personal needs, separately
from medical care. The individual requesting Medicaid may live alone, as a
member of a family, or with non-relatives.
(2) An individual requesting Medicaid
coverage of long- term care services and supports is not considered to be in a
community living arrangement.
(c) [Reserved]
(d) Long-term care living arrangement
An individual requesting Medicaid coverage of long-term care
services and supports, including services and supports in a home and
community-based setting, is considered to be in a long-term care living
arrangement. Medicaid eligibility is determined according to the applicable
long-term care Medicaid eligibility rules.
An individual receiving hospice services is considered to be
in a long-term care living arrangement. An individual receiving hospice
services is:
(1) Terminally
ill;
(2) Would be eligible for
Medicaid coverage of long-term care services and supports if they lived in a
medical institution; and
(3) Needs
additional interdisciplinary medical care and support services to enable them
and their families to maintain personal involvement and quality of life in
their choice of care setting and site of death.
(e) Income spenddown
The amount of qualifying medical expenses an individual must
incur to reduce their excess income to the maximum applicable to their Medicaid
coverage category.
(f)
Resource spenddown
The amount an individual must spend to reduce their excess
resources to the resource standard applicable to the appropriate Medicaid
coverage category.
Section
30.02 Accounting periods
(01/15/2017, GCR 16-098)
(a) Accounting periods are based on living
arrangements
The length of the accounting period used to compute spenddown
requirements depends on the living arrangement of the individual requesting
Medicaid. For the purposes of Medicaid eligibility, an individual may be in a
community living arrangement or a long-term care living arrangement.
(b) Six-month accounting period
for community living arrangement
(1) A
six-month accounting period is used to determine spenddown requirements for an
individual in a community living arrangement.
(2) The six-month period begins with the
first month for which Medicaid is requested, usually the month of application.
If Medicaid is requested for expenses incurred during any one or more of the
three months preceding the month of application, the six-month period begins
with the earliest of these three months in which expenses were incurred and the
individual met all other eligibility requirements.
(3) To determine the amount of income an
individual must spend down, AHS makes reasonable estimates of future income,
subject to review and adjustment if the individual's circumstances change
during the remainder of the six-month accounting period.
(c) One-month accounting period for long-term
care living arrangement
(1) A one-month
accounting period is used to determine spenddown requirements for an individual
in a long- term care living arrangement.
(2) The one-month accounting period begins
with the first calendar month during which the individual is in a long-term
care living arrangement for any part of the month, applies for Medicaid
coverage of long-term care services and supports for that month, and meets the
general and categorical requirements for eligibility for Medicaid coverage of
long-term care services and supports.
(3) The one-month accounting period ends with
the last calendar month during which the individual is in a long-term care
living arrangement for any part of the month and passes all other eligibility
tests for Medicaid coverage of long-term care services and supports.
Section 30.03 Spend
down of excess resources and income - in general
(01/15/2017, GCR 16-098)
An individual who passes all nonfinancial eligibility tests
may qualify for Medicaid by spending down the income or resources, if
applicable, that are in excess of the maximums applicable to them. The income
and resource maximums for each MABD eligibility category are specified in the
descriptions found in §§ 8.05 and 8.06. Income and resource maximums
can also be found in Vermont's Medicaid Procedures Manual. The income maximums
for the MCA categories are specified in the descriptions found in §
7.03(a).
Section 30.04
Resource spenddowns
(01/15/2017, GCR 16-098)
(a) Spending down excess resources
(1) An individual requesting MABD with excess
resources is determined to have passed the resource test upon proof that the
excess resources are no longer held as a resource and have actually been spent
or given away. However, an individual with excess resources seeking Medicaid
coverage of long-term care services and supports under MABD is subject to the
transfer-of-resource provisions at § 25.00 if they spend or give away
excess resources within the penalty period specified in § 25.04.
(2) MABD may be granted for the month of
application if the resource test is passed at any point in the month and all
other eligibility criteria are met. Resources may rise above the resource
maximum, for example, due to interest added to bank accounts or failure to use
the full monthly income amount protected for maintenance expenses during the
month it is received. An individual enrolled in MABD may maintain MABD
eligibility for any month in which resources exceed the resource maximum by
taking any action that reduces the excess amount, including giving the excess
to AHS to repay expenditures on the individual's care. As long as resources are
reduced to the resource maximum before the end of the month during which
resources exceed the limit, MABD continues without interruption.
(3) When a third party who handles any
resources of an individual receiving MABD or of a member of the individual's
financial responsibility group is unaware of a resource or its value, AHS
provides uninterrupted MABD to the individual as long as the excess amount is
paid to AHS as a recovery of Medicaid payments. Excess resources reimbursed to
AHS in these situations will not result in ineligibility.
(b) Retroactive coverage
One or more of the following actions may be taken to reduce
excess resources in order to qualify for MABD up to three months prior to the
month of application as long as all other eligibility tests are passed:
(1) Set up a burial fund that meets the
requirements specified in § 29.08 for an excluded resource.
(2) If countable income is less than the
applicable PIL, spend resources on maintenance expenses, such as housing, food,
clothing and fuel, up to a maximum per month of the difference between the
countable income and the applicable PIL.
(3) Spend excess resources on covered or
noncovered medical expenses.
Section 30.05 Income spenddowns
(01/15/2017, GCR 16-098)
(a) Spending down excess income on medical
expenses
AHS determines that an individual requesting Medicaid with
excess income has passed the income test upon proof that medical expenses have
been paid or incurred at least equal to the difference between the countable
income and the applicable income maximum for the accounting period.
(b) Allowable uses of excess
income
Medical expenses of any member of the individual's financial
responsibility group, whether they are paid or incurred but not paid, may be
used to meet the individual's income spenddown requirement; references in
§ 30.06 to the medical expenses of the "individual" include the medical
expenses of any member of the individual's financial responsibility
group.
(c) Income spenddown
methodology
(1) An individual requesting
Medicaid may spend their excess income down to the PIL on medical expenses
following the methodology specified below to receive Medicaid as part of the
medically-needy coverage group.
(2)
The spenddown methodology is the same for all living arrangements, except that
a one-month accounting period applies to an individual in a long-term care
living arrangement and a six-month accounting period applies to an individual
in a community living arrangement.
(d) Eligibility date
(1) An individual with excess income passes
their income test on the first day within their accounting period that
deductible medical expenses meet or exceed their spenddown requirement.
Sometimes this allows for retroactive coverage.
(2) Eligibility becomes effective:
(i) On the first day of the month when a
spenddown requirement is met using health insurance expenses and noncovered
medical expenses.
(ii) Later than
the first day of the month when a spenddown requirement is met using covered
medical expenses.
(3)
Special eligibility dates apply, as set forth in § 30.06, for an
individual who meets their spenddown requirement using noncovered assistive
community care services (ACCS).
(4)
Medicaid pays for covered services on the first day that the individual's
medical expenses exceed the amount of their spenddown requirement. Medicaid
continues until the end of the accounting period unless the individual's
situation or PIL changes.
(e) Continuing responsibility for medical
expenses incurred before the eligibility date
(1) An individual remains responsible for
medical expenses they incurred before the date of eligibility.
(2) When services are received from more than
one provider on the day that Medicaid begins, the individual must decide which
services they will be responsible for paying and which ones Medicaid will
cover.
(f) Deduction
sequence
Medical expenses are deducted from income in the following
order:
(1) Health insurance expenses
(see § 30.06(b)).
(2)
Noncovered medical expenses (see § 30.06(c)).
(3) Covered medical expenses (see §
30.06(d)) that exceed limitations on amount, duration, or scope of services
covered (see DVHA Rules 7201-7606).
(4) Covered medical expenses (see §
30.06(d)) that do not exceed limitations on amount, duration or scope of
services covered. These must be deducted in chronological order of the date the
service was received beginning with the oldest expense.
(g) Time frames for deductions
(1) Deductible medical expenses include
medical expenses incurred:
(i) During the
current accounting period, whether paid or unpaid;
(ii) Before the current accounting period and
paid in the current accounting period, or
(iii) Before the current accounting period,
remaining unpaid, and for which continuing liability can be established (see
paragraph (i) of this § 30.06 for details on how to establish continuing
liability).
(2)
Deductible medical expenses also include medical expenses paid during the
current accounting period by a state or local program other than a program that
receives Medicaid funding.
(3)
Medical expenses incurred before or during the accounting period and paid for
by a bona fide loan, as described in (4) below, may be deducted if the expense
has not been previously used to meet a spenddown requirement and the individual
establishes continuing liability for the loan (see paragraph (i) of this §
30.05 for details on how to establish continuing liability) and documents that
all or part of the principal amount of the loan remains outstanding at any time
during the accounting period. Only the amount of the principal outstanding
during the accounting period, including payments made on the principal during
the accounting period, may be deducted.
(4) For purposes of this subsection, a "bona
fide loan" is an obligation documented from its outset by a written contract
and a specified repayment schedule.
(h) Predictable expenses
In general, an expense is incurred on the date liability for
the expense begins. However, there are four types of predictable medical
expenses that may be deducted before they are incurred, if it can be reasonably
assumed that the expense will continue during the accounting period:
(1) Premiums on health insurance (see §
30.06(b));
(2) Medically necessary
over-the-counter drugs and supplies (see § 30.06(c)(1));
(3) Ongoing, noncovered personal care
services (see § 30.06(c)(3)); and
(4) ACCS provided to an individual residing
in a level III residential care home which is either:
(i) Not enrolled as a Medicaid provider;
or
(ii) With an admission agreement
specifying the resident's financial status as a privately-paying resident (see
§ 30.06(c)(4)).
(i) Establishing continuing liability for
prior medical expenses
Continuing liability for unpaid medical expenses, including
liability on a bona fide loan used to pay medical expenses, incurred before the
current accounting period is established when any of the following conditions
is met. The liability was incurred:
(1) Within six months of the date of
application or the first day of the accounting period, whichever is
later.
(2) More than six months
before the date of application or the first day of the accounting period,
whichever is later, and there is a bill for the liability dated within 90 days
of that date.
(3) More than six
months before the date of application or the first day of the accounting
period, whichever is later, and the service provider or lender has confirmed
that the unpaid liability has not been forgiven and is not expected to be
forgiven at any time within the current accounting period.
Section 30.06 Allowable medical
expenses
(01/15/2017, GCR 16-098)
(a) In general
(1) Medical expenses that are the current
liability of the individual and for which no third party is legally liable may
be deducted from total excess income or resources for the accounting
period.
(2) No medical expense may
be used more than once to meet a spenddown requirement.
(3) A medical expense may be used to spend
down either income or resources.
(4) If only a portion of a medical expense is
used to meet the spenddown requirement for a given accounting period, that
portion of the medical expense that was not used and remains a current
liability may be applied toward a spenddown requirement in a future accounting
period.
(5) Upon receiving
coverage, the individual remains directly responsible to providers for expenses
incurred before the spenddown was met.
(b) Health insurance expenses
(1) Health insurance is insurance that covers
medical care and services, such as Medicare part B, and similar group or
individual policies. A deduction is allowed for health insurance premiums paid
by the individual if it can be reasonably assumed that health insurance
coverage will continue during the accounting period. Deductions may also be
allowed for other health insurance expenses, including enrollment fees and
deductibles or coinsurance imposed by Medicare or other health insurance not
subject to payment by a third party (such as another insurance policy). Health
insurance coverage, the amount of the premium for the coverage, and any other
deductible expense amounts must be verified.
(2) Premiums, or other expenses, for the
following types of insurance are not deductible:
(i) Income protection or similar insurance
plans designed to replace or supplement income lost due to sickness or
accident; or
(ii) Automobile or
other liability insurance, although these may include medical benefits for the
insured or their family.
(c) Expenses not covered by Medicaid
A deduction is allowed for necessary medical and remedial
expenses recognized by state law but not covered by Medicaid in the absence of
an exception for Medicaid coverage under DVHA Rule 7104. In determining whether
a medical expense meets these criteria, AHS may require medical or other
related information to verify that the service or item for which the expense
was incurred was medically necessary and was a medical or remedial expense. The
patient's physician shall verify medical necessity with a written statement or
prescription specifying the need, quantity, and time period covered. Examples
of medical expenses not covered by Medicaid include, but are not limited to,
expenses for the services and items listed in (1) through (6) below. Any
medical bills, including those incurred during a period of Medicaid
eligibility, that are the current liability of the individual and have not been
used to meet a previous spenddown requirement may be deducted from excess
income. Generally, the individual is required to present a bill or receipt to
verify that medical expenses have been incurred or paid.
(1) Over-the-counter drugs
(i) In general
Either standard deductions or actual costs, if greater, may
be used to deduct noncovered over-the-counter drugs and supplies.
(ii) Documentation
(A) Documentation verifying medical necessity
is not required when AHS determines that an over-the- counter drug or supply is
a common remedy for the medical condition of the individual or of the member of
the individual's financial responsibility group and the usage is within the
maximum amount for common over-the-counter drugs and supplies.
(B) Documentation verifying medical necessity
may be required whenever one or both of the following two situations apply:
(I) When the drug or supply is not a common
remedy for the medical condition, or
(II) When the reported usage exceeds the
maximum amount.
(iii) Amount deductible
(A) Instead of actual expenses, a reasonable
estimate of ongoing expenses for over-the-counter drugs and supplies may be
applied prospectively to the accounting period. Reasonable estimates of unit
sizes, costs and maximums for common over-the- counter drugs and supplies used
to meet the spenddown requirement are found in Vermont's Medicaid Procedures
Manual.
(B) If an individual uses
an ongoing expense to meet their spenddown requirement, they are not eligible
to receive Medicaid coverage during that accounting period for the same
expense.
(2)
Transportation
Noncovered commercial and private transportation costs may be
deducted.
(i) For commercial
transportation, the actual cost of the transportation, verified by receipt, may
be deducted.
(ii) For private
transportation, either a standard deduction or the actual cost, if greater, may
be used. The process set forth in Vermont's Medicaid Procedures Manual
determines the deductible expense for private transportation.
(iii) The cost of transportation may be
deducted without verification of medical necessity provided that:
(A) The transportation was essential to
secure the medical service; and
(B)
The individual was responsible for the cost and was charged an agreed-upon fee
or purchased fuel to use a family-owned vehicle or other non-commercial
vehicle.
(iv) Mileage
reimbursement rates are the rates established by the U.S. General Services
Administration. The rates fluctuate periodically. It is important to refer to
the federal website in order to determine the current rate. The website is
www.gsa.gov/mileage.
(3)
Personal care services
(i) In general
A deduction for noncovered personal care services provided in
an individual's own home or in a level IV residential care home is allowed when
they are medically necessary in relation to an individual's medical
condition.
(ii) Deductible
personal care services
Deductible personal care services include the personal care
services described in DVHA Rule 7406.2 and assistance with managing money. They
also include general supervision of physical and mental well-being where a
physician states such care is required due to a specific diagnosis, such as
Alzheimer's disease or dementia or like debilitating diseases or injuries. Room
and board is not a personal care service.
(iii) Qualified personal-care service
providers
(A) Except as stated in (B) below,
services may be deducted when performed by a home-health agency or other
provider identified by the individual's physician as qualified to provide the
service.
(B) When the service
provider is living in the home, deductions may not be based on payments for
personal care services provided to an individual:
(I) Under age 21 by the individual's parent,
stepparent, or legal guardian, unless the individual is 18, 19, or 20 years old
and payment for personal care services is made from and does not exceed the
individual's own income or assets;
(II) By the individual's spouse;
(III) By the individual's sibling, child, or
grandchild when the person providing the services is under age 18; or
(IV) By a parent of the individual's minor
child.
(iv)
Documentation
(A) To document the need for
personal care services, the provider must submit:
(I) A plan of care;
(II) A list of the personal care services
required;
(III) A statement that
the services are necessary in relation to a particular medical condition;
and
(IV) A statement that the level
of care provided by the particular level IV residential care home is
appropriate or, if the individual is not living in a level IV residential care
home and the services are not provided by a home health agency, that the
provider is qualified to provide the service.
(B) Upon the initial submission of a plan of
care, it is assumed that the individual will continue to need the personal care
services for the entire accounting period, unless the plan of care has
specified a date by which the individual's need for services is expected to
change.
A plan of care can be submitted to AHS using a form provided
by AHS or using a statement, signed by the physician, that contains information
sufficient, as determined by AHS, to document the individual's need for
personal care services.
(C)
A new plan must be submitted:
(I) Once every
six months, when the provider has not specified an ongoing need for personal
care services in the current plan; or
(II) Once every two years, when the physician
has specified an ongoing need for personal care services in the current
plan.
(D) A new plan
must also be submitted:
(I) Whenever the
service provider changes, unless the service is performed by a home health
agency; and
(II) Whenever the need
for services in relation to the individual's condition is expected to change,
according to the current plan of care.
(v) Amount deductible
(A) Either standard deductions or actual
costs, if greater, may be used for deducting personal-care services. Expenses
that have not been incurred yet may be deducted if they are predictable and
meet the requirements in § 30.05(h). Expenses also may be deducted if they
have actually been incurred by the individual and are not subject to payment by
Medicaid or any other third party.
(B) The standard monthly deduction for
personal care services shall be deducted for each full or partial calendar
month in the accounting period during which the plan of care documents the need
for services. The actual documented costs of personal care services may be
deducted if they exceed the monthly standard deduction. Deductions may be made
for anticipated need through the end of the accounting period.
(C) All changes to these standards that
result in lower standard deductions will be made via the Administrative
Procedures Act.
(4) Assistive Community-Care Services (ACCS)
(i) Deductible assistive community-care
services
A deduction for noncovered assistive community care services
(ACCS) provided to an individual residing in a licensed level III residential
care home is allowed. The individual may also deduct medically-necessary
personal-care services included under the list at DVHA Rule 7406.2 but not part
of the list at DVHA Rule 7411.4.
(ii) Qualified Service Providers
(A) Qualified service providers include all
level III residential care homes licensed by AHS.
(B) When an individual that is a resident of
a level III residential care home becomes eligible for Medicaid by projecting
the cost of ACCS across part of the accounting period, the residential care
home may agree to function as a Medicaid provider for ACCS with respect to that
resident for the remainder of their accounting period. In these cases, the
provider may bill for ACCS services no sooner than the ACCS coverage date given
to the resident and the provider in a notice from AHS.
(C) When a privately-paying resident of a
level III residential care home becomes eligible for Medicaid after having met
a spenddown requirement by projecting the cost of ACCS across the entire
accounting period, the residential care home shall not function as a Medicaid
provider for ACCS with respect to that resident during the period when the
resident is meeting the spenddown requirement.
(iii) Documentation
(A) Documentation verifying medical necessity
is not required for ACCS. If an individual claims a deduction for
medically-necessary personal-care services included under the list at DVHA Rule
but not part of the list at DVHA Rule 7411.4 the individual's physician must
submit:
(I) A plan of care (form
288B);
(II) A list of the personal
care services required;
(III) A
statement that the services are necessary in relation to a particular medical
condition; and
(IV) A statement
that the level of care provided by the particular level III residential care
home is appropriate and that the provider is qualified to provide the
service.
(B) Upon the
initial submission of a plan of care, it is assumed that the individual will
continue to need the personal care services for the entire accounting period,
unless the plan of care has specified a date by which the individual's need for
services is expected to change.
(C)
An individual with an approved personal care services deduction must submit new
plans at the same frequencies specified under paragraph (c)(3)(iv) of this
subsection.
(iv) Amount
deductible
(A) The deduction for ACCS may be
used for the entire accounting period or part of it. Whether the standard daily
or monthly deduction is used depends on the size of the spenddown requirement.
The actual documented costs of ACCS may be deducted if they exceed the monthly
standard deduction. Deductions may be made for anticipated need through the end
of the accounting period. All changes in these standards that result in lower
standard deductions will be made via the Administrative Procedures
Act.
(B) If the individual's excess
income and resources after deduction of all expenses for which Medicaid
coverage is not available equal or exceed the deduction for ACCS for the entire
accounting period, for the purposes of meeting a spenddown requirement, ACCS
are projected and deducted as if they were not Medicaid-covered services for
the entire accounting period. Medicaid eligibility for services other than ACCS
becomes effective on the day the spenddown requirement is met. Expenses for
which Medicaid coverage is not available are:
(I) Medical expenses excluded from
coverage;
(II) Covered medical
expenses incurred prior to the accounting period, not used to meet a previous
spenddown requirement, and remaining unpaid; and
(III) Covered medical expenses incurred and
paid during the current accounting period.
(C) If the individual's excess income and
resources after deduction of all expenses for which Medicaid coverage is not
available are less than the deduction for ACCS for the entire accounting
period, ACCS expenses are not projected. Instead, they are deducted as covered
expenses on a daily basis. In this case, Medicaid eligibility for all covered
services other than ACCS becomes effective the first day of the accounting
period. Medicaid coverage for ACCS begins later. It starts the day cumulative
daily ACCS deductions exceed the individual's remaining excess income and
resources. The individual is not responsible for payment of a portion of the
ACCS expense on the first day of ACCS eligibility.
(D) In addition, the amount of the deduction
for any services included under the list at DVHA rule 7406.2 but not part of
the list at DVHA rule 7411.4 documented as medically necessary by the plan of
care is determined based on the number of hours times minimum wage, or actual
costs, if greater.
(5) Dental services
Dental services in excess of the allowable annual maximum may
be deducted.
(6)
Private-duty nursing services
Private-duty nursing services for an individual age 21 and
older may be deducted.
(d) Expenses for covered medical services
(1) A covered medical service is any medical
or remedial service that Medicaid would pay for if the individual were enrolled
in Medicaid (see DVHA Rules 7201- 7606).
(2) Deductions for covered medical services
are not limited to the Medicaid reimbursement for the service. The actual cost
paid or incurred is allowed. A standard deduction may be taken for ACCS (see
DVHA Rule 7411. 4), as set forth in Vermont's Medicaid Procedures
Manual.
(e) Third-party
coverage
(1) No deduction is allowed if the
medical expense is subject to payment by a third party such as health
insurance, worker's compensation, liability award, or other benefit program
unless the third party is a state or local program other than
Medicaid.
(2) When a third party is
liable for all or some medical expenses, only the portion owed by the
individual may be deducted. AHS is required to take reasonable measures to
determine the legal liability of third parties to pay for incurred expenses.
Estimates of payment by the third party may be used if actual third party
liability cannot be ascertained within the period for determining Medicaid
eligibility. An eligibility determination may not be delayed simply because
actual third party liability cannot be ascertained or payment by the third
party has not been received.
(3) If
an individual is pursuing a liability award, but liability has not yet been
established, a deduction is allowed. Eligibility must be based on AHS's
estimate of the amount the individual owes for the bill.
Part SIX SMALL EMPLOYER HEALTH-BENEFITS PROGRAM RULES
Section
31.00 Definitions
(01/15/2017, GCR 16-099)
As used only in Part Six, the following terms have the
following meanings:
Annual employee open enrollment period [1]
A period in which a qualified employee enrolling in a
qualified health plan through Vermont Health Connect (VHC) may:
(a) Create an account;
(b) Select QHPs, and if offered by the
employer, stand-alone dental coverage for himself/herself, and dependents, if
the qualified employer offers coverage to dependents;
(c) Complete the employee eligibility and
enrollment application;
(d) Receive
assistance from VHC in completing the application;
(e) Estimate whether the coverage offered by
the employer meets applicable federal affordability standards, by
(1) exiting the employee application;
and
(2) submitting an application
for individual eligibility determination for affordability assistance to
purchase coverage as a qualified individual;
(f) Designate an authorized representative
according to Section 5.02.
The annual employee open enrollment period shall precede the
end of the employer's current plan year and shall follow the annual employer
election period.
Annual employer election period [2]
The employer election period comes before both the employee
open enrollment period and the completion of the employer's current plan year.
During the employer election period, the qualified employer may change its
participation in VHC for the next plan year, and elect the following:
(a) The employees to whom it will offer
coverage;
(b) Whether to offer
coverage to the qualified employee's dependents, and the coverage tiers to
offer, i.e., single, two-person, adult plus dependent, or family;
(c) Whether to offer stand-alone dental
coverage;
(d) Whether the
individual owners, partners, retirees, or others will participate in a plan
offered to employees;
(e) During
the election period employers will be able to go on the VHC website and use the
available tools for assistance in deciding whether to offer their employees
group health coverage.
(f) The
method by which the qualified employer makes QHPs available to qualified
employees (see: employer choice, section 34.00); and
(g) The amount of its contribution towards
the premium cost of each coverage tier for each class of participant.
Dependent
Any individual who is or may become eligible for coverage
under the terms of a group health plan because of a relationship to a
participant. [3]
Employee [4]
Any individual employed by an employer. An employee does not
include an individual and his or her spouse with respect to a trade or
business, whether incorporated or unincorporated, which is wholly owned by the
individual or by the individual and his or her spouse, and does not include a
partner in a partnership and his or her spouse.
Employer [5]
(a) The
term "employer" means any person acting directly as an employer, or indirectly
in the interest of an employer, in relation to an employee benefit
plan.
(b) Such term includes
employers with one or more employees, and
(c) All persons treated as a single employer
such as a controlled group of corporations; partnerships, proprietorships,
etc., which are under common control; affiliated service groups; and other
arrangements such as separate organizations and employee leasing arrangements.
[6]
Full-time employee [7]
(a) An employee who is employed on average at
least 30 hours of service per week, for effective plan years beginning on or
after January 1, 2014.
(b) For
purposes of the definition of small employer, full-time employee does not
include seasonal workers.
(c) For
purposes of the definition of qualified employer, full-time employee does not
include seasonal employees.
Qualified employee [8]
An employee made eligible to enroll in coverage through VHC
through an offer of coverage from a qualified employer.
Qualified employer [9]
A qualified employer is a small employer that:
(a) Has its principal place of business in
Vermont, and elects to provide coverage for all full- time employees of such
employer through VHC, regardless of where an employee resides; or
(b) Elects to provide coverage through VHC
for all of its full-time employees who are principally employed in Vermont, and
if not principally employed in Vermont, to each full-time employee through the
small business health options program (SHOP) serving that employee's primary
worksite.
Seasonal employee [10]
The term seasonal employee means an employee who is hired
into a position for which the customary annual employment is six months or less
and the employee does not have any hour of service for the employer for a
period of at least 13 consecutive weeks before resuming employment
Customary means that by the nature of the position an
employee in this position typically works for a period of six months or less,
and that period should begin each calendar year in approximately the same part
of the year, such as summer or winter.11
In certain unusual instances, the employee can still be
considered a seasonal employee even if the seasonal employment is extended in a
particular year beyond its customary duration (regardless of whether the
customary duration is six months or is less than six months). For example, if
ski instructors at a resort have a customary period of annual employment of six
months, but are asked in a particular year to work an additional month because
of an unusually long or heavy snow season, they would still be considered
seasonal employees.12
Employers may but are not required to provide seasonal
employees with coverage for purposes of being a qualified employer.
Seasonal worker [13]
An employee who performs labor or services on a seasonal
basis, including ordinarily, when the employment pertains to or is of the kind
exclusively performed at certain seasons or periods of the year and which, from
its nature, may not be continuous or carried on throughout the year. A worker
who moves from one seasonal activity to another, while employed in agriculture
or performing agricultural labor, is employed on a seasonal basis even though
she may continue to be employed during a major portion of the year. Seasonal
workers include retail workers employed exclusively during holiday
seasons.
Seasonal workers are not counted when determining whether an
employer is a small employer.
Small employer [14]
(a) For plan years beginning on or after
January 1, 2014 through December 31, 2015, an entity which employed an average
of at least 1 but not more than 50 full-time employees on working days during
the preceding calendar year and who employs at least one employee on the first
day of the plan year.
(b) Beginning
on January 1, 2016, an entity which employed an average of at least 1 but not
more than 100 employees on working days during the preceding calendar year and
which employs at least 1 employee on the first day of the plan year. The number
of employees shall be calculated using the method set forth in section
4980H(c)(2) of the Internal Revenue Code; in general, by:
(1) Counting each full-time employee as one
employee;
(2) Adding the number of
hours worked by part-time employees in a month and dividing by 120;
and
(3) Excluding seasonal workers
if the employer's workforce exceeds 50 full-time employees for 120 days or
fewer during the calendar year.
Section 32.00 Employer Eligibility
(01/15/2017, GCR 16-099)
(a) Employer's continuing eligibility [15]
A qualified employer which ceases to be a small employer
solely because of an increase in the number of employees shall continue to be
treated as a qualified employer until the qualified employer otherwise fails to
meet eligibility criteria or elects to no longer purchase coverage for
qualified employees through VHC.
(b) Employer eligibility requirements [16]
To the extent permitted by HHS:
(1) VHC shall permit small employers to
purchase QHPs directly from a health insurer under contract with VHC.
(2) Upon request, VHC must provide a small
employer with an eligibility determination as to whether it is a qualified
employer with a notice of approval or denial of eligibility and the employer's
right to appeal such eligibility determination. VHC may accept an employer's
attestation of eligibility as eligibility is defined in §§ 31.00 and
32.00(b) instead of determining the employer's eligibility.
(c) Employer application [17]
VHC must use a single application to determine employer
eligibility and to collect information necessary for purchasing coverage. Such
application must collect the following:
(1) Employer name and address of employer's
locations;
(2) Number of full time
employees;
(3) Employer
Identification Number (EIN); and
(4) A list of qualified employees and their
taxpayer identification numbers.
(d) Filing the application [18]
VHC must provide the tools to file an application
(1) Via an Internet Web site;
(2) By telephone through a call
center;
(3) By mail; and
(4) In person, with reasonable accommodations
for those with disabilities.
(e) Verification of eligibility [19]
For the purpose of verifying employer eligibility VHC:
(1) May establish, in addition to or in lieu
of reliance on the employer application or attestation, additional methods to
verify the information provided by the employer on the application;
and
(2) Must collect only the
minimum information necessary for verification of eligibility in accordance
with the eligibility standards described in §§ 31.00, and
32.00(a).
(f)
Eligibility adjustment period [20]
When the information submitted on the VHC employer
application is inconsistent with the eligibility definitions and standards
described in §§ 31.00, 32.00(b), and 33.00, VHC must:
(1) Make a reasonable effort to identify and
address the causes of such inconsistency, including as a result of
typographical or other clerical errors;
(i) A
reasonable effort by VHC includes resolution of VHC errors, and
(ii) VHC outreach to the employer contact, as
necessary;
(2) Issue a
written notice to the employer if the inconsistency remains unresolved after
reasonable efforts have been made by VHC to resolve the
inconsistency;
(3) Provide the
employer with a period of 30 days from the date on which the notice described
in paragraph (f)(2) of this section is sent to the employer to either present
satisfactory documentary evidence to support the employer's application, or
resolve the inconsistency; and
(4)
If, after the 30-day period described in paragraph (3) VHC has not received
satisfactory documentary evidence, VHC must:
(i) Notify the employer of its denial of
eligibility in accordance with this subsection, 32.00(f), and of the employer's
right to appeal such determination; and
(ii) If the employer was enrolled pending the
confirmation or verification of eligibility information, discontinue the
employer's participation in VHC at the end of the month following the month in
which the notice is sent.
(g) Notice of employer eligibility
determination [21]
Upon request, VHC must provide a small employer with an
eligibility determination as to whether it is a qualified employer and a notice
of approval or denial of eligibility, and the employer's right to appeal such
eligibility determination.
Section 33.00 Employee Eligibility
(01/15/2017, GCR 16-099)
(a) Eligibility to enroll in VHC [22]
(1) A qualified employee is eligible to
enroll in employer sponsored coverage through VHC if that employee receives an
offer of coverage from a qualified employer. A qualified employee is eligible
to enroll his or her dependents in coverage through VHC if the offer from the
qualified employer includes an offer of dependent coverage.
(2) An individual and his or her spouse with
respect to a trade or business, whether incorporated or unincorporated, which
is wholly owned by the individual and his or her spouse may participate and
enroll in any qualified health plan that he or she is offering to at least one
qualified employee.
(3) A member of
a partnership that is a qualified employer may participate and enroll in any
qualified health plan that the partnership is offering to at least one
qualified employee.
(b)
Employee application [23]
VHC must use a single application for eligibility
determination, QHP selection, and enrollment for qualified employees, and their
dependents (if the employer offers dependent coverage).
(c) Employee application verification [24]
For the purpose of verifying employer and employee
eligibility, VHC
(1) Must verify that
an individual applicant is identified by the employer as an employee to whom
the qualified employer has offered coverage and must otherwise accept the
information attested to within the application unless the information is
inconsistent with the employer-provided information;
(2) May establish, in addition to or in lieu
of reliance on the application, additional methods to verify the information
provided by the applicant on the application; and
(3) Must collect only the minimum information
necessary for verification of eligibility in accordance with the eligibility
standards described in § 33.00(a)(1).
(d) Eligibility adjustment period. [25]
For an employee requesting eligibility to enroll in a QHP
through VHC for whom VHC receives information on the application inconsistent
with the employer provided information, VHC must--
(1) Make a reasonable effort to identify and
address the causes of such inconsistency, including as a result of
typographical or other clerical errors;
(2) Notify the individual of the inability to
substantiate his or her employee status;
(3) Provide the employee with a period of 30
days from the date on which the notice described in subsection (2) is sent to
the employee to either present satisfactory documentary evidence to support the
employee's application, or resolve the inconsistency; and
(4) If, after the 30-day period described in
subsection (3), VHC has not received satisfactory documentary evidence, VHC
must notify the employee of its denial of eligibility in accordance with this
subsection, 33.00(f).
(e) Employee information safeguarded [26]
VHC shall not provide to the employer any information
collected on the employee application with respect to spouses or dependents
other than the name, address, and birth date of the spouse or dependent.
(f) Notification of employee
eligibility. [27]
For an employee requesting an eligibility determination as to
whether the employee is a qualified employee, VHC must notify the employee and
employer of the determination and the employee's right to appeal such
eligibility determination.
Section 34.00 Employer Choice [28]
(01/15/2017, GCR 16-099)
Two models of employer choice
(a) Except as provided for in 34.00(c), a
qualified employer may offer QHPs on VHC to its employees and at the employer's
option to the employees' dependents29 in one of the following ways:
(1) Permitting the qualified employee to
select any plan from among all QHPs offered on VHC; or
(2) Permitting the qualified employee to
select any QHP offered on VHC by one issuer of the employer's choice;
(b) A qualified employer may
choose to offer in addition to QHPs any stand-alone dental plans offered on VHC
to its eligible employees and at the employer's option to their
dependents.
Section
35.00 Employee Enrollment Waiting Periods [30]
(01/15/2017, GCR 16-099)
(a) A group health plan or health insurance
issuer offering group health insurance coverage shall not apply any enrollment
waiting period that exceeds 90 days.
(b) Eligibility conditions that are based
solely on the lapse of a time period are permissible for no more than 90
days.
(c) [Reserved]
Section 36.00 Rolling Enrollment
and Short Plan Years. [31]
(01/15/2017, GCR 16-099)
(a) Qualified employers' plan years must be
on a calendar year term beginning January 1, 2015.
(b) VHC will permit a qualified employer to
purchase coverage for its small group at any point during the year. The plan
year will end on December 31 of the calendar year in which coverage first
became effective.
(c) In 2016,
qualified employers with 51 to 100 employees will be eligible to enroll in a
QHP for the first time and may experience a short plan year.
(i) QHP issuers may provide transitional
relief to employers renewing during the 2015 plan year which have a short
subsequent plan year as a result of becoming a small employer, by extending
cost share accumulators into the short 2016 plan year.
Section 37.00 Employer Election
Period
(01/15/2017, GCR 16-099)
(a) Annual employer election period [32]
VHC will provide qualified employers with a standard election
period prior to the completion of the employer's plan year and before the
annual employee open enrollment period.
(b) Notice of election period [33]
VHC shall ensure that employers are notified of the annual
election period in advance of the start of the employer election period.
Section 38.00 Employee
Enrollment Periods [34]
(01/15/2017, GCR 16-099)
(a) Employee enrollment periods, generally
(1) Employees will have the opportunity to
select qualified health plans, and a stand- alone dental plan if the employer
offers dental coverage, verify and provide necessary personal information for
enrollment of himself or herself and his or her dependents, if the employer
offers coverage to employee dependents, and make changes to
enrollment.
(2) VHC may only permit
a qualified employee to enroll in a QHP or an enrollee to change QHPs during
initial, annual, or special open enrollment periods.
(b) Annual open enrollment period [35]
VHC will provide a standardized annual open enrollment period
for qualified employees prior to the completion of the applicable qualified
employer's plan year and after that employer's annual election period.
(c) Notice of annual open
enrollment period [36]
VHC must provide notification to a qualified employee of the
annual open enrollment period in advance of the open enrollment period.
(d) Newly qualified employees
enrollment period [37]
For an employee who becomes a qualified employee outside of
the initial or annual open enrollment period, a 30-day enrollment period begins
on the first day of becoming a qualified employee. The enrollment period must
end no sooner than 15 days prior to the date that any applicable employee
waiting period longer than 45 days would end if the employee made a plan
selection on the first day of becoming eligible.
Section 39.00 Employee Special Enrollment
Periods
(01/15/2017, GCR 16-099)
(a) Events resulting in a special enrollment
period [38]
(1) VHC must allow qualified
employees or their dependents to enroll in or change from one QHP to another as
a result of the following triggering events:
(i) An event described in § 71.03(d)(1),
(2), (4), (5), (7), (8), or (9);
(ii) A qualified employee or dependent loses
eligibility for coverage under a Medicaid plan under title XIX of the Social
Security Act or a state child health plan under title XXI of the Social
Security Act; or
(iii) A qualified
employee or dependent becomes eligible for premium assistance with a small
employer plan under such Medicaid plan or a state child health plan (including
any waiver or demonstration project conducted under or in relation to such a
plan).
(2) A dependent
of a qualified employee is not eligible for a special enrollment period if the
employer does not extend the offer of coverage to dependents.
(b) Duration of special enrollment
periods [39]
A qualified employee or dependent of a qualified employee who
experiences a qualifying event described above has 60 days from the date of a
triggering event to select a QHP through VHC.
(c) Loss of minimum essential coverage. [40]
Loss of minimum essential coverage is determined using the
provisions of § 71.03(e).
Section 40.00 Enrollment
(01/15/2017, GCR 16-099)
(a) Generally
(1) VHC must ensure that employee coverage
shall be effective for the coverage effective date selected by the employer on
its application during the employer election period, if VHC receives all
necessary enrollee information by the employee plan selection deadline, and
payment is made in full.
(2) Upon
receipt of full payment, VHC must transfer enrollment information to issuers on
or before the next non-holiday business day.
(3) For employers choosing to direct enroll
with the issuers, employee coverage shall be effective for the coverage
effective date agreed upon by the employer and the issuer.
(b) New enrollments
(1) The effective date of coverage for a QHP
selection received by VHC from a newly qualified employee being added to an
employer's plan will be the first day of a month following plan selection,
unless the employee is subject to a waiting period consistent with §
35.00, in which case the effective date may be on the first day of a later
month, but in no case may the effective date fail to comply with §
35.00.
(2) For plan selections
received by VHC within the last five days of the month, VHC will transfer
enrollment information and QHP issuer will effectuate coverage without undue
delay and, if necessary, retroactive to the effective date in (1) of this
subsection.
Section
41.00 Coverage Effective Dates [41]
(01/15/2017, GCR 16-099)
(a) Generally
(1) Coverage will become effective on the
employer selected date provided full payment is received by VHC by the due date
on the invoice of the month before the coverage month, except that
(2) When a qualified employee is eligible to
make, and makes a plan selection during a special enrollment period, coverage
will become effective under (c) of this section, and
(3) Coverage for a newly qualified employee
being added to an employer's plan will become effective under §
40.00(b).
(b) Coverage
effective dates generally, for plan years beginning on or after January 1, 2015
(1) VHC shall ensure a coverage effective
date of January 1st for a QHP selection received by VHC from a qualified
employee on or before November 30 of the year before a plan year beginning
January 1, 2015, and subsequent years as long as payment is received in
accordance with (a) of this section.
(2) For an employer choosing to direct enroll
with a QHP issuer, an issuer may provide a January 1 coverage effective date
for a plan selection made by a qualified employee after November 30.
(c) Employee special enrollment
period coverage effective dates [42]
The effective dates of coverage are determined using the
provisions of § 70.03(b)(2).
(d) Notification of effective date [43]
VHC must ensure that a QHP issuer notifies a qualified
employee enrolled in a QHP of the effective date of coverage.
Section 42.00 Renewal of Employee
Coverage [44]
(01/15/2017, GCR 16-099)
If a qualified employee enrolled in a QHP through VHC remains
eligible for coverage, such employee will remain in the QHP selected the
previous year unless:
(a) The
qualified employee terminates coverage from such QHP;
(b) The qualified employee enrolls in another
QHP; or
(c) The QHP is no longer
available to the qualified employee.
Section 43.00 Terminations [45]
(01/15/2017, GCR 16-099)
(a) In general
The provisions of this section apply when enrollment in a QHP
takes place through Vermont Health Connect.
Section 43.01 Employer withdrawal from VHC
[46]
(01/15/2017, GCR 16-099)
(a) Employer withdrawal
A qualified employer may withdraw from coverage through VHC
with advance notice in accordance with applicable state and federal law.
(b) Employee notice of termination
VHC will ensure that:
(1) Each QHP issuer terminates the enrollment
through VHC of the employer's qualified employees enrolled in the QHP through
VHC.
(2) Each of the employer's
qualified employees enrolled in a QHP through VHC is notified of the
termination of coverage prior to such termination.
(i) Such notification provides information
about other potential sources of coverage, including access to individual
market coverage through VHC.
Section 43.02 Termination of employer group
for non-payment of premiums [47]
(01/15/2017, GCR 16- 099)
(a) Conditions under which QHP issuer may
terminate coverage
(1) If premium payment is
not received one month from the first of the coverage month, the QHP issuer may
terminate the qualified employer for lack of payment provided notice
requirements in 43.06 are met.
(b) Reinstatement
(1) The QHP issuer must reinstate the
qualified employer in its previous coverage if the qualified employer:
(i) Requests reinstatement within 30 days
following its termination for non-payment,
(ii) Pays all premiums owed including any
prior premiums owed for coverage during the one month grace period,
and
(iii) Pays the premium for the
next month's coverage.
(2) Reinstatement is not allowed more than
twice within a plan year. Upon a third instance of termination for non-payment,
a qualified employer may not re-enroll until the following calendar
year.
(3) VHC will ensure that the
employer's qualified employees enrolled in a QHP through VHC are notified of
the group's reinstatement.
(c) Payment for COBRA Continuation Coverage
Nothing in this section modifies existing obligations related
to the administration of coverage required under
29
U.S.C. 1161, et seq., as described in 26 CFR
part 54.
Section
43.03 Termination of employee or dependent coverage [48]
(01/15/2017, GCR 16-099)
(a) Termination due to loss of eligibility
(1) If a qualified employee or their
dependent is no longer eligible for coverage under the employer's group health
plan, VHC will notify the QHP issuer of the loss of eligibility.
(b) Employee voluntary termination
(1) To the extent permitted by the qualified
employer and allowable under applicable state and federal law, [49] VHC will
allow an employee to terminate his or her coverage in a QHP, including as a
result of the employee obtaining other minimum essential coverage, with
fourteen day notice to VHC.
(2) VHC
will:
(i) Notify the employee's employer of
employee termination. [50]
(ii)
Notify the QHP issuer of employee termination.
(3) The last day of coverage is the last day
of the month in which VHC receives notice in accordance with (1), unless
employee requests and QHP issuer agrees to an earlier termination effective
date.
Section
43.04 Termination effective dates
(01/15/2017, GCR 16-099)
(a) Other termination effective dates
The effective dates of termination resulting from events not
described in this section are determined using the provisions of §
76.00(d).
Section
43.05 Termination of coverage tracking and approval [51]
(01/15/2017, GCR 16-099)
(a) Termination of coverage tracking and
approval
VHC and QHP issuers must maintain records of termination of
coverage in compliance with § 76.00(c).
Section 43.06 Notice of Termination [52]
(01/15/2017, GCR 16-099)
(a) Employee notice
(1) If a qualified employee or their
dependent is terminated from coverage due to non- payment of premiums or due to
a loss of eligibility to participate in VHC, including where an employee loses
his or her eligibility because a qualified employer has lost its eligibility,
VHC will ensure that the employee is notified of the termination.
(2) The notice will include the termination
effective date, reason for termination, and information about other potential
sources of coverage, including access to individual market coverage through
VHC.
(3) The notice will be sent
within 3 business days of the determination to terminate coverage, if an
electronic notice is sent, and within 5 business days if a mailed hard copy
notice is sent.
(b)
Employer notice
(1) If an employer group's
coverage or enrollment through VHC is terminated due to non- payment of
premiums or, where applicable, due to a loss of the qualified employer's
eligibility to offer coverage through VHC, VHC will ensure that the employer is
notified of the termination.
(2)
Such notice will include the termination effective date and reason for
termination.
(3) Such notice will
be sent within 3 business days of the determination to terminate coverage, if
an electronic notice is sent, and within 5 business days if a mailed hard copy
notice is sent.
(c)
Notices to dependents
When a primary subscriber and his or her dependents live at
the same address, a separate termination notice need not be sent to each
dependent at that address, provided that the notice sent to each primary
subscriber at that address contains all required information about the
termination for the primary subscriber and his or her dependents at that
address.
Section
44.00 Employer and Employee Eligibility Appeals [53]
(01/15/2017, GCR 16-099)
(a) Employer right to appeal
An employer may appeal:
(1) A notice of denial of eligibility under
§ 32.00(g); or
(2) A failure
of the VHC to provide a timely eligibility determination or a timely notice of
an eligibility determination in accordance with § 32.00(g).
(b) Employee right to appeal
An employee may appeal:
(1) A notice of denial of eligibility under
§ 33.00(f); or
(2) A failure
of the VHC to provide a timely eligibility determination or a timely notice of
an eligibility determination in accordance with § 33.00(f).
(c) Notices
Notices of the right to appeal a denial of eligibility must
be written and include --
(1) The
reason for the denial of eligibility, including a citation to the applicable
regulations; and
(2) The procedure
by which the employer or employee may request an appeal of the denial of
eligibility.
(d) Appeal
request
VHC and AHS must:
(1) Allow an employer to request an appeal
within 90 days from the date of the notice of denial of eligibility.
(2) Accept appeal requests submitted --
(i) By telephone;
(ii) By mail; or
(iii) Via the Internet.
(3) Assist the applicant or enrollee in
making the appeal request, if requested.
(4) Not limit or interfere with the
applicant's right to make an appeal request; and
(5) Consider an appeal request valid if it is
submitted within 90 days from the date of the notice of denial of
eligibility.
(e) Notice
of appeal request
Upon receipt of a valid appeal request, AHS must --
(1) Send timely acknowledgement to the
employer of the receipt of the appeal request, including --
(i) An explanation of the appeals process;
and
(ii) Instructions for
submitting additional evidence for consideration by AHS.
(2) Promptly notify VHC of the appeal, if the
appeal request was not initially made to VHC.
(3) Upon receipt of an appeal request that is
not valid because it fails to meet the requirements of this section, AHS must
--
(i) Promptly and without undue delay, send
written notice to the employer or employee that is appealing that --
(A) The appeal request has not been
accepted,
(B) The nature of the
defect in the appeal request; and
(C) An explanation that the employer or
employee may cure the defect and resubmit the appeal request within 90 days
from the date of the notice of denial of eligibility, or within a reasonable
timeframe established by AHS.
(ii) Treat as valid an amended appeal request
that meets the requirements of this section.
(f) Transmittal and receipt of records
(1) Upon receipt of a valid appeal request
VHC must promptly transmit, via secure electronic interface, to AHS --
(i) The appeal request, if the appeal request
was initially made to VHC; and
(ii)
The eligibility record of the employer or employee that is appealing.
(2) AHS must promptly confirm
receipt to VHC of the records VHC transmitted.
(g) Dismissal of appeal
AHS:
(1) Must
dismiss an appeal if the employer that is appealing --
(i) Withdraws the request in writing;
or
(ii) Fails to submit an appeal
request 90 days from the date of the notice of denial of eligibility to
AHS.
(2) Must provide
timely notice to the employer or employee that is appealing of the dismissal of
the appeal request, including the reason for dismissal, and must notify VHC of
the dismissal.
(3) May vacate a
dismissal if the employer or employee makes a written request within 30 days of
the date of the notice of dismissal showing good cause why the dismissal should
be vacated.
(h)
Procedural rights of the employer and employee
AHS must provide the employer, or the employer and employee
if an employee is appealing, the opportunity to submit relevant evidence for
review of the eligibility determination.
(i) Adjudication of VHC appeals
Employer or employee appeals must:
(1) Be reviewed de novo by one or more
impartial officials who have not been directly involved in the employer or
employee eligibility determination implicated in the appeal, and
(2) Consider the information used to
determine the employer or employee's eligibility as well as any additional
relevant evidence submitted during the course of the appeal by the employer or
employee.
(j) Appeal
decisions
Appeal decisions must:
(1) Be based solely on
(i) The evidence referenced in (h)(2) of this
section, and
(ii) The employer and
employee eligibility requirements for VHC.
(2) State the decision, including a plain
language description of the effect of the decision on the appellant's
eligibility;
(3) Summarize the
facts relevant to the appeal;
(4)
Identify the legal basis, including the regulations that support the
decision;
(5) State the effective
date of the decision; and
(6) Be
effective as follows:
(i) If an employer is
found eligible under the decision, then at the employer's option, the effective
date of coverage or enrollment through VHC under the decision can either be
made retroactive to the effective date of coverage or enrollment through VHC
that the employer would have had if the employer had been correctly determined
eligible, or prospective to the first day of the month following the date of
the notice of the appeal decision.
(ii) For employee appeal decisions only, if
an employee is found eligible under the decision, then at the employee's
option, the effective date of coverage or enrollment through VHC under the
decision can either be made effective retroactive to the effective date of
coverage or enrollment through VHC that the employee would have had if the
employee had been correctly determined eligible, or prospective to the first
day of the month following the date of the notice of the appeal
decision.
(iii) If the employer or
employee is found ineligible under the decision, then the appeal decision is
effective as of the date of the notice of the appeal decision.
(k) Notice of appeal
decision
AHS must issue written notice of the appeal decision to the
employer or to the employer and employee if an employee's eligibility is
implicated, and to VHC within 90 days of the date the appeal request is
received.
(l)
Implementation of VHC appeal decisions
VHC must promptly implement the appeal decision upon
receiving the notice of appeal decision under (j) of this section.
(m) Appeals record
(1) Subject to the requirements of all
applicable federal and state laws regarding privacy, confidentiality,
disclosure, and personally identifiable information the appeal record must be
accessible to the employer, or employer and employee if an employee's
eligibility is implicated, in a convenient format and at a convenient
time.
(2) AHS must provide public
access to all appeal records, subject to all applicable federal and state laws
regarding privacy, confidentiality, disclosure, and personally identifiable
information.
Section
45.00 Employer Appeals of Employee Eligibility for APTC/CSR [54]
(01/15/2017, GCR 16-099)
(a) Notice to an employer of employee's
receipt of APTCs and CSRs
VHC will notify an employer that an employee has been
determined eligible for advance payments of the premium tax credit and
cost-sharing reductions and has enrolled in a qualified health plan through VHC
in accordance with § 71.01(e).
(b) Employer Right to appeal
An employer may, in response to a notice of an employee's
eligibility for advance payments of the premium tax credit and cost-sharing
reductions to an employer, appeal a determination that the employer does not
provide minimum essential coverage through an employer sponsored plan or that
the employer does provide that coverage but it is not affordable coverage with
respect to an employee. The employer will file the appeal with the HHS appeals
entity or other entity as directed by VHC in the notice in (a) of this
section.
Section
46.00 Premium Processing
(01/15/2017, GCR 16-099)
(a) Premium aggregation
VHC must perform the following functions related to premium
payment administration:
(1) Provide
each qualified employer with a bill on a monthly basis that identifies the
employer contribution, the employee contribution, and the total amount that is
due to the QHP issuers from the qualified employer;
(2) Collect from each employer the total
amount due and make payments to QHP issuers for all enrollees; and
(3) Maintain books, records, documents, and
other evidence of accounting procedures and practices of the premium
aggregation program for each benefit year for at least 10 years.
(b) QHP issuers must accept VHC
payments
QHP Issuer must accept payment from the VHC on behalf of a
qualified employer or an enrollee.
Section 47.00 Reserved
(01/15/2017, GCR 16-099)
Section 48.00 Reserved
(01/15/2017, GCR 16-099)
Section 49.00 Reserved
(01/15/2017, GCR 16-099)
Section 50.00 Reserved
(01/15/2017, GCR 16-099)
Part SEVEN ELIGIBILITY-AND-ENROLLMENT PROCEDURES
Section 51.00 Automatic
Entitlement to Medicaid Following a Determination of Eligibility under Other
Programs [1]
(01/15/2017, GCR 16-100)
A separate application for Medicaid is not required from an
individual who receives SSI or AABD.
Section 52.00 Application [2]
(01/15/2017, GCR 16-100)
Section 52.01 In general
(01/15/2017, GCR 16-100)
An individual will be afforded the opportunity to apply for
health benefits at any time, without delay. [3]
Section 52.02 Application filing [4]
(01/15/2017, GCR 16-100)
(a) The application
A single, streamlined application will be used to determine
eligibility and to collect information necessary for:
(1) Enrollment in a QHP;
(2) APTC;
(3) CSR;
(4) Vermont Premium Reduction;
(5) Vermont Cost Sharing Reduction;
and
(6) MAGI-based Medicaid. For
Medicaid categories that are not based on MAGI methodologies, the single,
streamlined application may be supplemented with a form (or forms) to collect
additional information, or an appropriate, alternative application may be
used.
(b) Filing the
application
AHS will:
(1) Accept
the application from an application filer; and
(2) Provide the tools to file an application:
(i) Via an internet website;
(ii) By telephone through a call
center;
(iii) By mail;
(iv) Through other commonly available
electronic means; and
(v) In
person.
(c)
Assistance [5]
AHS will provide assistance to any individual seeking help
with the application or renewal process, in the manner prescribed in §
5.01.
(d) Application
filers
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.
(e) Missing
information [6]
(1) The applicant's
eligibility for health benefits will not be determined before the applicant
provides answers to all required questions on the application.
(2) 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.
(3) If a full response to the request is
received on or before the request 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.
(4) 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 health benefits. The date that the incomplete application was
received will not be used in any subsequent eligibility
determinations.
(f)
Limits on information [7]
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.
(g) Information collection from
non-applicants [8]
Information regarding citizenship, status as a national, or
immigration status will not be requested for an individual who is not seeking
health benefits for themselves.
(h) Signature required
An initial application must be signed under penalty of
perjury.
Electronic, including telephonically-recorded, signatures and
handwritten signatures transmitted via any other electronic transmission will
be accepted.
(i)
Accessibility
Any application or supplemental form must be accessible to
individuals who are limited English proficient and individuals who have
disabilities, consistent with the provisions of § 5.01.
Section 53.00 Attestation and
Verification in - General
(01/15/2017, GCR 16-100)
(a) Basis and scope
The income and eligibility verification requirements set
forth in §§ 53.00 through 56.00 are based on §§ 1137,
1902(a)(4),
1902(a)(19),
1902(a)(46)(B),
1902(ee),
1903(r)(3),
1903(x),
and 1943(b)(3) of the Act, and § 1413 of the ACA.
(b) In general
AHS will verify or obtain information as provided in
§§ 53.00 through 56.00 before making a determination about an
individual's eligibility for health benefits. Such information will be used in
making the eligibility determination. See § 58.00 for details on the
eligibility determination process.
(c) Attestation [9]
Except where the law requires other procedures (such as for
citizenship and immigration-status information), attestation of information
needed to determine the eligibility of an individual for health benefits will
be accepted (either self-attestation by the individual or attestation by an
adult who is in the individual's household, an authorized representative, or,
if the individual is under age 18 [10] or incapacitated, someone acting
responsibly for the individual) without requiring further information
(including documentation) from the individual.
(d) Use of federal electronic verification
service [11]
To the extent that information related to determining
eligibility for health benefits is available through an electronic service
established by HHS, AHS will obtain the information through such service,
unless AHS has secured HHS approval of alternative procedures described in (e)
below. [12]
(e) Flexibility
in information collection and verification
Subject to approval by HHS, AHS may request and use
information from a source or sources alternative to those listed in §
56.01(b), or through a mechanism other than the electronic service described in
(d) above, provided that such alternative source or mechanism will reduce the
administrative costs and burdens on individuals and the state while maximizing
accuracy, minimizing delay, and meeting applicable requirements relating to
confidentiality, disclosure, maintenance, or use of information.
(f) Notice of intent to obtain and
use information [13]
Before it requests information for an individual from another
agency or program, AHS will inform the individual that it will obtain and use
information available to it to verify income, resources (when applicable), and
eligibility or for other purposes directly connected to the administration of a
health-benefits program or to enrollment in a QHP.
(g) Security of electronic information
exchanges [14]
Information exchanged electronically between AHS and any
other agency or program will be sent and received via secure electronic
interfaces, as specified in § 4.09. Any such exchange of data will be made
pursuant to written agreements with such other agencies or programs, which will
provide for appropriate safeguards limiting the use and disclosure of
information as required by federal or state law or regulations.
(h) Limitation on scope of
information requests
(1) An individual will
not be required to provide information beyond the minimum necessary to support
eligibility and enrollment processes.
(2) An individual will not be required to
provide additional information or documentation unless information needed by
AHS cannot be obtained electronically or the information obtained
electronically is not reasonably compatible, as that term is defined in §
57.00(a), with information provided by or on behalf of the
individual.
(i)
Limitation on use of evidence of immigration status
Evidence of immigration status may not be used to determine
that an individual is not a Vermont resident.
Section 54.00 Attestation and Verification of
Citizenship and Immigration Status
(01/15/2017, GCR 16-100)
Section 54.01 Definitions
(01/15/2017, GCR 16-100)
For definitions relevant to citizenship and immigration
status, see § 17.00.
Section
54.02 Declaration of citizenship or immigration status
(01/15/2017, GCR 16- 100)
Except as provided in § 54.06 for certain individuals
applying for Medicaid, and except for employees enrolling in a qualified
employer- sponsored plan, an individual seeking health benefits must sign a
declaration that they are:
(a) A
citizen or national of the United States ( § 17.01(a) and (c));
(b) A qualified non-citizen ( § 17.01(d)
); or
(c) Lawfully present in the
United States ( § 17.01(g)).
For the effect that citizenship and immigration status has on
eligibility for health benefits, see § 17.00
Section 54.03 Verification frequency
(01/15/2017, GCR 16-100)
(a) Citizenship [15]
Verification or documentation of citizenship is a one-time
activity; once an individual's citizenship is documented and recorded,
subsequent changes in eligibility should not require repeating the
documentation unless later evidence raises a question about the individual's
citizenship.
(b)
Immigration status [16]
Immigration status, including lawful presence, must be
verified or documented at the time of initial application and at the time of
eligibility renewal. In verifying immigration status at the time of renewal,
AHS will first rely on information provided at the time of initial application
to determine ongoing eligibility. AHS will only require the individual to
provide further documentation or to re-verify satisfactory status if it cannot
verify continued eligibility based on the information already available to
it.
Section
54.04 Electronic verification [17]
(01/15/2017, GCR 16-100)
(a) Verification with records from the SSA
For an individual who attests to citizenship and has a Social
Security number, AHS will transmit their Social Security number and other
identifying information to HHS, which will submit it to the SSA for
verification.
(b)
Verification with the records of DHS
For an individual who has documentation that can be verified
through DHS and who either attests to lawful immigration status or lawful
presence, or who attests to citizenship and for whom AHS cannot substantiate a
claim of citizenship through SSA, AHS will transmit information from the
individual's documentation and other identifying information to HHS, which will
submit necessary information to DHS for verification.
Section 54.05 Inconsistencies and
inability to verify information [18]
(01/15/2017, GCR 16-100)
(a) In general
Except as provided in § 54.06, for an individual who
attests to citizenship or eligible immigration status, and for whom such
attestation cannot be verified through SSA or DHS, AHS will:
(1) Follow the procedures specified in §
57.00 (inconsistencies), except that:
(i) The
opportunity period described in § 57.00(c)(2)(ii) during which the
individual must submit documentation or resolve the inconsistency begins with
the date the notice described in § 57.00(c)(2)(i) is received by, rather
than sent to, the individual and, for both QHP and Medicaid purposes, extends
90 days from that date. The date on which the notice is received is considered
to be five days after the date on the notice, unless the individual
demonstrates that they did not receive the notice within the five-day
period.
(ii) In addition to the
reason described in § 57.00(c)(3), the opportunity period may also be
extended beyond 90 days if the individual is making a good-faith effort to
resolve any inconsistencies or AHS needs more time to complete the verification
process.
(2) If the
individual does not have a Social Security number, assist the individual in
obtaining a Social Security number;19
(3) Attempt to resolve any inconsistencies,
including typographical or other clerical errors, between information provided
by the individual and data from an electronic data source, and resubmit
corrected information to the electronic data source;
(4) Provide the individual with information
on how to contact the source of the electronic data so they can attempt to
resolve inconsistencies directly with such data source; and
(5) Permit the individual to provide other
documentation of citizenship or immigration status.20
(b) Eligibility activities during opportunity
period [21]
During the opportunity period described in paragraphs
(a)(1)(i) and (ii) of this subsection, AHS will:
(1) Not delay, deny, reduce, or terminate
benefits for an individual who is otherwise eligible for health
benefits.
(2) Begin to furnish
Medicaid benefits to otherwise eligible individuals effective on the date of
the application containing the declaration of citizenship or immigration status
by or on behalf of the individual.
(3) If relevant, proceed with respect to QHP
enrollment, APTC, and CSR, as provided for in § 57.00(c)(4).
[22]
(c) Failure to
complete verification during opportunity period
If, by the end of the opportunity period described in
paragraphs (a)(1)(i) and (ii) of this subsection, the individual's citizenship
or immigration status has not been verified in accordance with paragraph (a) of
this subsection, AHS will:
(1) With
regard to the individual's eligibility for Medicaid, take action within 30 days
to terminate eligibility. [23]
(2)
With regard to the individual's eligibility for enrollment in a QHP, APTC and
CSR, proceed in accordance with the provisions of § 57.00(c)(4)(ii).
[24]
(d) Records of
verification
AHS will maintain a record of having verified citizenship or
immigration status for each individual in a case record or electronic
database.
Section
54.06 Individuals not required to document citizenship or national
status for Medicaid [25]
(01/15/2017, GCR 16-100)
The following individuals are not required to document
citizenship or national status as a condition of receipt of Medicaid
benefits:
(a) An individual receiving
SSI benefits under Title XVI of the Act;
(b) An individual entitled to or enrolled in
any part of Medicare;
(c) An
individual receiving Social Security disability insurance benefits under §
223 of the Act or monthly benefits under § 202 of the Act, based on the
individual's disability (as defined in § 223(d) of the Act);
(d) An individual who is in foster care and
who is assisted under Title IV-B of the Act, and an individual who is a
recipient of foster-care maintenance or adoption assistance payments under
Title IV-E of the Act; and
(e) A
child born in the United States on or after April 1, 2009, who was deemed
eligible for Medicaid as a newborn ( § 9.03(b)). [26]
Section 54.07 Documentary evidence
of citizenship and identity
(01/15/2017, GCR 16- 100)
(a) Definition: available
Document exists and can be obtained within the period of time
specified in § 54.05.
(b) Standalone evidence of citizenship [27]
The following will be accepted as satisfactory documentary
evidence of citizenship:
(1) A U.S.
passport, including a U.S. Passport Card issued by the Department of State,
without regard to any expiration date as long as such passport or Card was
issued without limitation.
(2) A
Certificate of Naturalization.
(3)
A Certificate of U.S. Citizenship.
(4) A valid state-issued driver's license if
the state issuing the license requires proof of U.S. citizenship, or obtains
and verifies a Social Security number from the applicant who is a citizen
before issuing such license.
(5)
Tribal documents:
(i) Documentary evidence
issued by a federally-recognized Indian tribe, as published in the Federal
Register by the Bureau of Indian Affairs within the U.S. Department of the
Interior, and including tribes located in a State that has an international
border, which:
(A) Identifies the
federally-recognized Indian tribe that issued the document;
(B) Identifies the individual by name;
and
(C) Confirms the individual's
membership, enrollment, or affiliation with the tribe.
(ii) Documents described in paragraph
(b)(5)(i) of this subsection include, but are not limited to:
(iii) A tribal enrollment card;
(iv) A Certificate of Degree of Indian
Blood;
(v) A tribal census
document;
(vi) Documents on tribal
letterhead, issued under the signature of the appropriate tribal official, that
meet the requirements of paragraph (b)(5)(i) of this subsection.
(c) Other evidence of
citizenship [28]
If an applicant does not provide documentary evidence from
the list in paragraph (b) of this subsection, the following must be accepted as
satisfactory evidence to establish citizenship if also accompanied by an
identity document listed in paragraph (d) of this subsection:
(1) A U.S. public birth certificate showing
birth in one of the 50 States, the District of Columbia, Puerto Rico (if born
on or after January 13, 1941), Guam, the Virgin Islands of the U.S. (on or
after January 17, 1917), American Samoa, Swain's Island, or the Commonwealth of
the Northern Mariana Islands (CNMI) (after November 4, 1986 (CNMI local time)).
The birth record document may be issued by the State, Commonwealth, Territory,
or local jurisdiction. If the document shows the individual was born in Puerto
Rico, the Virgin Islands of the U.S., or the CNMI before these areas became
part of the U.S., the individual may be a collectively naturalized
citizen.
(2) At state option, a
cross-match with a state vital statistics agency documenting a record of
birth.
(3) A Certification of
Report of Birth, issued to U.S. citizens who were born outside the
U.S.
(4) A Report of Birth Abroad
of a U.S. Citizen.
(5) A
Certification of birth.
(6) A U.S.
Citizen I.D. card.
(7) A Northern
Marianas Identification Card, issued to a collectively naturalized citizen, who
was born in the CNMI before November 4, 1986.
(8) A final adoption decree showing the
child's name and U.S. place of birth, or if an adoption is not final, a
statement from a state-approved adoption agency that shows the child's name and
U.S. place of birth.
(9) Evidence
of U.S. Civil Service employment before June 1, 1976.
(10) U.S. Military Record showing a U.S.
place of birth.
(11) A data match
with the Systematic Alien Verification for Entitlements (SAVE) Program or any
other process established by DHS to verify that an individual is a
citizen.
(12) Documentation that a
child meets the requirements of §
101 of the
Child Citizenship Act of 2000 (
8
USC §
1431) .
(13) Medical records, including, but not
limited to, hospital, clinic, or doctor records or admission papers from a
nursing facility, skilled care facility, or other institution that indicate a
U.S. place of birth.
(14) Life,
health, or other insurance record that indicates a U.S. place of
birth.
(15) Official religious
record recorded in the U.S. showing that the birth occurred in the
U.S.
(16) School records, including
pre-school, Head Start and daycare, showing the child's name and U.S. place of
birth.
(17) Federal or State census
record showing U.S. citizenship or a U.S. place of birth.
(18) If the individual does not have one of
the documents listed in paragraphs (b) or (c)(1) through (17) of this
subsection, they may submit an affidavit signed by another individual under
penalty of perjury who can reasonably attest to the individual's citizenship,
and that contains the individual's name, date of birth, and place of U.S.
birth. The affidavit does not have to be notarized.
(d) Evidence of identity [29]
(1) The following will be accepted as proof
of identity, provided such document has a photograph or other identifying
information including, but not limited to, name, age, sex, race, height,
weight, eye color, or address:
(i) Identity
documents listed at
8 CFR §
274a.2(b)(1)(v)(B)(1),
except a driver's license issued by a Canadian government authority.
(ii) Driver's license issued by a State or
Territory.
(iii) School
identification card.
(iv) U.S.
military card or draft record.
(v)
Identification card issued by the federal, state, or local
government.
(vi) Military
dependent's identification card.
(vii) U.S. Coast Guard Merchant Mariner
card.
(2) For children
under age 19, a clinic, doctor, hospital, or school record, including preschool
or day care records.
(3) Two
documents containing consistent information that corroborates an individual's
identity. Such documents include, but are not limited to, employer
identification cards, high school and college diplomas (including high school
equivalency diplomas), marriage certificates, divorce decrees, and property
deeds or titles.
(4) AHS will
accept as proof of identity:
(i) A finding of
identity from a federal agency or another state agency, including but not
limited to a public assistance, law enforcement, internal revenue or tax
bureau, or corrections agency, if the agency has verified and certified the
identity of the individual.
(ii)
[Reserved]
(5) If the
individual does not have any document specified in paragraphs (d)(1) through
(d)(3) of this subsection and identity is not verified under paragraph (d)(4)
of this subsection, the individual may submit an affidavit signed, under
penalty of perjury, by another person who can reasonably attest to the
individual's identity. Such affidavit must contain the individual's name and
other identifying information establishing identity, as describe in paragraph
(d)(1) of this subsection. The affidavit does not have to be
notarized.
(e)
Verification of citizenship by a federal agency or another state [30]
AHS may rely, without further documentation of citizenship or
identity, on a verification of citizenship made by a federal or state agency,
if such verification was done on or after July 1, 2006.
(f) Assistance [31]
AHS will assist individuals who need assistance to secure
satisfactory documentary evidence of citizenship in a timely manner.
(g) Documentary evidence [32]
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.
Section 54.08 Documentation of
immigration status for qualified non-citizens
(01/15/2017, GCR 16-100)
If verification of immigration status cannot be obtained
through the process described in § 54.04, a non-citizen individual seeking
health benefits as a qualified non-citizen must provide United States
Citizenship and Immigration Services (USCIS) documents to establish immigration
status, as specified below:
(a) Lawful
Permanent Resident
(1) USCIS Form I-551;
or
(2) For recent arrivals, a
temporary I-551 stamp on a foreign passport or on Form I-94.
(3) Note: Forms I-151, AR-3 and AR-3A have
been replaced by USCIS. If presented as evidence of status, contact USCIS to
verify status by filing a G-845 with a copy of the old form. Refer the
individual to USCIS to apply for a replacement card.
(b) Refugee
(1) The following documents may be used to
document refugee status:
(i) USCIS Form I-94
endorsed to show entry as refugee under §
207
of INA and date of entry to the United States;
(ii) USCIS Form I-688B annotated
"274a.12(a)(3)";
(iii) Form I-766
annotated "A3"; or
(iv) Form
I-571.
(2) Refugees
usually change to Lawful Permanent Resident status after 12 months in the
United States, but for the purposes of health-benefits eligibility are still
considered refugees. They are identified by Form I-551 with codes RE-6, RE-7,
RE-8, or RE-9.
(3) The following
documents may be used to document that the individual is a "Cuban or Haitian
entrant":
(i) An I-94 Arrival/departure card
with a stamp showing parole into the United States on or after April 21, 1980.
I-94 may refer to § 212(d)(5). I-94 may refer to humanitarian or public
interest parole. I-94 may be expired.
(ii) An I-94 Arrival/departure card with a
stamp showing parole at any time as a "Cuban/Haitian Entrant (Status Pending)."
I- 94 may refer to § 212(d)(5). I-94 may be expired.
(iii) CH6 adjustment code on the I-551. Even
after a Cuban/Haitian Entrant (Status Pending) becomes a permanent resident,
they technically retain the status Cuban/Haitian Entrant (Status Pending).
I-551 may be expired.
(iv) A Cuban
or Haitian passport with a § 212(d)(5) stamp dated after October 10, 1980.
Passport may be expired.
(c) Asylee
(1) USCIS Form I-94 annotated with stamp
showing grant of asylum under §
208
of the INA;
(2) A grant letter from
the Asylum Office of the USCIS;
(3)
Form I-688B annotated "274a.12(a)(5)";
(4) Form I-766 annotated "A5"; or
(5) An order of the Immigration Judge
granting asylum. If a court order is presented, file a G-845 with the local USS
district office attaching a copy of the document to verify that the order was
not overturned on appeal.
(d) American Indian born outside of the
United States
(1) Documentation of LPR status
(See I-313.1);
(2) Birth or
baptismal certificate issued on a reservation;
(3) Membership card or other tribal
records;
(4) Letter from the
Canadian Department of Indian Affairs;
(5) School records; or
(6) Contact with the tribe in
question.
(e)
Non-citizen granted parole for at least one year by the USCIS
USCIS Form I-94 endorsed to show grant of parole under §
212(d)(5) of the INA and a date showing granting of parole for at least one
year.
(f) Non-citizen
granted conditional entry under the immigration law in effect before April 1,
1980
(1) USCIS Form I-94 with stamp showing
admission under § 203(a)(7) of the INA, refugee-conditional entry;
(2) Form I-688B annotated "274a.12
(a)(3)"; or
(3) Form I-766
annotated "A-3."
(g)
Non-citizen who has had deportation withheld under § 243(h) of the INA
(1) Order of an Immigration Judge showing
deportation withheld under § 243(h) of the INA and date of the
grant;
(2) USCIS Form I-688B
annotated "247a.12(a)(10)"; or
(3)
Form I-766 annotated "A10."
Section 54.09 Documentation of entry date for
determining the Medicaid fiveyear bar for qualified noncitizens
(01/15/2017, GCR 16-100)
(a) The following are the documents that may
be used to determine the Medicaid five-year bar for qualified non-citizens (
§ 17.03):
(1) Form I-94. The date of
admission should be found on the refugee stamp. If missing, AHS will contact
USCIS to verify the date of admission by filing a G-845 with a copy of the
document;
(2) If an individual
presents Forms I-688B or I-766 (Employment Authorization Documents), and I-57
(refugee travel document), AHS will ask the individual to present Form I-94. If
not available, AHS will contact USCIS by filing a G-845 with a copy of the
document presented; or
(3) Grant
letters or court orders. AHS will derive the date status is granted from the
date of the letter or court order. If missing, AHS will contact USCIS to verify
date of grant by filing a G-845 with a copy of the document.
(b) If an individual presents a
receipt indicating that they have applied to USCIS for a replacement document
for one of the documents identified above, AHS will contact the USCIS to verify
status by filing a G-845 with the local USCIS district office with a copy of
the receipt. AHS will contact the USCIS any time there is a reason to question
the authenticity of a document presented or the information on the document is
insufficient to determine whether non-citizen status requirements are
met.
Section 54.10
Ineligible non-citizens and non-immigrants
(01/15/2017, GCR 16-100)
Some non-citizens may be lawfully admitted but only for a
temporary or specified period of time as legal non-immigrants. These
non-citizens are never qualified non-citizens. Because of the temporary nature
of their admission status, they generally will be unable to establish residency
and are not eligible for health benefits as qualified non- citizens. For
example, a non-citizen in possession of a student visa is not a qualified
non-citizen. In rare instances, an ineligible non-citizen may be able to
establish residency and meet all other Medicaid eligibility criteria and
therefore be eligible for treatment of emergency medical conditions only (see
§ 17.02(d)).
Section
54.11 Visitors, tourists, and some workers and diplomats
ineligible for Medicaid
(01/15/2017, GCR 16-100)
For purposes of Medicaid eligibility, visitors, tourists, and
some workers and diplomats are also ineligible non-citizens and
non-immigrants.
These non-citizens would have the following types of
documentation:
(a) Form I-94
Arrival-Departure Record;
(b) Form
I-185 Canadian Border Crossing Card;
(c) Form I-186 Mexican Border Crossing
Card;
(d) Form SW-434 Mexican
Border Visitor's Permit; or
(e)
Form I-95A Crewman's Landing Permit.
Section 55.00 Attestation and Verification of
Other Nonfinancial Information. [33]
(01/15/2017, GCR 16-100)
Section 55.01 Attestation only
(01/15/2017, GCR 16-100)
Unless information from an individual is not reasonably
compatible with other information provided or otherwise available to AHS, as
described in § 57.00(b)(3), attestation of information needed to determine
the following eligibility requirements will be accepted without requiring
further information from the individual:
(a) Residency;
(b) Age;
(c) Date of birth; and
(d) Pregnancy.
Section 55.02 Verification of attestation
(01/15/2017, GCR 16-100)
An individual's attestations of information needed to
determine the following eligibility requirements will be verified by
AHS:
(a) Social Security number [34]
(1) The Social Security number furnished by
an individual will be verified with SSA to insure the Social Security number
was issued to that individual, and to determine whether any other Social
Security numbers were issued to that individual.
(2) For any individual who provides a Social
Security number, AHS will transmit the number and other identifying information
to HHS, which will submit it to SSA.
(3) To the extent that an individual's Social
Security number is not able to be verified through the SSA, or the SSA
indicates that the individual is deceased, the procedures specified in §
57.00 will be followed, except that, for purposes of QHP eligibility:
(i) The individual will be provided with a
period of 90 days from the date on which the notice described in §
57.00(c)(2)(i) is received, rather than sent, for the individual to provide
satisfactory documentary evidence or resolve the inconsistency with the
SSA.
(ii) The date on which the
notice is received means five days after the date on the notice, unless the
individual demonstrates that they did not receive the notice within the
five-day period.
For more information about Social Security numbers and
eligibility for health benefits, see § 16.00.
(b) Incarceration status [35]
When determining an individual's eligibility for enrollment
in a QHP, the individual's attestation regarding incarceration status will be
verified by:
(1) Relying on any
electronic data sources that are available to AHS; or
(2) If an approved data source is
unavailable, accepting the individual's attestation, except as provided in (3)
below.
(3) To the extent that an
individual's attestation is not reasonably compatible with information from
available data sources described in (1) above or other information provided by
the individual or in AHS's records, AHS will follow the procedures specified in
§ 57.00.
(c)
Eligibility for MEC other than through an eligible employer-sponsored plan [36]
When determining eligibility for APTC and CSR:
(1) AHS will verify whether an individual is
eligible for MEC other than through an eligible employer-sponsored plan or
Medicaid, using information obtained by transmitting identifying information
specified by HHS to HHS.
(2) AHS
will also verify whether an individual already has been determined eligible for
coverage through Medicaid within the state.
(d) Enrollment in an eligible
employer-sponsored plan and eligibility for qualifying coverage in an eligible
employer- sponsored plan [37]
(1) General
requirement
When determining eligibility for APTC and CSR, AHS will
verify whether an individual reasonably expects to be enrolled in an eligible
employer- sponsored plan or is eligible for qualifying coverage in an eligible
employer-sponsored plan for the benefit year for which coverage is
requested.
(2) Data
AHS will:
(i) Obtain
data about enrollment in and eligibility for an eligible employer-sponsored
plan from any electronic data sources that are available to it and which have
been approved by HHS, based on evidence showing that such data sources are
sufficiently current, accurate, and minimize administrative burden.
(ii) Obtain any available data regarding
enrollment in employer- sponsored coverage or eligibility for qualifying
coverage in an eligible employer-sponsored plan based on federal employment by
transmitting identifying information specified by HHS to HHS for HHS to provide
the necessary verification using data obtained by HHS.
(iii) Utilize data regarding small-group
enrollment in QHPs.
(3)
Verification procedures
(i) Except as
specified in paragraphs (d)(3)(ii) or (iii) of this subsection, an individual's
attestation regarding the verification specified in paragraph (d)(1) of this
subsection will be accepted without further verification.
(ii) If an individual's attestation is not
reasonably compatible with the information obtained by AHS as specified in
paragraphs (d)(2)(i) through (d)(2)(iii) of this subsection, other information
provided by the individual or by the application filer on the individual's
behalf, or other information in AHS's records, the procedures specified in
§ 57.00 will be followed.
(iii) Except as specified in (iv) below, for
any benefit year for which AHS does not reasonably expect to obtain sufficient
verification data as described in paragraphs (d)(2)(i) through (d)(2)(iii) of
this subsection, AHS will follow the alternative procedures described in this
paragraph (d)(3)(iii). AHS reasonably expects to obtain sufficient verification
data for any benefit year when, for the benefit year, AHS is able to obtain
data about enrollment in and eligibility for qualifying coverage in an eligible
employer-sponsored plan from at least one electronic data source that is
available to AHS and that has been approved by HHS, based on evidence showing
that the data source is sufficiently current, accurate, and minimizes
administrative burden, as described under paragraph (d)(2)(i) of this
subsection. AHS will select a statistically significant random sample of all
such individuals for whom AHS does not have any of the information specified in
paragraphs (d)(2)(i) through (d)(2)(iii) of this subsection and:
(A) Provide notice to the selected
individuals indicating that AHS will be contacting any employer identified on
the application for the individual and the members of their household to verify
whether the individual is enrolled in an eligible employer-sponsored plan or is
eligible for qualifying coverage in an eligible employer-sponsored plan for the
benefit year for which coverage is requested;
(B) Proceed with all other elements of
eligibility determination using the individual's attestation, and provide
eligibility for enrollment in a QHP to the extent that an individual is
otherwise qualified;
(C) Ensure
that APTC and CSR are provided on behalf of an individual who is otherwise
qualified for such payments and reductions, if the tax filer for the individual
attests that they understand that any APTC paid on their behalf is subject to
reconciliation;
(D) Make reasonable
attempts to contact any employer identified on the application for the
individual and the members of their household, to verify whether the individual
is enrolled in an eligible employer-sponsored plan or is eligible for
qualifying coverage in an eligible employer- sponsored plan for the benefit
year for which coverage is requested;
(E) If AHS receives any information from an
employer relevant to the individual's enrollment in an eligible employer-
sponsored plan or eligibility for qualifying coverage in an eligible
employer-sponsored plan, AHS will determine the individual's eligibility based
on such information and in accordance with the effective dates specified in
§ 73.06, and if such information changes their eligibility determination,
notify the individual and their employer or employers of such
determination;
(F) If, after a
period of 90 days from the date on which the notice described in paragraph
(d)(3)(iii)(A) of this subsection is sent to the individual, AHS is unable to
obtain the necessary information from an employer, the individual's eligibility
will be determined based on their attestation regarding coverage provided by
that employer.
(G) In order to
carry out the process described in paragraph (d)(3)(iii) of this subsection,
AHS will only disclose an individual's information to an employer to the extent
necessary for the employer to identify the employee.
(iv) For benefit years 2016 and 2017, AHS may
establish an alternative process approved by HHS.
Section 56.00
Attestation and Verification of Financial Information. [38]
(01/15/2017, GCR 16-100)
Section 56.01 Data
(01/15/2017, GCR 16-100)
(a) Tax data [39]
(1) For all individuals whose income is
counted in making a health-benefits eligibility determination, and for whom
Social Security numbers are available, AHS will request tax return data
regarding income and family size from the Secretary of the Treasury and data
regarding Social Security benefits from the Commissioner of Social Security by
transmitting identifying information specified by HHS to HHS.
(2) If the identifying information for one or
more individuals does not match a tax record on file with the Secretary of the
Treasury that may be disclosed, AHS will proceed in accordance with the
provisions in § 57.00(c)(1).
(b) Non-tax data
For all individuals whose income is counted in making a
health-benefits eligibility determination, AHS will request non-tax data from
other agencies in the state and other state and federal programs, as
follows:
(1) To the extent that AHS
determines such information is useful to verifying the financial eligibility of
an individual, the following will be requested:
(i) Information related to wages, net
earnings from self- employment, and unearned income and resources from:
(A) The State Wage Information Collection
Agency (SWICA);
(B) The
IRS;
(C) The SSA;
(D) The State of Vermont's new-hire
database;
(E) The agency or
agencies administering the state unemployment compensation laws;
(F) The state-administered supplementary
payment program under § 1616(a) of the Act (AABD, See AABD Rule 2700);
and
(G) Any state program
administered under a plan approved under Titles I, X, XIV, or XVI of the
Act;
(ii) Information
related to eligibility or enrollment from the 3SquaresVt Program, the Reach Up
Program, other health- benefits programs, and other public-assistance programs
that are administered by the State of Vermont; and
(iii) Any other information source bearing
upon the individual's financial eligibility.
(2) To the extent that the information
identified in this subsection is available through the federal electronic
verification service ( § 53.00(d)), the information will be obtained
through such service.
(3) The
information will be requested by Social Security number, or if a Social
Security number is not available, using other personally-identifying
information in the individual's account, if possible.
Section 56.02 Verification process
for Medicaid
(01/15/2017, GCR 16-100)
In determining an individual's eligibility for
Medicaid:
(a) Family size [40]
For purposes of MAGI-based Medicaid eligibility, attestation
of information needed to determine family size in accordance with the procedure
set forth in § 55.01 will be accepted (attestation only).
(b) Income [41]
Income will be verified by comparing the individual's
attestations with tax- and non-tax data obtained pursuant to § 56.01. If
the attestations are not reasonably compatible, as that term is defined in
§ 57.00(a)(2), with such data or if such data is not available, AHS will
proceed in accordance with the provisions in § 57.00(c).
(c) Resources
For purposes of MABD (non-MAGI-based Medicaid) eligibility,
resources will be verified by comparing the individual's attestations with
available data sources. If the attestations are not compatible with such
sources, or if no such sources exist, or if sources exist but are not
available, AHS will proceed in accordance with the provisions in §
57.00(c).
Section
56.03 Verification process for APTC and CSR - general procedures
(01/15/2017, GCR 16-100)
An individual must be eligible for APTC and have household
income at or below 300% of the FPL in order for the individual to be eligible
for the Vermont Premium Reduction and Vermont CSR. To receive the federal and
Vermont CSR, an individual who is not an Indian must be enrolled in a
silver-level QHP.
In determining eligibility for APTC and CSR:
(a) Family size [42]
(1) The individual must attest to the persons
that comprise a tax filer's family size.
(2) To the extent that the individual attests
that the tax data described in § 56.01(a) represent an accurate projection
of a tax filer's family size for the benefit year for which coverage is
requested, the individual's attestation will be accepted without further
verification.
(3) To the extent
that tax data are unavailable, or the individual attests that a change in
circumstances has occurred or is reasonably expected to occur, and so they do
not represent an accurate projection of a tax filer's family size for the
benefit year for which coverage is requested, the tax filer's family size will
be verified by accepting the individual's attestation without further
verification, except as specified in paragraph (a)(4) of this
subsection.
(4) If the individual's
attestation to a tax filer's family size is not reasonably compatible, as that
term is defined in § 57.00(a)(1), with other information provided by the
individual or in AHS's records, data obtained through other electronic data
sources will be used to verify the attestation. If such data sources are
unavailable or information in such data sources is not reasonably compatible
with the individual's attestation, additional documentation will be requested
to support the attestation within the procedures specified in §
57.00.
(5) Verification regarding
APTC and CSR. AHS will verify that neither APTC nor CSR is being provided on
behalf of an individual by using information obtained by transmitting
identifying information specified by HHS to HHS. [43]
(b) Basic verification process for annual
household income [44]
(1) The individual must
attest to the tax filer's projected annual household income.
(2) AHS will compute annual household income
based on the tax data described in § 56.01(a) (tax-based income
calculation), if available.
(3) To
the extent that the individual's attestation indicates that the tax-based
income calculation under paragraph (b)(2) of this subsection represents an
accurate projection of the tax filer's household income for the benefit year
for which coverage is requested, the tax filer's eligibility for APTC and CSR
will be determined based on that calculation.
(4) To the extent the tax data described in
§ 56.01(a) are unavailable or the individual attests that a change in
circumstances has occurred or is reasonably expected to occur, and so they do
not represent an accurate projection of the tax filer's household income for
the benefit year for which coverage is requested, AHS will require the
individual to attest to the tax filer's projected household income for the
benefit year for which coverage is requested.
(c) Verification process for increases in
household income
(1) Except as specified in
paragraphs (c)(2) or (3) of this subsection, the individual's attestation for
the tax filer's household will be accepted without further verification if:
(i) The individual attests that the tax
filer's annual household income has increased or is reasonably expected to
increase from the tax-based income calculation under paragraph (b)(2) of this
subsection; and
(ii) AHS has not
verified the individual's income through the process specified in §
56.02(b) to be within the applicable Medicaid income standard.
(2) If the non-tax data available
to AHS, as described in § 56.01(b), indicate that a tax filer's projected
annual income is in excess of their attestation by more than twenty-five
percent, AHS will proceed in accordance with §
57.00(c)(1)-(4)(i).
(3) If other
information provided by the individual indicates that a tax filer's projected
annual household income is in excess of the individual's attestation by more
than twenty-five percent, the non-tax data will be used to verify the
attestation. If such data are unavailable or information in such data is not
reasonably compatible with the individual's attestation, AHS will proceed in
accordance with § 57.00(c)(1)-(4)(i).
Section 56.04 Eligibility for alternate APTC
and CSR verification procedures
(01/15/2017, GCR 16-100)
Eligibility for alternate verification procedures for
decreases in annual household income and situations in which tax data are
unavailable [45]
AHS will determine a tax filer's annual household income for
purposes of APTC and CSR based on the alternate APTC and CSR verification
procedures described in §§ 56.05 through 56.07 if:
(a) An individual attests to the tax filer's
projected annual household income;
(b) The tax filer does not meet the criteria
specified in § 56.03(c) (attestation of increase in household
income);
(c) The individuals in the
tax filer's household have not established income through the process specified
in § 56.02(b) (verification of income for Medicaid) that is within the
applicable Medicaid income standard; and
(d) One of the following conditions is met:
(1) The Secretary of the Treasury does not
have tax data that may be disclosed under § 6103(l)(21) of the Code for
the tax filer that are at least as recent as the calendar year two years prior
to the calendar year for which APTC or CSR would be effective;
(2) The individual attests that:
(i) The tax filer's applicable family size
has changed or is reasonably expected to change for the benefit year for which
the individuals in the tax filer's household are requesting coverage;
or
(ii) The members of the tax
filer's household have changed or are reasonably expected to change for the
benefit year for which the individuals in their household are requesting
coverage;
(3) The
individual attests that a change in circumstances has occurred or is reasonably
expected to occur, and so the tax filer's annual household income has decreased
or is reasonably expected to decrease from the tax data described in §
56.01(a) for the benefit year for which the individuals in the tax filer's
household are requesting coverage;
(4) The individual attests that the tax
filer's filing status has changed or is reasonably expected to change for the
benefit year for which the individual(s) in tax filer's household are
requesting coverage; or
(5) An
individual in the tax filer's household has filed an application for
unemployment benefits.
Section 56.05 Alternate APTC and CSR
verification procedure: small decrease in projected household income [46]
(01/15/2017, GCR 16-100)
If a tax filer qualifies for an alternate APTC and CSR
verification process and the individual's attestation to the tax filer's
projected annual household income is no more than ten percent below the
tax-based income calculation ( § 56.03(b)(2)), the individual's
attestation will be accepted without further verification.
Section 56.06 Alternate APTC and CSR
verification procedure: large decrease in projected household income and
situations where tax data are unavailable [47]
(01/15/2017, GCR 16-100)
(a) In general
AHS will attempt to verify the individual's attestation of
the tax filer's projected annual household income with the process specified in
paragraph (b) of this subsection and in §§ 56.07 and 56.08 if the tax
filer qualifies for an alternate APTC and CSR verification process under §
56.04 and:
(1) The individual's
attestation to the tax filer's projected annual household income is greater
than ten percent below the tax- based income calculation ( § 56.03(b)(2)
); or
(2) The tax data described in
§ 56.01(a) are unavailable.
(b) Applicable process
The alternate APTC and CSR verification process is as
follows:
(1) Data. Data from non-tax
income sources, as described in § 56.01(b), will be annualized
(non-tax-based income calculation).
(2) Eligibility. To the extent that the
individual's attestation indicates that the non-tax-based income calculation
under paragraph (b)(1) of this subsection represents an accurate projection of
the tax filer's household income for the benefit year for which coverage is
requested, the tax filer's eligibility for APTC and CSR will be determined
based on such data.
(3) If the
individual's attestation indicates that the tax filer's projected annual
household income is more than ten percent below the non-tax-based income
calculation under paragraph (b)(1) of this subsection, AHS will request
additional documentation using the procedures specified in § 57.00(c)(1)
through (4)(i). If, following the 90-day period described in §
57.00(c)(2)(ii), the individual has not responded to the request for
documentation or AHS remains unable to verify the individual's attestation, AHS
will follow the applicable procedures described in § 56.08.
Section 56.07 Alternate
APTC and CSR verification procedure: Increases in household income when tax
data are unavailable [48]
(01/15/2017, GCR 16-100)
(a) Attestation sufficient
Except as provided in paragraph (b) of this subsection, the
individual's attestation for the tax filer's household will be accepted without
further verification if:
(1) The
individual's attestation indicates that a tax filer's annual household income
has increased or is reasonably expected to increase from the non-tax-based
income calculation
( § 56.06(b)(1)); and
(2) AHS has not verified the individual's
income through the process specified in § 56.02(b) to be within the
applicable Medicaid income standard.
(b) Additional verification required
Additional documentation will be requested using the
procedures specified in § 57.00 if AHS finds that an individual's
attestation of a tax filer's annual household income is not reasonably
compatible with other information provided by the individual or the non-tax
data available to AHS under § 56.01(b).
Section 56.08 Alternate APTC and CSR
verification procedure: following 90-day period
(01/15/2017, GCR 16-100)
(a) Individual does not respond to
request/data indicate individual's income within Medicaid standard
If, following the 90-day period described in §
57.00(c)(2)(ii) as required by § 56.06(b)(3), an individual has not
responded to a request for additional information and the tax data or non-tax
data indicate that an individual in the tax filer's household is eligible for
Medicaid, the application for a health-benefits program (for example, Medicaid,
APTC or CSR) will be denied.
(b) Attestation cannot be verified/tax data
available
If, following the 90-day period described in §
57.00(c)(2)(ii) as required by § 56.06(b)(3), AHS remains unable to verify
the individual's attestation, AHS will determine the individual's eligibility
based on AHS's tax-based income calculation ( § 56.03(b)(2)), notify the
individual of such determination, and implement such determination in
accordance with the effective dates specified in § 73.06.
(c) Attestation cannot be
verified/tax data unavailable
If, following the 90-day period described in §
57.00(c)(2)(ii) as required by § 56.06(b)(3), AHS remains unable to verify
the individual's attestation for the tax filer and tax data necessary for a
tax-based income calculation ( § 56.03(b)(2)) are unavailable, AHS will
determine the tax filer ineligible for APTC and CSR, notify the individual of
such determination, and discontinue any APTC or CSR in accordance with the
effective dates specified in § 73.06.
Section 56.09 Verification related to
eligibility for enrollment in a catastrophic plan [49]
(01/15/2017, GCR 16-100)
(a) AHS will verify an individual's
attestation that they meet the requirements of § 14.00 (eligibility for
enrollment in a catastrophic plan) by:
(1)
Verifying the individual's attestation of age as follows:
(i) Except as provided in paragraph
(a)(1)(iii) of this subsection, accepting their attestation without further
verification; or
(ii) Examining
electronic data sources that are available and which have been approved by HHS
for this purpose, based on evidence showing that such data sources are
sufficiently current and accurate, and minimize administrative costs and
burdens.
(iii) If information
regarding age is not reasonably compatible with other information provided by
the individual or in AHS's records, examining information in data sources that
are available and which have been approved by HHS for this purpose based on
evidence showing that such data sources are sufficiently current and
accurate.
(2) Verifying
that an individual has a certificate of exemption in effect as described in
§ 14.00(b).
(b) To
the extent that AHS is unable to verify the information required to determine
eligibility for enrollment in a catastrophic plan as described in paragraphs
(a)(1) and (2) of this subsection, the procedures specified in § 57.00,
except for § 57.00(c)(4) (eligibility for APTC and CSR), will be
followed.
Section 56.10
Education and assistance
(01/15/2017, GCR 16-100)
Education and assistance will be provided to an individual
regarding the processes specified in this section.
Section 57.00 Inconsistencies
(01/15/2017, GCR 16-100)
(a) Reasonable compatibility [50]
(1) For purposes of QHP, information obtained
through electronic data sources, other information provided by the individual,
or other information in AHS's records will be considered reasonably compatible
with an individual's attestation when the difference or discrepancy does not
impact the eligibility of the individual or the benefits to which the
individual may be entitled, including the APTC amount and CSR
category.
(2) For purposes of
Medicaid, income information obtained through an electronic data match shall be
considered reasonably compatible with income information provided by or on
behalf of an individual if both are either above or at or below the applicable
income standard or other relevant income threshold. For eligibility criteria
other than income, an individual's attestation will be considered reasonably
compatible with information obtained through electronic data sources, other
information provided by the individual, or other information in AHS's records
if the discrepancy does not affect eligibility for a specific Medicaid
category.
(b)
Applicability of reasonable-compatibility procedures
Except as otherwise specified in this rule, the procedures
outlined in this section will be used when:
(1) Information needed in accordance with
§§ 53.00 through 56.00 is not available electronically and
establishing a data match would not be effective, considering such factors as
the administrative costs associated with establishing and using the data match,
compared with the administrative costs associated with relying on paper
documentation, and the impact on program integrity in terms of the potential
for ineligible individuals to be approved as well as for eligible individuals
to be denied coverage;
(2) AHS
cannot verify information required to determine eligibility for health
benefits, including when:
(i) Electronic data
sources are required but data for individuals relevant to the eligibility
determination are not included in such data sources; or
(ii) Electronic data from IRS, DHS and SSA
are required but it is not reasonably expected that data sources will be
available within one day of the initial request to the data source, except that
an individual's attestation of residency or, for purposes of QHP, eligibility
for MEC, may be accepted, and the procedures outlined in this section will not
be used, when verification of those criteria would otherwise be required and
the electronic data to support the attestation are not reasonably expected to
be available within one day of the initial request to the data source;
or
(3) Attested
information that would not otherwise be verified is not reasonably compatible
with other information that is provided by the application filer or that is
otherwise available to AHS.
(c) Procedures for determining reasonable
compatibility
In circumstances described in paragraph (b) of this section,
AHS will:
(1) Make a reasonable effort
to identify and address the causes of such inconsistency, including through
typographical or other clerical errors, by contacting the application filer to
confirm the accuracy of the information submitted by the application filer, and
by allowing the individual, or the application filer on the individual's
behalf, the opportunity to provide AHS with a statement that reasonably
explains the discrepancy.
(2) If
unable to resolve the inconsistency as provided in paragraph (c)(1) of this
section:
(i) Provide notice to the individual
regarding the inconsistency; and
(ii) Provide the individual with an
opportunity period, as described in this paragraph (c)(2)(ii), from the date on
which such notice is sent to the individual to either present satisfactory
documentary evidence via the channels available for the submission of an
application, (except for by telephone through a call center), or otherwise
resolve the inconsistency. [51] If, because of evidence submitted by the
individual, one or more requests for additional evidence is necessary, such
additional evidence must be submitted by the individual within the same
opportunity period that begins with the first verification request.
(A) For purposes of QHP, the individual's
opportunity period is 90 days.
(B)
For purposes of Medicaid, the individual's opportunity period is as follows:
(I) If the individual is a new Medicaid
applicant, the opportunity period is 20 days, communicated in the form of two
separate and sequential notices permitting the individual 10 days within which
to respond.
(II) If the individual
is a Medicaid enrollee, the opportunity period is 10 days.
(3) Extend the
opportunity period described in paragraph (c)(2)(ii) of this section if the
individual demonstrates that a good-faith effort has been made to obtain the
required documentation during the period.
(4) In connection with the verification of an
attestation for QHP eligibility:
(i) During
the opportunity period described in paragraph (c)(2)(ii) of this section:
(A) Proceed with all other elements of
eligibility determination using the individual's attestation, and provide
eligibility for enrollment in a QHP to the extent that an individual is
otherwise qualified; and
(B) Ensure
that APTC, the Vermont Premium Reduction, and federal and state CSR are
provided on behalf of an individual within this period who is otherwise
qualified for such payments and reductions, if the tax filer attests that they
understand that any APTC paid on their behalf is subject to
reconciliation.
(ii)
After the period described in paragraph (c)(2)(ii) of this section, determine
whether the individual is eligible to enroll in a QHP using the information
available from the data sources specified above, if any, if AHS remains unable
to verify the attestation. AHS will notify the individual of such
determination, including notice that AHS is unable to verify the attestation.
For an individual determined eligible for enrollment in a QHP who is seeking
financial assistance (APTC/CSR):
(A) If AHS
can determine the individual is not eligible for Medicaid based on available
information, determine whether the individual is eligible for APTC, the Vermont
Premium Reduction, and federal and state CSR based on the information available
from the data sources specified above, and notify the individual of such
determination, including notice that AHS is unable to verify the
attestation.
(B) If AHS cannot
determine, based on available information, that the individual is ineligible
for Medicaid, deny the application for or terminate the individual's APTC,
Vermont Premium Reduction and federal and state CSR on the basis that there is
insufficient information to determine the individual's eligibility for
Medicaid. [52]
(C) If an individual
is determined ineligible for financial assistance, the individual would still
be eligible for enrollment in a QHP without financial assistance.
(5) In connection with
the verification of an attestation for Medicaid eligibility, if, after the
opportunity period described in paragraph (c)(2)(ii) of this section, the
individual has not responded to a request for additional information or has not
provided information sufficient to resolve the inconsistency, or AHS otherwise
remains unable to verify the attestation, deny the application or disenroll the
individual on the basis that there is insufficient information to determine the
individual's eligibility for Medicaid. Medicaid coverage cannot begin for a new
Medicaid applicant until verification of the attestation is received, unless
the verification is for purposes of establishing citizenship or immigration
status as described in § 54.05(b).
(d) Exception for special circumstances [53]
(1) Except for an inconsistency related to
citizenship or immigration status, AHS will provide an exception, on a case-
by-case basis, to accept an individual's attestation as to the information
which cannot otherwise be verified, because such documentation:
(i) Does not exist; or
(ii) Is not reasonably available.
(2) To receive such an exception:
(i) The inconsistency must not be able to be
otherwise resolved; and
(ii) The
individual must provide an adequate explanation of the circumstances as to why
they cannot obtain the documentation needed to resolve the
inconsistency.
(e) Pursuit of additional information in
cases where verification data are not reasonably compatible with information
provided for or on behalf of an individual [54]
Eligibility will not be denied or terminated nor benefits
reduced for any individual on the basis of verification information received in
accordance with this part Seven unless additional information from the
individual has been sought in accordance with this section, and proper notice
and hearing rights have been provided to the individual.
Section 58.00 Determination of
Eligibility for Health-Benefits Programs [55]
(01/15/2017, GCR 16-100)
Section 58.01 In general [56]
(01/15/2017, GCR 16-100)
(a) MAGI screen [57]
For each individual who has submitted an application for a
health- benefits program (i.e., health benefits other than enrollment in a QHP
without APTC or CSR), or whose eligibility is being renewed, and who meets the
nonfinancial requirements for eligibility (or for whom AHS is providing an
opportunity to verify citizenship or immigration status), AHS will do the
following:
(1) Promptly and without
undue delay, consistent with timeliness standards established under §
61.00, furnish MAGI-based Medicaid to each such individual whose household
income is at or below the applicable MAGI-based standard.
(2) For each individual described in
paragraph (c) of this subsection (individuals subject to determination of
Medicaid eligibility on a basis other than the applicable MAGI-based income
standard), collect such additional information as may be needed to determine
whether such individual is eligible for Medicaid on any basis other than the
applicable MAGI-based income standard, and furnish Medicaid on such
basis.
(3) For an individual who
submits an application or renewal form which includes sufficient information to
determine Medicaid eligibility, or whose eligibility is being renewed pursuant
to a change in circumstance, and whom AHS determines is not eligible for
Medicaid, promptly and without undue delay, determine eligibility for other
health benefits.
(b)
MAGI-based income standards for certain individuals enrolled for Medicare
benefits [58]
In the case of an individual who has attained at least age 65
and an individual who has attained at least age 19 and who is entitled to or
enrolled for Medicare benefits under part A or B or Title XVIII of the Act,
non-MAGI-based income standards will be used, except that in the case of such
an individual:
(1) Who is also
pregnant, the applicable MAGI-based standard is the standard established under
§ 7.03(a)(2); and
(2) Who is
also a parent or caretaker relative (as defined in § 3.00), the
applicable MAGI-based standard is the standard established under §
7.03(a)(1).
(c)
Individuals subject to determination of Medicaid eligibility on basis other
than the applicable MAGI-based income standard [59]
For purposes of paragraph (a)(2) of this subsection, an
individual includes:
(1) An individual
who is identified, on the basis of information contained in an application or
renewal form, or on the basis of other information available, as potentially
eligible on a basis other than the applicable MAGI-based standard;
and
(2) An individual who otherwise
requests a determination of eligibility on a basis other than the applicable
MAGI-based standard.
(d)
Individuals requesting additional screening [60]
AHS will notify an applicant of the opportunity to request a
full determination of eligibility for Medicaid on a basis other than the
applicable MAGI-based income standard, and will provide such an opportunity.
Such notification will also be made to an enrollee, and such opportunity
provided in any redetermination of eligibility.
(e) Determination of eligibility for Medicaid
on a basis other than the applicable MAGI-based income standard [61]
If an individual is identified as potentially eligible for
Medicaid on a basis other than the applicable MAGI-based income standard or an
individual requests a full determination for Medicaid under paragraph (d) of
this subsection, and the individual provides all additional information needed
to determine eligibility for such benefits, eligibility will be determined
promptly and without undue delay, as provided in this section.
(f) Eligibility for APTC and CSR,
pending determination of eligibility for Medicaid [62]
An individual who is described in paragraph (e) of this
subsection and has not been determined eligible for Medicaid based on
MAGI-based income standards will be considered as ineligible for Medicaid for
purposes of eligibility for APTC or CSR until the individual is determined
eligible for Medicaid.
Section 58.02 Special rules relating to APTC
eligibility [63]
(01/15/2017, GCR 16-100)
(a) An individual may accept less than the
full amount of APTC for which the individual is determined eligible.
(b) Before APTC on behalf of a tax filer may
be authorized, the tax filer must provide necessary attestations, including,
but not limited to, attestations that:
(1)
They will file an income tax return for the benefit year, in accordance with
26 USC
§§
6011 and
6012,
and implementing regulations;
(2)
If married (within the meaning of
26 CFR §
1.7703-1) , they will file a joint tax return
for the benefit year unless they meet the exception criteria defined in §
12.03(b) (victim of domestic abuse or spousal abandonment); [64]
(3) No other tax filer will be able to claim
them as a tax dependent for the benefit year; and
(4) They will claim a personal exemption
deduction on their tax return for the individuals identified as members of
their household, including the tax filer and their spouse, in accordance with
§ 56.03(a). [65]
Section 59.00 Special Eligibility Standards
and Process for Indians [66]
(01/15/2017, GCR 16-100)
Section 59.01 Eligibility for CSR
(01/15/2017, GCR 16-100)
(a) An individual who is an Indian, as
defined in § 3.00, will be determined eligible for CSR if they:
(1) Meet the requirements specified in
§§ 11.00 and 12.00; and
(2) Are expected to have household income,
using MAGI methodologies for purposes of determining eligibility for APTC and
CSR, that does not exceed 300 percent of the FPL for the benefit year for which
coverage is requested.
(b) CSR may be provided to an individual who
is an Indian only if they are enrolled in a QHP.
Section 59.02 Special cost-sharing rule for
Indians regardless of income
(01/15/2017, GCR 16-100)
AHS must determine an individual eligible for the special
cost-sharing rule described in § 1402(d)(2) of the ACA (items or services
furnished through Indian health providers) if the individual is an Indian,
without requiring the individual to request an eligibility determination for
health- benefits programs in order to qualify for this rule.
Section 59.03 Verification related to Indian
status [67]
(01/15/2017, GCR 16-100)
To the extent that an individual attests that they are an
Indian, such attestation will be verified by:
(a) Utilizing any relevant documentation
verified in accordance with § 53.00;
(b) Relying on any electronic data sources
that are available and which have been approved by HHS for this purpose, based
on evidence showing that such data sources are sufficiently accurate and offer
less administrative complexity than paper verification; or
(c) To the extent that approved data sources
are unavailable, an individual is not represented in available data sources, or
data sources are not reasonably compatible with an individual's attestation,
following the procedures specified in § 57.00 and verifying documentation
provided by the individual in accordance with the standards for acceptable
documentation provided in § 54.07(b)(5).
Section 60.00 Computing the
Premium-Assistance Credit Amount [68]
(01/15/2017, GCR 16- 100)
Section 60.01 In general [69]
(01/15/2017, GCR 16-100)
This section explains the calculation of the federal and
state premium assistance of QHPs. A tax filer's premium assistance credit
amount for a benefit year is the sum of the premium-assistance amounts
determined under § 60.04 for all coverage months for individuals in the
tax filer's household.
Section
60.02 Definition [70]
(01/15/2017, GCR 16-100)
For purposes of this section:
Coverage family
The term "coverage family" means, in each month, the members
of the tax filer's household for whom the month is a coverage month.
Section 60.03 Coverage month [71]
(01/15/2017, GCR 16-100)
(a) In general
A month is a coverage month for an individual if:
(1) As of the first day of the month, the
individual is enrolled in a QHP;
(2) The tax filer pays the tax filer's share
of the premium for the individual's coverage under the plan for the month by
the unextended due date for filing the tax filer's income tax return for that
benefit year, or the full premium for the month is paid by APTC and the Vermont
Premium Reduction; and
(3) The
individual is not eligible for the full calendar month for MEC other than
coverage in the individual market.
(b) Certain individuals enrolled during a
month
If an individual enrolls in a QHP and the enrollment is
effective on the date of the individual's birth, adoption or placement for
adoption or in foster care, or on the effective date of a court order, the
individual is treated as enrolled as of the first day of that month for
purposes of this subsection.
(c) Premiums paid for a tax filer
Premiums another person pays for coverage of the tax filer,
tax filer's spouse, or tax dependent are treated as paid by the tax
filer.
(d) Examples
The following examples illustrate the provisions of this
§ 60.03:
(1) Example 1: Tax filer
M is single with no tax dependents
(i) In
December 2013, M enrolls in a QHP for 2014 and AHS approves APTC. M pays M's
share of the premiums. On May 15, 2014, M enlists in the U.S. Army and is
eligible immediately for government-sponsored MEC.
(ii) Under paragraph (a) of this subsection,
January through May 2014 are coverage months for M. June through December 2014
are not coverage months because M is eligible for other MEC for those months.
Thus, under § 60.01, M's premium assistance credit amount for 2014 is the
sum of the premium-assistance amounts for the months January through
May.
(2) Example 2: Tax
filer N has one tax dependent S
(i) S is
eligible for government-sponsored MEC. N is not eligible for MEC other than
through VHC. N enrolls in a QHP for 2014 and AHS approves APTCs. On August 1,
2014, S loses eligibility for government-sponsored MEC. N terminates enrollment
in the QHP that covers only N and enrolls in a QHP that covers N and S for
August through December 2014. N pays all premiums not covered by
APTCs.
(ii) Under paragraph (a) of
this subsection, January through December of 2014 are coverage months for N and
August through December are coverage months for N and S. N's premium assistance
credit amount for 2014 is the sum of the premium-assistance amounts for these
coverage months.
(3)
Example 3: O and P are the divorced parents of T
(i) Under the divorce agreement between O and
P, T resides with P and P claims T as a tax dependent. However, O must pay
premiums for health insurance for T. P enrolls T in a QHP for 2014. O pays the
portion of T's QHP premiums not covered by APTCs.
(ii) Because P claims T as a tax dependent, P
(and not O) may claim a premium tax credit for coverage for T. See § 1.36B
-
2(a)
of the Code. Under paragraph (c) of this subsection, the premiums that O pays
for coverage for T are treated as paid by P. Thus, the months when T is covered
by a QHP and not eligible for other MEC are coverage months under paragraph (a)
of this subsection in computing P's premium tax credit under §
60.01.
(4) Example 4: Q,
an American Indian, enrolls in a QHP for 2014
Q's tribe pays the portion of Q's QHP premiums not covered by
APTCs. Under paragraph (c) of this subsection, the premiums that Q's tribe pays
for Q are treated as paid by Q. Thus, the months when Q is covered by a QHP and
not eligible for other MEC are coverage months under paragraph (c) of this
subsection in computing Q's premium tax credit under § 60.01.
Section
60.04 Premium-assistance amount [72]
(01/15/2017, GCR 16-100)
(a) In general
Except as provided in paragraph (b) of this subsection, the
premium- assistance amount for a coverage month is the lesser of:
(1) The premiums for the month for one or
more QHPs in which a tax filer or a member of the tax filer's household enrolls
(enrollment premiums); or
(2) The
excess of the monthly premium for the applicable benchmark plan (ABP)
(benchmark plan premium) ( § 60.06) over 1/12 of the product of a tax
filer's household income and the applicable percentage for the benefit year
(the tax filer's contribution amount).
(b) Partial month of coverage
(1) If a QHP is terminated before the last
day of a month or an individual is enrolled in coverage effective on the date
of the individual's birth, adoption, or placement for adoption or in foster
care, or on the effective date of a court order, the premium assistance amount
for the month is the lesser of:
(i) The
enrollment premiums for the month (reduced by any amounts that were refunded);
or
(ii) The excess of the benchmark
plan premium for a full month of coverage over the full contribution amount for
the month.
(2) Examples.
The following examples illustrate the rules of this paragraph (b):
(i) Example 1.
(A) Tax filer R is single and has no
dependents. R enrolls in a QHP with a monthly premium of $ 450. The difference
between R's benchmark plan premium and contribution amount for the month is $
420. R's premium assistance amount for a coverage month with a full month of
coverage is $ 420 (the lesser of $ 450 and $ 420).
(B) The issuer of R's QHP is notified that R
died on September 20. The issuer terminates coverage as of that date and
refunds the remaining portion of the September enrollment premiums ($ 150) for
R's coverage.
(C) Under this
paragraph (b), R's premium assistance amount for September is the lesser of the
enrollment premiums for the month ($ 300 ($ 450 - $ 150)) or the difference
between the benchmark plan premium for a full month of coverage and the full
contribution amount for the month ($ 420). R's premium assistance amount for
September is $ 300, the lesser of $ 420 and $ 300.
(ii) Example 2. The facts are the same as in
Example 1 of this paragraph (b), except that the QHP issuer does not refund any
enrollment premiums for September. Under this paragraph (b), R's premium
assistance amount for September is $ 420, the lesser of $ 450 and $
420.
(iii) Example 3. The facts are
the same as in Example 1 of this paragraph (b), except that the difference
between R's benchmark plan premium and contribution amount for a month is $
275. Accordingly, R's premium assistance amount for a coverage month with a
full month of coverage is $ 275 (the lesser of $ 450 and $ 275). Under this
paragraph (b), R's premium assistance amount for September remains $ 275, the
lesser of $ 300 and $ 275.
Section 60.05 Monthly premium for ABP [73]
(01/15/2017, GCR 16-100)
The monthly premium for an ABP is the premium an issuer would
charge for the ABP to cover all members of the tax filer's coverage family. The
monthly premium is determined without regard to any premium discount or rebate
under the wellness discount demonstration project under § 2705(d) of the
PHS Act (
42
USC §§
300gg-4(d)
) and may not include any adjustments for tobacco use. The monthly premium for
an ABP for a coverage month is determined as of the first day of the
month.
Section 60.06
Applicable benchmark plan (ABP) [74]
(01/15/2017, GCR 16-100)
(a) In general
The ABP helps determine the total amount of premium
assistance. The ABP is the QHP from which the product of the applicable
percentage and household income is subtracted to obtain the subsidy amount that
will be provided on behalf of the qualified individual. Except as otherwise
provided in this subsection, the ABP for each coverage month is the
second-lowest-cost silver plan offered through VHC for:
(1) Self-only coverage for a tax filer:
(i) Who computes tax under §
1(c)
of the Code (unmarried individuals other than surviving spouses and heads of
household) and is not allowed a deduction under § 151 of the Code for a
tax dependent for the benefit year;
(ii) Who purchases only self-only coverage
for one individual; or
(iii) Whose
coverage family includes only one individual; and
(2) Family coverage for all other tax
filers.
(b) Family
coverage
The ABP for family coverage is the second-lowest-cost silver
plan that applies to the members of the tax filer's coverage family (such as a
plan covering two adults if the members of a tax filer's coverage family are
two adults).
(c)
Silver-level plan not covering a tax filer's family
If one or more silver-level plans for family coverage do not
cover all members of a tax filer's coverage family under one policy (for
example, because of the relationships within the family), the premium for the
ABP determined under paragraphs (a) and (b) of this subsection may be the
premium for a single policy or for more than one policy, whichever is the
second-lowest-cost silver option. (See, example 10 in paragraph (g) of this
subsection.)
(d) Family
members residing at different locations
The benchmark plan premium determined under paragraphs (a)
and (b) of this subsection for family members who live in different states and
enroll in separate QHPs is the sum of the premiums for the ABPs for each group
of family members living in the same state.
(e) Plan closed to enrollment
A QHP that is not open to enrollment by a tax filer or a
member of the tax filer's household at the time the tax filer or member enrolls
in a QHP is disregarded in determining the ABP.
(f) Benchmark plan terminates or closes to
enrollment during the year
A QHP that is the ABP under this subsection for a tax filer
does not cease to be the ABP solely because the plan or a lower cost plan
terminates or closes to enrollment during the benefit year.
(g) Examples
The following examples illustrate the rules of this
subsection. Unless otherwise stated, in each example the plans are open to
enrollment to a tax filer or a member of the tax filer's household at the time
of enrollment and are offered through VHC:
(1) Example 1. Single tax filer enrolls
Tax filer M is single, has no dependents and enrolls in a
QHP. Under paragraph (a)(1) of this subsection, M's ABP is the
second-lowest-cost silver plan providing self-only coverage for M.
(2) Example 2. Family enrolls
The facts are the same as in Example 1, except that M, her
spouse, N, and their tax dependent enroll in a QHP. Under paragraphs (a)(2) and
(b) of this subsection, M's and N's ABP is the second-lowest-cost silver plan
covering M, N, and their tax dependent.
(3) Example 3. Single tax filer enrolls with
nondependent
Tax filer O is single and resides with his daughter, K, but
may not claim K as a tax dependent. O purchases family coverage for himself and
K. Under paragraphs (a)(1)(i) and (a)(1)(iii) of this subsection, O's ABP is
the second-lowest-cost silver plan providing self-only coverage for O. However,
K may qualify for a premium tax credit if K is otherwise eligible. See §
60.08.
(4) Example 4.
Single tax filer enrolls with dependent and nondependent
The facts are the same as in Example 3, except that O also
resides with his teenage son, L, and claims L as a tax dependent. O purchases
family coverage for himself, K, and L. Under paragraphs (a)(2) and (b) of this
subsection, O's ABP is the second-lowest-cost silver plan covering O and
L.
(5) Example 5. Children
only enroll
The facts are the same as in Example 4, except that O enrolls
only K and L in the coverage. Under paragraph (a)(1)(iii) of this subsection,
O's ABP is the second-lowest-cost silver plan providing self-only coverage for
L.
(6) Example 6. ABP
unrelated to coverage purchased
Tax filers P and Q, who are married, reside with Q's two
teenage daughters, M and N, whom they claim as tax dependents. P and Q purchase
self-only coverage for P and family coverage for Q, M, and N. Under paragraphs
(a)(2) and (b) of this subsection, P's and Q's ABP is the second-lowest-cost
silver plan covering P, Q, M, and N.
(7) Example 7. Change in coverage family
Tax filer R is single and has no tax dependents when she
enrolls in a QHP for 2014. On August 1, 2014, R has a child, O, whom she claims
as a tax dependent for 2014. R enrolls in a QHP covering R and O effective
August 1. Under paragraph (a)(1) of this subsection, R's ABP for January
through July is the second-lowest-cost silver plan providing self-only coverage
for R. Under paragraphs (a)(2) and (b) of this section, R's ABP for the months
August through December is the second-lowest-cost silver plan covering R and
O.
(8) Example 8. Other MEC
for some coverage months
Tax filer S claims his daughter, P, as a tax dependent. S and
P enroll in a QHP for 2014. S, but not P, is eligible for government-sponsored
MEC for September to December 2014. Thus, under paragraph (a)(3) of §
60.03, January through December are coverage months for P and January through
August are coverage months for S. Because, under § 60.04 and paragraph (a)
of this subsection, the premium-assistance amount for a coverage month is
computed based on the ABP for that coverage month, S's ABP for January through
August is the second- lowest-cost silver plan under paragraphs (a)(2) and (b)
of this subsection covering S and P. Under paragraph (a)(1)(iii) of this
subsection, S's ABP for September through December is the second- lowest-cost
silver plan providing self-only coverage for P.
(9) Example 9. Family member eligible for
other MEC for the benefit year
The facts are the same as in Example 8, except that S is not
eligible for government-sponsored MEC for any months and P is eligible for
government-sponsored MEC for the entire year. Under paragraph (a)(1)(iii) of
this subsection, S's ABP is the second-lowest-cost silver plan providing
self-only coverage for S.
(10) Example 10. QHPs not covering certain
families
(i) Tax filers V and W are married
and live with W's mother, K, whom they claim as a tax dependent. The Exchange
offers self-only and family coverage at the silver level through Issuers A, B,
and C, who each offer only one silver-level plan. Issuers A and B respectively
charge V and W a monthly premium of $ 900 and $ 700 for family coverage, but do
not allow individuals to enroll a parent in family coverage. Issuers A and B
respectively charge $ 600 and $ 400 for self- only coverage for K. Issuer C
offers a QHP that provides family coverage for V, W, and K under one policy for
a $ 1,200 monthly premium. Thus, the Exchange offers the following silver-level
options for covering V's and W's coverage family:
(A) Issuer A: $ 1,500 for premiums for two
policies ($ 900 for V and W, $ 600 for K)
(B) Issuer B: $ 1,100 for premiums for two
policies ($ 700 for V and W, $ 400 for K)
(C) Issuer C: $ 1,200 for premiums for one
policy ($ 1,200 for V, W, and K)
(ii) Because some silver-level QHPs for
family coverage offered on the Exchange do not cover all members of their
coverage family under one policy, under paragraph (c) of this subsection, the
premium for V's and W's ABP may be the premium for a single policy or for more
than one policy. The coverage offered by Issuer C is the second-lowest-cost
silver-level option for covering V's and W's family. The premium for their ABP
is the premium for the Issuer C coverage.
(11) Example 11
(i) The facts are the same as in Example 10,
except that Issuer B covers V, W, and K under one policy for a premium of $
1,100, and Issuer C does not allow individuals to enroll parents in family
coverage. Issuer C charges a monthly premium of $ 700 for family coverage for V
and W and a monthly premium of $ 500 for self-only coverage for K. Thus, the
Exchange offers the following silver-level options for covering V's and W's
coverage family:
(A) Issuer A: $ 1,500 for
premiums for two policies ($ 900 for V and W, $ 600 for K)
(B) Issuer B: $ 1,100 for premiums for one
policy ($ 1,100 for V, W, and K)
(C) Issuer C: $ 1,200 for premiums for two
policies ($ 700 for V and W, $ 500 for K)
(ii) The coverage offered by Issuer C is the
second-lowest-cost silver-level option for covering V's and W's family. The
premium for their ABP is the premiums for the two policies available through
Issuer C.
(12) Example
12. Family members residing in different locations
[Reserved]
(13) Example 13. QHP closed to enrollment
Tax filer Y has two tax dependents, R and S. Y, R, and S
enroll in a QHP. The Exchange offers silver-level plans J, K, L, and M, which
are the first, second, third, and fourth lowest cost silver plans covering Y's
family. When Y's family enrolls, Plan J is closed to enrollment. Under
paragraph (e) of this subsection, Plan J is disregarded in determining Y's ABP,
and Plan L is Y's ABP.
(14)
Example 14.
Benchmark plan closes to new enrollees during the year
(i) Tax filers X, Y, and Z each have coverage
families consisting of two adults. In the rating area where X, Y, and Z reside,
Plan 2 is the second-lowest-cost silver plan and Plan 3 is the third lowest
cost silver plan covering the two adults in each coverage family offered
through the Exchange. The X and Y families each enroll in a QHP that is not the
ABP (Plan 4) in November during the AOEP. Plan 2 closes to new enrollees the
following June. Thus, on July 1, Plan 3 is the second-lowest-cost silver plan
available to new enrollees through the Exchange. The Z family enrolls in a QHP
in July.
(ii) Under paragraphs (a),
(b), and (f) of this subsection, the ABP is Plan 2 for X and Y for all coverage
months during the year. The ABP for Z is Plan 3, because Plan 2 is not open to
enrollment through the Exchange when the Z family enrolls.
(15) Example 15.
Benchmark plan terminates for all enrollees during the
year
The facts are the same as in Example 14, except that Plan 2
terminates for all enrollees on June 30. Under paragraphs (a), (b), and (f) of
this subsection, Plan 2 is the ABP for X and Y for all coverage months during
the year, and Plan 3 is the ABP for Z.
Section 60.07 Applicable percentage [75]
(01/15/2017, GCR 16-100)
(a) In general
The applicable percentage multiplied by a tax filer's
household income determines the tax filer's required share of premiums for the
ABP. This required share is subtracted from the monthly premium for the ABP
when computing the premium-assistance amount. The applicable percentage is
computed by first determining the percentage that the tax filer's household
income bears to the FPL for the tax filer's family size. The resulting FPL
percentage is then compared to the income categories described in the table in
paragraph (b) of this subsection (or successor tables). An applicable
percentage within an income category increases on a sliding scale in a linear
manner and is rounded to the nearest one-hundredth of one percent. For taxable
years beginning after December 31, 2014, the applicable percentages in the
table will be adjusted by the ratio of premium growth to growth in income for
the preceding calendar year and may be further adjusted to reflect changes to
the data used to compute the ratio of premium growth to income growth for the
2014 calendar year or the data sources used to compute the ratio of premium
growth to income growth. Premium growth and income growth will be determined in
accordance with IRS-published guidance. In addition, the applicable percentages
in the table may be adjusted to taxable years beginning after December 31,
2018, to reflect rates of premium growth relative to growth in the consumer
price index.
(b) Applicable
percentage table for APTC [76]
|
Household income percentage of FPL
|
2014 initial percentage
|
2014 final percentage
|
|
Less than 133%
|
2.0
|
2.0
|
|
At least 133% but less than 150%
|
3.0
|
4.0
|
|
At least 150% but less than 200%
|
4.0
|
6.3
|
|
At least 200% but less than 250%
|
6.3
|
8.05
|
|
At least 250% but less than 300%
|
8.05
|
9.5
|
|
At least 300% but not more than 400%
|
9.5
|
9.5
|
(c)
Applicable percentage table with the Vermont Premium Reduction [77]
The State reduces the APTC's applicable percentage by 1.5%
for an individual expected to have household income, as defined in §
28.05(c), that does not exceed 300 percent of the FPL for the benefit year for
which coverage is requested.
|
Household income percentage of FPL
|
2014 initial percentage
|
2014 final percentage
|
|
Less than 133%
|
0.5
|
0.5
|
|
At least 133% but less than 150%
|
1.5
|
2.5
|
|
At least 150% but less than 200%
|
2.5
|
4.8
|
|
At least 200% but less than 250%
|
4.8
|
6.55
|
|
At least 250% but less than 300%
|
6.55
|
8.0
|
|
At least 300% but not more than 400%
|
9.5
|
9.5
|
(d)
Examples
The following examples illustrate the rules of this
subsection:
(1) Example 1. A's
household income is 275 percent of the FPL for A's family size for that benefit
year
In the table in paragraph (b) of this subsection, the initial
percentage for a tax filer with household income of 250 to 300 percent of the
FPL is 6.55 and the final percentage is 8.0. A's FPL percentage of 275 percent
is halfway between 250 percent and 300 percent. Thus, rounded to the nearest
one-hundredth of one percent, A's applicable percentage is 7.28, which is
halfway between the initial percentage of 6.55 and the final percentage of
8.0.
(2) Example 2
(i) B's household income is 210 percent of
the FPL for B's family size. In the table in paragraph (b) of this subsection,
the initial percentage for a tax filer with household income of 200 to 250
percent of the FPL is 4.8 and the final percentage is 6.55. B's applicable
percentage is 5.15, computed as follows.
(ii) Determine the excess of B's FPL
percentage (210) over the initial household income percentage in B's range
(200), which is 10. Determine the difference between the initial household
income percentage in the tax filer's range (200) and the ending household
income percentage in the tax filer's range (250), which is 50. Divide the first
amount by the second amount:
210 -200 = 10
250 -200 = 50
10/50 =.20.
(iii) Compute the difference between the
initial premium percentage (4.8) and the second premium percentage (6.55) in
the tax filer's range; 6.55 -4.8 = 1.75.
(iv) Multiply the amount in the first
calculation (.20) by the amount in the second calculation (1.75) and add the
product (.35) to the initial premium percentage in B's range (4.8), resulting
in B's applicable percentage of 6.65:
.20 x 1.75 =.35
4.8 +.35 = 5.15.
Section 60.08 Plan covering more
than one household [78]
(01/15/2017, GCR 16-100)
(a) In general
If a QHP covers more than one household under a single
policy, each applicable tax filer covered by the plan may claim a premium tax
credit, if otherwise allowable. Each tax filer computes the credit using that
tax filer's applicable percentage, household income, and the ABP that applies
to the tax filer under § 60.06. In determining whether the amount computed
under § 60.04(a) (the premiums for the QHP in which the tax filer enrolls)
is less than the amount computed under § 60.04(b) (the benchmark plan
premium minus the product of household income and the applicable percentage),
the premiums paid are allocated to each tax filer in proportion to the premiums
for each tax filer's ABP.
(b) Example: Tax filers A and B enroll in a
single policy under a QHP.
The following example illustrates the rules of this
subsection:
(1) B is A's 25-year old
child who is not A's tax dependent. B has no tax dependents. The plan covers A,
B, and A's two additional children who are A's dependents. The premium for the
plan in which A and B enroll is $ 15,000. The premium for the
second-lowest-cost silver family plan covering only A and A's tax dependents is
$ 12,000 and the premium for the second-lowest-cost silver plan providing
self-only coverage to B is $ 6,000. A and B are applicable tax filers and
otherwise eligible to claim the premium tax credit.
(2) Under paragraph (a) of this subsection,
both A and B may claim premium tax credits. A computes her credit using her
household income, a family size of three, and a benchmark plan premium of $
12,000. B computes his credit using his household income, a family size of one,
and a benchmark plan premium of $ 6,000.
(3) In determining whether the amount in
§ 60.04(a) (the premiums for the QHP A and B purchase) is less than the
amount in § 60.04(b) (the benchmark plan premium minus the product of
household income and the applicable percentage), the $ 15,000 premiums paid are
allocated to A and B in proportion to the premiums for their ABPs. Thus, the
portion of the premium allocated to A is $ 10,000 ($ 15,000 x $ 12,000/$
18,000) and the portion allocated to B is $ 5,000 ($ 15,000 x $ 6,000/$
18,000).
Section
60.09 Reserved
(01/15/2017, GCR 16-100)
Section 60.10 Additional benefits [79]
(01/15/2017, GCR 16-100)
(a) In general
If a QHP offers benefits in addition to the essential health
benefits a QHP must provide, the portion of the premium for the plan properly
allocable to the additional benefits is excluded from the monthly premiums
under § 60.04(a) or (b). Premiums are allocated to additional benefits
before determining the ABP.
(b) Method of allocation
The portion of the premium properly allocable to additional
benefits is determined under guidance issued by the Secretary of HHS. [80
]
(c) Examples
The following examples illustrate the rules of this
subsection:
(1) Example 1
(i) Tax filer B enrolls in a QHP that
provides benefits in addition to the essential health benefits the plan must
provide (additional benefits). The monthly premiums for the plan in which B
enrolls are $ 370, of which $ 35 is allocable to additional benefits. B's
benchmark plan premium (determined after allocating premiums to additional
benefits for all silver level plans) is $ 440, of which $ 40 is allocable to
additional benefits. B's monthly contribution amount, which is the product of
B's household income and the applicable percentage, is $ 60.
(ii) Under this subsection, B's enrollment
premiums and the benchmark plan premium are reduced by the portion of the
premium that is allocable to the additional benefits provided under that plan.
Therefore, B's monthly enrollment premiums are reduced to $ 335 ($ 370 - $ 35)
and B's benchmark plan premium is reduced to $ 400 ($ 440 - $ 40). B's premium
assistance amount for a coverage month is $ 335, the lesser of $ 335 (B's
enrollment premiums, reduced by the portion of the premium allocable to
additional benefits) and $ 340 (B's benchmark plan premium, reduced by the
portion of the premium allocable to additional benefits ($ 400), minus B' $ 60
contribution amount).
(2) Example 2
The facts are the same as in Example 1, except that the plan
in which B enrolls provides no benefits in addition to the essential health
benefits required to be provided by the plan. Thus, under this subsection, B's
benchmark plan premium ($ 440) is reduced by the portion of the premium
allocable to the additional benefits provided under that plan ($ 40). B's
enrollment premiums ($ 370) are not reduced under this subsection. B's premium
assistance amount for a coverage month is $ 340, the lesser of $ 370 (B's
enrollment premiums) and $ 340 (B's benchmark plan premium, reduced by the
portion of the premium allocable to additional benefits ($ 400), minus B's 60
contribution amount).
Section 60.11 Pediatric dental coverage [81]
(01/15/2017, GCR 16-100)
(a) In general
For purposes of determining the amount of the monthly premium
a tax filer pays for coverage under § 60.04(a), if an individual enrolls
in both a QHP and a stand-alone dental plan, the portion of the premium for the
stand-alone dental plan that is properly allocable to pediatric dental benefits
that are essential benefits required to be provided by a QHP is treated as a
premium payable for the individual's QHP.
(b) Method of allocation
The portion of the premium for a stand-alone dental plan
properly allocable to pediatric dental benefits is determined under guidance
issued by the Secretary of HHS.
(c) Example
The following example illustrates the rules of this
subsection:
(1) Tax filer C and C's
tax dependent, R, enroll in a QHP. The premium for the plan in which C and R
enroll is $ 7,200 ($ 600/month) (Amount 1). The plan does not provide dental
coverage. C also enrolls in a stand-alone dental plan covering C and R. The
portion of the premium for the dental plan allocable to pediatric dental
benefits that are essential health benefits is $ 240 ($ 20 per month). The
excess of the premium for C's ABP over C's contribution amount (the product of
C's household income and the applicable percentage) is $ 7,260 ($ 605/month)
(Amount 2).
(2) Under this
subsection, the amount C pays for premiums (Amount 1) for purposes of computing
the premium-assistance amount is increased by the portion of the premium for
the stand-alone dental plan allocable to pediatric dental benefits that are
essential health benefits. Thus, the amount of the premiums for the plan in
which C enrolls is treated as $ 620 for purposes of computing the amount of the
premium tax credit. C's premium-assistance amount for each coverage month is $
605 (Amount 2), the lesser of Amount 1 (increased by the premiums allocable to
pediatric dental benefits) and Amount 2.
Section 60.12 Households that include
individuals who are not lawfully present [82]
(01/15/2017, GCR 16-100)
(a) In general
If one or more individuals for whom a tax filer is allowed a
deduction under § 151 of the Code are not lawfully present (see §
17.01(g) for definition of lawfully present), the percentage a tax filer's
household income bears to the FPL for the tax filer's family size for purposes
of determining the applicable percentage under § 60.07 is determined by
excluding individuals who are not lawfully present from family size and by
determining household income in accordance with paragraph (b) of this
subsection.
(b) Revised
household income computation
(1) Statutory
method
For purposes of (a) of this subsection, household income is
equal to the product of the tax filer's household income (determined without
regard to this paragraph (b)) and a fraction:
(i) The numerator of which is the FPL for the
tax filer's family size determined by excluding individuals who are not
lawfully present; and
(ii) The
denominator of which is the FPL for the tax filer's family size determined by
including individuals who are not lawfully present.
(2) Comparable method
The IRS Commissioner may describe a comparable method in
additional published guidance. [83]
Section 61.00 Timely Determination of
Eligibility. [84]
(01/15/2017, GCR 16-100)
(a) In general
(1) AHS strives to complete eligibility
determinations for health- benefits programs and QHP enrollment promptly and
without undue delay. The amount of time needed to complete such determinations
will necessarily vary, depending on such factors as:
(i) The capabilities and cost of
generally-available systems and technologies;
(ii) The general availability of electronic
data matching and ease of connections to electronic sources of authoritative
information to determine and verify eligibility; and
(iii) The needs of an individual, including:
(A) Individual preferences for mode of
application (such as through an internet Website, telephone, mail, in-person,
or other commonly available electronic means); and
(B) The relative complexity of adjudicating
the eligibility determination based on household, income or other relevant
information.
(2) An eligibility determination is complete
once AHS sends written notice of decision to the individual.
(b) Real-time determination of
eligibility
When an individual files a complete, accurate and web-based
application and relevant data can be fully verified through the use of
available electronic means, an individual can expect a real-time or
near-real-time eligibility determination.
(c) Normal maximum time for determining
eligibility [85]
In cases involving such factors as described in paragraph (a)
of this section, eligibility determinations may require additional time to
complete. In any event, a decision on a health-benefits application will be
made as soon as possible, but no later than:
(1) 90 days after the application date, if
the application is based on a person's disability; or
(2) 30 days after the application date for
any other health-benefits application.
(d) Extenuating circumstances
A determination may take longer in unusual situations, such
as:
(1) An individual delays providing
needed verification or other information;
(2) An examining physician delays sending a
necessary report; or
(3) An
unexpected emergency or administrative problem outside the control of AHS
delays action on applications.
(e) Notice of timeliness standards
Individuals will be informed of the timeliness standards set
forth in this section.
Section 62.00 Interviews
(01/15/2017, GCR 16-100)
An in-person interview will not be required as part of the
application process for a determination of eligibility using MAGI-based income.
However, an interview may be required for eligibility determinations for which
MAGI-based methods do not apply or when an individual is applying for Medicaid
coverage of long-term care services and supports.
Section 63.00 Individual Choice
(01/15/2017, GCR 16-100)
(a) Choice of Medicaid category [86]
If an individual would be eligible under more than one
Medicaid category, the individual may choose to have eligibility determined for
the category of the individual's choosing.
(b) Choice to determine eligibility for
health- benefits programs [87]
An individual may request only an eligibility determination
for enrollment in a QHP without APTC or CSR. However, if the individual is
requesting an eligibility determination for a health-benefits program, the
individual may not request an eligibility determination for less than all of
the health-benefits programs. For example, if an individual seeks a subsidy to
help pay for the cost of QHP coverage, they may not limit their application to
APTC or CSR. Rather, they must likewise submit to a determination of
eligibility for Medicaid.
Section 64.00 Premiums
(01/15/2017, GCR 16-100)
Section 64.01 In general
(01/15/2017, GCR 16-100)
(a) Scope
An individual who is enrolled in a QHP, as well as some
individuals enrolled in Medicaid's Dr. Dynasaur program, are required to pay
monthly premiums.
(b)
Medicaid premium methodologies and amounts
The Vermont legislature sets Medicaid premium methodologies
and amounts. Premium schedules are made publicly available via website.
(c) Determination of premium
obligation for Medicaid eligibility; premium recalculation for Medicaid and QHP
(1) As a part of the health-benefits
application, redetermination, and renewal processes:
(i) AHS will determine whether an individual
eligible for Medicaid will be required to pay monthly premiums.
(ii) AHS will determine the premium amount
due from an individual enrolled in a QHP based on the individual's plan
selection and any financial assistance amount credited.
(A) An amount will be credited for the amount
of APTC for which the individual has been determined eligible and which the
individual has selected to be applied toward the QHP premium(s) due.
(B) An amount will be credited for the amount
of the Vermont Premium Reduction for which the individual has been determined
eligible.
(2)
AHS will recalculate the premium amount for an individual enrolled in Medicaid
or enrolled in a QHP receiving premium assistance when:
(i) AHS is informed of a change in income,
family size, or health-insurance status, or
(ii) An adjustment is made in premium amounts
or calculation methodologies.
(3) A change that increases the premium
amount will appear on the next regularly-scheduled monthly bill, created after
the premium amount is recalculated.
(d) Premium calculation for Medicaid
(1) The premium calculation for an individual
on Medicaid will be based on the MAGI-based income of the individual's Medicaid
household following the MAGI methodology described in § 28.03, as
established on the most recently approved version of eligibility on the case
record at the time that the premium bill is generated. If a premium obligation
is calculated for an individual and if that individual is living together with,
and under the same premium payer account as, one or more other individuals for
whom a premium obligation is also calculated, only one premium bill will be
generated for those individuals. The bill will be for the highest premium
obligation that is calculated.
Example. If A and B live together and are under the same
premium payer account, and if A's calculated premium is $ 60.00 based on A's
Medicaid household income and B's calculated premium is $ 15.00 based on B's
Medicaid household income, AHS will not generate separate bills for A and B.
Rather, AHS will generate one premium bill for a total of $ 60.00 and, when
paid, the premium payment will cover eligibility for both A and B.
(2) Prior to the start of the
coverage month pertaining to the bill in question, the individual may notify
AHS to show that, due to changed household circumstances, the individual is
eligible for Medicaid without a premium obligation or a lower premium amount.
(i) If the showing indicates that the
individual is eligible for Medicaid without a premium obligation for the
coverage month, the individual will be enrolled in Medicaid effective the first
day of such coverage month.
(ii) If
the showing indicates that the individual is eligible for a lower premium
amount, the premium amount billed for that coverage month will be
adjusted.
(3) No premium
adjustments will be made for the coverage month if the individual has already
paid the premium for the coverage month and the individual notifies AHS after
the start of that coverage month that the individual is eligible for Medicaid
without a premium obligation or for a lower premium amount. If the individual
is entitled to a premium change, the change will be applied to the following
coverage month.
(e)
Aggregate limits for Medicaid premiums [88]
(1) Subject to paragraph (e)(2) of this
subsection, any Medicaid premiums and cost sharing incurred by all individuals
in the Medicaid household may not exceed an aggregate limit of five percent of
the family's income applied on a quarterly basis.
(2) If an individual incurs out-of-pocket
expenses in excess of the aggregate limit described in paragraph (e)(1) of this
subsection, AHS will refund that excess amount to the individual.
(3) An individual may request a reassessment
of their family aggregate limit if they have a change in circumstances or if
they are being terminated for failure to pay a premium.
(f) Notice of change in premium amount
An individual will be notified as provided in § 67.00
each time a premium amount is recalculated based on a reported change, whether
or not the recalculation results in a change in the premium amount. In other
cases (e.g., periodic system-generated recalculations), the individual will be
notified only in cases where there is a change in the premium amount.
(g) Prospective billing and
payment [89]
(1) Premiums are billed, and
payments are due, prior to the start of a coverage month. For purposes of
Medicaid, premium bills will be sent to the person identified on the
application as the primary contact or application filer. That person will be
responsible for payment of the Medicaid premium (referred to in this rule as
the premium payer). AHS will establish an account for the premium
payer.
(2) Except as provided in
paragraph (g)(3) of this subsection, an individual enrolled in a QHP may pay
any applicable premium owed by such individual directly to the QHP
issuer.
(3) If an individual owes
premiums for a QHP and for Medicaid, they may:
(i) Pay all such premiums in a combined
payment transaction directly to AHS; or
(ii) Pay such premiums due for Medicaid
directly to AHS in one transaction and such premiums due for a QHP in a
separate transaction directly to the QHP issuer.
(h) Conditions of eligibility and
enrollment
(1) For purposes of Medicaid,
timely payment of a premium is required as a condition of initial enrollment
and ongoing eligibility and enrollment.
(2) For purposes of QHP, timely payment of a
premium is required as a condition of initial and ongoing enrollment.
(i) Premium requirement for
partial coverage month
(1) The full amount due
must be paid to obtain coverage for all or a part of a month.
(2) The premium for QHP coverage lasting less
than one month must equal the product of:
(i)
The premium for one month of coverage divided by the number of days in the
month; and
(ii) The number of days
for which coverage is being provided that month. [90]
(3) If APTC and the Vermont Premium Reduction
are received for a partial coverage month consistent with § 73.06, APTC
and the Vermont Premium Reduction amounts are prorated using the methodology in
(2) above.
(j) Premiums
are nonrefundable
Premium payments are generally nonrefundable. See §
64.11 for exceptions related to Medicaid premiums. With respect to QHPs,
premiums may be refundable in certain cases, including death, overpayment
(including retroactive adjustment of APTC), and invoicing errors.
(k) [Reserved]
(l) Dr. Dynasaur retroactive island
If an individual advises AHS that they have unpaid medical
bills incurred during one or more of the three months prior to their
application, they may be able to obtain an island of retroactive coverage for
any or all of those months (called a "Dr. Dynasaur retroactive island"). If so,
AHS will bill the individual for the premium applicable to the Dr. Dynasaur
retroactive island. Premium payments for Dr. Dynasaur retroactive islands are
subject to allocation as provided under § 64.05(b).
Section 64.02 Public-notice
requirements for Medicaid [91]
(01/15/2017, GCR 16-100)
(a) Schedule of Medicaid premiums and cost-
sharing requirements
A public schedule will be available describing current
Medicaid premiums and cost-sharing requirements containing the following
information:
(1) The group or groups
of individuals who are subject to premiums and cost-sharing requirements and
the current amounts;
(2) Mechanisms
for making payments for required premiums and cost-sharing charges;
(3) The consequences for an individual who
does not pay a premium or cost-sharing charge;
(4) A list of hospitals charging cost sharing
for non-emergency use of the emergency department; and
(5) A list of preferred drugs or a mechanism
to access such a list, including the state's health-benefits website.
(b) Schedule availability
The public schedule will be available to the following in a
manner that ensures that affected individuals and providers are likely to have
access to the notice:
(1) Enrollees,
at the time of their enrollment and reenrollment after a redetermination of
eligibility, and, when premiums, cost- sharing charges or aggregate limits are
revised, notice to enrollees will be in accordance with §
5.01(d);
(2) Applicants, at the
time of application;
(3) All
participating providers; and
(4)
The general public.
(c)
[Reserved]
Section 64.03
Reserved
(01/15/2017, GCR 16-100)
Section 64.04 Ongoing premium billing and
payment
(01/15/2017, GCR 16-100)
(a) After enrollment, ongoing premiums are
billed and premium payments are due for an individual enrolled in Medicaid or a
QHP as follows:
(1) A monthly bill for
ongoing premiums will be sent by the 5th day of the month or the first
non-holiday business day thereafter immediately preceding the month for which
the premium covers. Payment is due on or before the last day of the month in
which the bill is sent.
(2) For
example, a premium bill for coverage in July 2014 will be sent by June 5, 2014.
Payment of the premium will be due on or before June 30, 2014.
(b) If the full premium payment is
received by the premium payment due date, coverage will continue without
further notice.
(c) If the premium
payment is made by mail, the payment will be considered received as of the date
it is postmarked.
(d) AHS
periodically publishes an operational document describing enrollment and
premium billing timelines for QHPs.
Section 64.05 Partial payment
(01/15/2017, GCR 16-100)
(a) Single-premium obligation
When there is only a single premium obligation, payment of
the full amount due is required to maintain coverage and eligibility. A payment
of less than the full amount due will be considered by AHS as
nonpayment.
(b) Allocation
of partial payments when multiple- premium obligations
(1) Basic rule
(i) Except as provided in paragraph (b)(2) of
this subsection, when a payment covers at least one, but fewer than all, of the
premiums due, the payment will be applied as payment of one or more premiums in
full rather than as a partial payment of any billed premium or premiums. The
payment will be allocated by AHS in the following order:
(A) Dr. Dynasaur.
(B) VPharm.
(C) QHP.
(D) Stand-alone dental plan.
(E) Dr. Dynasaur retroactive island (see
§ 64.01(l) for definition).
(ii) Coverage will only continue for those
for whom the full premium amount due has been received.
(2) Exception
An individual who wishes to specify a different payment
allocation for the premiums due may do so by calling AHS at the number listed
on the bill. The individual must make such a request prior to the time the
payment is received by AHS.
Section 64.06 Late payment/grace period
(01/15/2017, GCR 16-100)
(a) Grace Period
(1) An individual enrolled in a QHP, with or
without APTC, or in Dr. Dynasaur is entitled to a premium grace period as
described in this paragraph (1) if the individual has not paid their monthly
premium by its due date.
(i) For an
individual enrolled in a QHP with APTC, the grace period is three consecutive
months.
(ii) For an individual
enrolled in a QHP without APTC, the grace period is one month.
(iii) For an individual enrolled in Dr.
Dynasaur, the grace period is 60 days; it starts the day after the due date,
extends 60 days, and then ends on the last day of the month in which the 60-
day period ends. [92]
(2) During the grace period for an individual
enrolled in a QHP with APTC, the QHP issuer:
(i) Will pay all appropriate claims for
services rendered to the individual during the first month of the grace period;
and
(ii) May pend claims for
services rendered to the individual in the second and third months of the grace
period.
(3) During the
grace period for an individual enrolled in a QHP without APTC, the QHP issuer
will pay all appropriate claims for services rendered to the individual during
the grace period.
(4) During the
grace period for an individual enrolled in Dr. Dynasaur, Medicaid will pay all
appropriate claims for services rendered to the individual.
(b) Notice of premium nonpayment
and reinstatement
(1) In the case of an
individual enrolled in a QHP:
(i) If the full
premium payment is not received on or before the premium due date:
(A) The QHP issuer will notify the individual
of:
(I) The payment delinquency;
(II) The grace period and the consequences of
being in that status;
(III) The
effect of premium nonpayment on their eligibility for APTC and CSR, if
applicable, and their eligibility for future enrollment in a QHP;
(IV) The actions the individual must take to
resume good standing; and
(V) The
consequences of exhausting the grace period without paying all outstanding
premiums.
(B) The QHP
issuer will also:
(I) Notify HHS of the
nonpayment as required by federal law; and
(II) With respect to an individual enrolled
in a QHP with APTC, notify providers of the possibility for denied claims when
the enrollee is in the second and third months of the grace period.
(ii) Except in the
following circumstances, the individual will generally not be reinstated
following termination for non- payment of premium at the end of the grace
period:
(A) In the case of erroneous
termination.
(B) If the individual
is enrolled in a QHP without APTC, the individual may request reinstatement of
coverage after termination for non-payment of premium once per plan year. The
individual must request reinstatement within 30 days of termination for
non-payment and must pay all invoiced and past-due premiums prior to the last
day of the month following the last month of coverage.
(2) In the case of an individual
enrolled in Dr. Dynasaur:
(i) If a full
premium payment is not received by AHS on or before the premium due date,
before the fifth business day of the grace period, AHS will send a notice
advising that the individual is in a grace period status. The notice will also
advise the individual:
(A) Of the Dr.
Dynasaur disenrollment protection as provided under § 64.07;
(B) Of the consequences of being in a grace
status;
(C) The actions the
individual must take to resume good standing; and
(D) The consequences of exhausting the grace
period without paying all outstanding premiums.
(ii) At least 11 days before the end of the
grace period, AHS will send the individual a closure notice advising that
enrollment will terminate at the end of the grace period.
(iii) Subject to the payment allocation
described in (iv) below, if AHS receives at least a full premium payment for
the grace period on or before the end of the grace period:
(A) The payment will first be applied to
cover the premium due for the grace period;
(B) The individual will be reinstated;
and
(C) The individual will be
reenrolled for coverage in the month following the grace period.
(iv) Payment allocation. If an
individual is in grace period status for more than one unpaid premium when AHS
receives payment and the payment covers the premium due for at least one, but
fewer than all, of the grace periods, the payment will be applied as payment of
one or more premiums in full and allocated in chronological order beginning
with the oldest grace period.
(v)
If AHS receives a full premium payment for the grace period after the end of
the grace period, the individual will not be reinstated or reenrolled, and will
need to re-apply.
Section 64.07 Dr. Dynasaur disenrollment
protection [93]
(01/15/2017, GCR 16-100)
(a) Prior to closure, an individual enrolled
in Dr. Dynasaur who has received a grace period notice as provided under §
64.06(b)(2)(i) may contact AHS to show that, due to changed household
circumstances, the individual is eligible for Medicaid without a premium
obligation or with a lower premium amount.
(b) If the showing indicates that the
individual is eligible for Medicaid without a premium obligation, AHS will
reinstate and reenroll the individual and waive all outstanding
premiums.
(c) If the showing
indicates that the individual is obligated to pay a premium, but at a lower
amount, any outstanding premium amounts due will be adjusted. If the individual
pays the adjusted premium amount prior to closure, AHS will reinstate and
reenroll the individual.
Section
64.08 Reserved
(01/15/2017, GCR 16-100)
Section 64.09 Medical incapacity for VPharm
(01/15/2017, GCR 16-100)
(a) "Medical incapacity" means a serious
physical or mental infirmity to the health of an individual enrolled in VPharm
( § 10.01) that prevented the individual from paying the premium timely,
as verified in a physician's certificate furnished to AHS. Notice by telephone
or otherwise by the physician that such certificate will be forthcoming will
have the effect of receipt, provided that the certificate is in fact received
within seven days.
(b) If an
individual's VPharm coverage is terminated solely because of nonpayment of the
premium, and the reason is medical incapacity as defined in (a) of this
subsection, the individual's representative may request coverage for the period
between the day coverage ended and the last day of the month in which they
requested coverage. AHS will provide this coverage if it has received
verification of medical incapacity and all premiums due for the period of
non-coverage. The individual is responsible for all bills incurred during the
period of non-coverage until AHS receives the required verification and premium
amounts due.
(c) If the health
condition related to this medical incapacity is expected to continue or recur,
AHS will encourage the individual to sign up for automatic withdrawal of their
premium or designate an authorized representative to receive and pay future
premiums for as long as the anticipated duration of the condition.
Section 64.10 Medicaid premium
payment balances
(01/15/2017, GCR 16-100)
Medicaid premium payment balances that result from partial
payments or overpayments will be credited to the premium payer's account and
will be applied to subsequent Medicaid premium bills.
Section 64.11 Refund of prospective Medicaid
premium payments
(01/15/2017, GCR 16-100)
(a) Basic rule for Medicaid premiums
A paid Medicaid premium will automatically be refunded to the
premium payer when, prior to the beginning of the coverage month associated
with the premium payment, no one under the premium payer's account is subject
to a premium obligation.
(b) Exception
A paid Medicaid premium will not be refunded if a change
occurs after the beginning of the coverage month associated with the premium
payment.
Section
64.12 Reserved
(01/15/2017, GCR 16-100)
Section 64.13 Appeal of Medicaid or QHP
premium amount
(01/15/2017, GCR 16-100)
(a) Medicaid.
If an individual subject to a premium appeals a decision by
AHS that ends their Medicaid eligibility, reduces their benefits or services,
or increases the amount of their Medicaid premium, the individual must continue
to pay the premium amount in effect prior to the decision that resulted in
their appeal in order to have their Medicaid coverage continue pending the
outcome of their appeal.
AHS may recover from the individual the difference between
the premium level that would have become effective had the individual not
appealed AHS's decision and the premium level actually paid during the fair
hearing period when the individual withdraws the fair hearing request before
the decision is made or following a final disposition of the matter in favor of
AHS.
(b) QHP.
An individual who appeals the amount of their QHP premium
must pay the billed amount until the appeal is decided for coverage to
continue. If the individual wins the appeal, any overpayment will be
refunded.
Section
65.00 Medicaid Copayments
(01/15/2017, GCR 16-100)
Section 65.01 In general
(01/15/2017, GCR 16-100)
(a) Copayments from some Medicaid enrollees
are required for certain services. Copayments will be deducted from the
Medicaid payment for each service subject to copayment. § 1916(e) of the
Act requires that "no provider participating under the State (Medicaid) plan
may deny care or services to an individual eligible for (Medicaid)... on
account of such individual's inability to pay (the copayment)." This subsection
further provides, however, that these requirements "shall not extinguish the
liability of the individual to whom the care or services were furnished for the
payment of (the copayment)."
(b)
The state is not responsible for copayments that a provider may collect in
error or that an individual makes on a service that is not paid for by
Medicaid.
Section 65.02
Enrollees not subject to copayments
(01/15/2017, GCR 16-100)
Copayments are never required from individuals who
are:
(a) Receiving Medicaid coverage
of long-term care services and supports in a long-term care facility or through
hospice;
(b) Medicaid enrollees
under age 21; or
(c) MCA enrollees
who are pregnant or in the 60-day post- pregnancy period.
Section 65.03 Services that require
copayments
(01/15/2017, GCR 16-100)
See DVHA Rules 7101.2(C) and 7101.3(E) for the services that
require copayments and the required amounts.
Section 66.00 Presumptive Medicaid
Eligibility Determined by Hospitals. [94]
(01/15/2017, GCR 16-100)
Section 66.01 Basis
(01/15/2017, GCR 16-100)
This section implements §
1902(a)(47)(B)
of the Act.
Section 66.02
In general
(01/15/2017, GCR 16-100)
(a) Basic rule
Medicaid will be provided during a presumptive eligibility
period to an individual who is determined by a qualified hospital, on the basis
of preliminary information, to be presumptively eligible in accordance with the
policies and procedures established by AHS consistent with this section.
(b) Qualified hospital
A qualified hospital is a hospital that:
(1) Participates as a Medicaid provider;
notifies AHS of its election to make presumptive eligibility determinations
under this section; and agrees to make presumptive eligibility determinations
consistent with state policies and procedures;
(2) Assists individuals in completing and
submitting the full Medicaid application and understanding any documentation
requirements; and
(3) Has not been
disqualified by AHS in accordance with paragraph (d) of this
subsection.
(c) Scope of
authority to make determinations of presumptive eligibility
Hospitals may only make determinations of presumptive
eligibility under this section based on income for:
(1) Children under §
7.03(a)(3);
(2) Pregnant women
under § 7.03(a)(2);
(3)
Parents and caretaker relatives under § 7.03(a)(1);
(4) Adults under § 7.03(a)(5);
(5) Former foster children under §
9.03(e);
(6) Individuals receiving
breast and cervical cancer treatment under § 9.03(f); and
(7) Individuals receiving family planning
services under § 9.03(g).
(d) Disqualification of hospitals
(1) AHS may establish standards for qualified
hospitals related to the proportion of individuals determined presumptively
eligible for Medicaid by the hospital who:
(i) Submit a regular application before the
end of the presumptive eligibility period; or
(ii) Are determined eligible for Medicaid
based on such application.
(2) AHS will take action, including, but not
limited to, disqualification of a hospital as a qualified hospital under this
section, if it determines that the hospital is not:
(i) Making, or is not capable of making,
presumptive eligibility determinations in accordance with applicable state
policies and procedures; or
(ii)
Meeting the standard or standards established under paragraph (d)(1) of this
section.
(3) AHS may
disqualify a hospital as a qualified hospital under this paragraph only after
it has provided the hospital with additional training or taken other reasonable
corrective action measures to address the issue.
Section 66.03 Procedures
(01/15/2017, GCR 16-100)
(a) In general [95]
AHS will provide Medicaid services to an individual during
the presumptive-eligibility period that follows a determination by a qualified
hospital that, on the basis of preliminary information, the individual has
gross income at or below the Medicaid income standard established for the
individual.
(b) AHS's
responsibilities [96]
AHS will:
(1)
Provide qualified hospitals with application forms for Medicaid and information
on how to assist individuals in completing and filing such forms;
(2) Establish oversight mechanisms to ensure
that presumptive- eligibility determinations are being made consistent with
applicable laws and rules; and
(3)
Allow determinations of presumptive eligibility to be made by qualified
hospitals on a statewide basis.
(c) Qualified hospital's responsibilities
[97]
(1) On the basis of preliminary
information, a qualified hospital must determine whether the individual is
presumptively eligible under this rule.
(2) For the purpose of the presumptive
eligibility determination, a qualified hospital must accept self-declaration of
the presumptive-eligibility criteria.
(3) If the individual is presumptively
eligible, a qualified hospital must:
(i)
Approve presumptive coverage for the individual;
(ii) Notify the individual within twenty-four
hours of the eligibility determination, in writing or orally, if appropriate:
(A) That the individual is eligible for
presumptive coverage;
(B) The
presumptive eligibility determination date;
(C) That the individual is required to make
application for ongoing Medicaid by not later than the last day of the
following month; and
(D) That
failure to cooperate with the standard eligibility determination process will
result in denial of ongoing Medicaid and termination of presumptive coverage on
the date described in § 66.04;
(iii) Notify AHS of the presumptive
eligibility determination within five working days after the date on which
determination is made;
(iv) Provide
the individual with a Medicaid application form;
(v) Advise the individual that:
(A) If a Medicaid application on behalf of
the individual is not filed by the last day of the following month, the
individual's presumptive eligibility will end on that last day; and
(B) If a Medicaid application on behalf of
the individual is filed by the last day of the following month, the
individual's presumptive eligibility will end on the day that a decision is
made on the Medicaid application; and
(vi) Take all reasonable steps to help the
individual complete an application for ongoing Medicaid or make contact with
AHS.
(4) If the
individual is not presumptively eligible, a qualified hospital must notify the
individual at the time the determination is made, in writing and orally if
appropriate:
(i) Of the reason for the
determination;
(ii) That their
ineligibility for presumptive coverage does not necessarily mean that they are
ineligible for other categories of Medicaid; and
(iii) That the individual may file an
application for Medicaid with AHS, and that, if they do so, that the
individual's eligibility for other categories of Medicaid will be
reviewed.
(5) A
qualified hospital may not delegate the authority to determine presumptive
eligibility to another entity. [98]
(d) Required attestations [99]
For purposes of making a presumptive eligibility
determination under this section, an individual (or another person having
reasonable knowledge of the individual's status) must attest to the individual
being a:
(1) Citizen or national of
the United States or in satisfactory immigration status; and
(2) Resident of the state.
(e) Limitation on other conditions
[100]
(1) The conditions specified in this
subsection are the only conditions that apply in the case of a
presumptive-eligibility determination.
(2) Verification of the conditions that apply
for presumptive eligibility is not required.
Section 66.04 Presumptive coverage [101]
(01/15/2017, GCR 16-100)
(a) Effective dates
(1) Presumptive coverage begins on the date
the individual is determined to be presumptively eligible.
(2) Presumptive coverage ends with the
earlier of (and includes):
(i) The date that
the individual is determined to be eligible or ineligible for ongoing
Medicaid.
(ii) If the individual
has not applied for ongoing Medicaid, the last day of the month following the
month in which the individual was determined to be presumptively
eligible.
(b)
No retroactive coverage
No retroactive coverage may be provided as a result of a
presumptive eligibility determination.
(c) Frequency
An individual may receive only one presumptive Medicaid
eligibility period in a calendar year. A pregnant woman may receive only one
presumptive Medicaid eligibility period for each pregnancy, even if she has not
yet otherwise received a presumptive Medicaid eligibility period during the
current calendar year.
Section 66.05 Notice and fair hearing rules
[102]
(01/15/2017, GCR 16-100)
Notice and fair hearing regulations in Part Eight of this
rule do not apply to determinations of presumptive eligibility under this
section.
Section 67.00
General Notice Standards. [103]
(01/15/2017, GCR 16-100)
(a) General requirement
Any notice required to be sent by AHS must be written and
include:
(1) An explanation of the
action reflected in the notice, including the effective date of the
action.
(2) Any factual findings
relevant to the action.
(3)
Citations to, or identification of, the relevant regulations supporting the
action.
(4) Contact information for
available customer service resources.
(5) An explanation of appeal rights, if
applicable.
(b)
Accessibility and readability
All applications, forms, and notices, including the single,
streamlined application and notice of redetermination, will conform to the
standards outlined in § 5.01(c).
Section 67.01 Use of electronic notices [104]
(01/15/2017, GCR 16-100)
(a) Choice of notice format
Effective no later than January 1, 2015, an individual will
be provided with a choice to receive notices and information required under
these rules in electronic format or by regular mail. If the individual elects
to receive communications electronically, AHS will:
(1) Confirm by regular mail the individual's
election to receive notices electronically;
(2) Inform the individual of their right to
change such election, at any time, to receive notices through regular
mail;
(3) Post notices to the
individual's electronic account within one business day of notice
generation;
(4) Send an email or
other electronic communication alerting the individual that a notice has been
posted to his or her account. Confidential information will not be included in
the email or electronic alert;
(5)
Send a notice by regular mail within three business days of the date of a
failed electronic communication if an electronic communication is
undeliverable; and
(6) At the
individual's request, provide through regular mail any notice posted to the
individual's electronic account.
(b) Limitation on use of electronic notices
and other communications
Notice or other communications will be provided
electronically only if the individual:
(1) Has affirmatively elected to receive
electronic communications in accordance with paragraph (a) of this subsection;
and
(2) Is permitted to change such
election at any time.
Section 68.00 Notice of Decision and Appeal
Rights
(01/15/2017, GCR 16-100)
Section 68.01 Notice of decision concerning
eligibility [105]
(01/15/2017, GCR 16-100)
(a) In general
AHS will send to an individual notice of any decision
affecting their eligibility, including an approval, denial, termination or
suspension of eligibility in accordance with federal and state laws. A notice
of a decision that adversely affects an enrollee's eligibility, including a
notice of termination or suspension, will comply with the requirements under
§ 68.02.
(b) Content
of eligibility notice
(1) In general
Any notice of decision will contain:
(i) A statement of the action that AHS is
taking or intends to take;
(ii) The
effective date of the action, if applicable;
(iii) The specific regulations that support,
or the change in federal or state law that requires, the action;
(iv) An explanation of the individual's
appeal rights, including the right to request a fair hearing;
(v) An explanation of the circumstances under
which the individual has the right to an expedited administrative appeal
pursuant to § 80.07;
(vi) A
description of the procedures by which the individual may submit a fair hearing
request;
(vii) Information on the
individual's right to represent themselves at a fair hearing or use legal
counsel, a relative, a friend or other spokesperson;
(viii) In cases of an action based on a
change in law, an explanation of the circumstances under which a fair hearing
may be granted;
(ix) An explanation
of the circumstances under which the individual's eligibility for QHP, APTC or
CSR or their Medicaid benefits may continue pending a fair hearing decision;
and
(x) In connection with
eligibility for a QHP, an explanation that a fair hearing decision for one
household member may result in a change in eligibility for other household
members and that change may be handled as a redetermination.
(2) Notice of approved eligibility
In addition to the information in paragraph (b)(1) of this
subsection, a notice of approval of eligibility will contain:
(i) The basis and effective date of the
eligibility;
(ii) The circumstances
under which the individual must report, and the procedure for reporting, any
changes that may affect their eligibility;
(iii) For an individual approved for
Medicaid, information on the level of Medicaid benefits and services approved,
including, if applicable, the notice relating to any premiums and cost-sharing
required, and the right to appeal the level of benefits and services approved;
and
(iv) For an individual approved
for Medicaid subject to a spenddown, the amount of medical expenses which must
be incurred to establish eligibility.
(3) Notices on bases of Medicaid eligibility
other than MAGI- based standard [106]
[Reserved]
(c) Timing of notification
Notice will be provided:
(1) At the time that the individual applies
for health benefits; or
(2) At the
time of any action affecting the individual's eligibility.
Section 68.02 Advance notice of
adverse action decision [107]
(01/15/2017, GCR 16-100)
(a) In general
AHS will send a notice of a decision that adversely affects
an enrollee's eligibility, including a notice of termination or suspension,
(adverse action) at least 11 days before the date the adverse action is to take
effect (date of action), except as permitted under paragraph (b) of this
subsection.
(b) Exception
[108]
A notice may be sent not later than the date of action
if:
(1) There is factual information
confirming the death of an enrollee;
(2) A clear written statement signed by an
enrollee is received that:
(i) The enrollee
no longer wishes eligibility; or
(ii) Gives information that requires
termination or reduction of eligibility and indicates that the enrollee
understands that this must be the result of supplying that
information;
(3) The
enrollee has been admitted to an institution where they are
ineligible;
(4) The enrollee's
whereabouts are unknown and the post office returns mail directed to the
enrollee indicating no forwarding address; or
(5) AHS establishes the fact that the
enrollee has been accepted for Medicaid eligibility by another state,
territory, or commonwealth.
(c) Exception: probable fraud [109]
The period of advance notice may be shortened to 5 days
before the date of action if:
(1)
There are facts indicating that action should be taken because of probable
fraud by the enrollee; and
(2) The
facts have been verified, if possible, through secondary sources.
Section 69.00
Corrective Action [110]
(01/15/2017, GCR 16-100)
Corrective payments will be promptly made, retroactive to the
date an incorrect action was taken if:
(a) A fair hearing decision is favorable to
an individual; or
(b) An issue is
decided in an individual's favor before a fair hearing.
Section 70.00 Medicaid Enrollment
(01/15/2017, GCR 16-100)
Section 70.01 Enrollment when no premium
obligation
(01/15/2017, GCR 16-100)
(a) Prospective enrollment
Except when a spenddown is necessary, an individual approved
for Medicaid without a premium obligation will be enrolled in Medicaid 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 [111]
(1) 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:
(i) Eligibility is determined and a budget
computed separately for each of the three months;
(ii) A medical need exists; and
(iii) Elements of eligibility were met at
some time during each month.
(2) An individual may be eligible for the
retroactive period (or any single month(s) of the retroactive period) even
though ineligible for the prospective period.
(3) If an individual, at the time of
application, declares that they incurred medical expenses during the
retroactive period and eligibility is not approved, the individual's case
record must contain documentation of the reason the individual was not eligible
in one or more months of the retroactive period.
Section 70.02 Premium obligation;
initial billing and payment
(01/15/2017, GCR 16- 100)
(a) Initial billing
An individual who is approved for Medicaid with a premium
obligation will be notified of the premium obligation and premium amount in a
bill that will be sent at the time of approval. The individual will not be
enrolled in Medicaid until AHS receives payment of the initial premium. The
bill will include payment instructions.
(b) Initial premium bill amount
(1) The initial bill will include premium
charges for the month in which the individual's application was received (the
application month) and the month following the application month if eligibility
is approved in the same month as the application month. The premium due date is
the last day of the month following the application month. If the month
eligibility is approved is different than the application month, the initial
bill will include the application month, the approval month, any month (or
months) between the application month and the approval month, and the month
following the approval month. The premium due date is the last day of the month
following the approval month.
(2)
If the individual is eligible for, and requests, retroactive coverage at the
time of their initial application, the initial bill will include premium
charges for each month of retroactive coverage. See § 70.01(b) for details
on the requirements that must be met for retroactive eligibility.
(c) Payment allocation
When a premium payment is made for the initial months of
coverage, and the payment covers the premiums due for at least one, but fewer
than all, of the months included in the bill, the payment will be allocated in
reverse chronological order, beginning with the latest month included in the
bill and extending back as follows:
(1) each month between the latest month and
the application month,
(2) the
application month, and
(3) any
retroactive coverage months included in the bill.
Coverage will begin on the first day of the earliest month
for which a full premium has been paid in accordance with the allocation method
described above.
Once an individual is in an ongoing billing cycle due to the
issuance of a bill for a subsequent month not included in the bill for the
initial months, payments will be applied to the coverage month for which the
latest bill was issued and to future coverage months. See § 64.04 for a
description of the ongoing billing and payment process.
(d) Coverage islands; premiums
paid after enrollment
(1) Individuals who
initially pay the premiums due for fewer than all of the months included in the
initial bill may subsequently obtain coverage islands for any or all of the
remaining months (a "coverage island" is a period of eligibility with specific
beginning and end dates).
(2) To
obtain one or more coverage islands, the individual must pay the full premium
amount that was initially billed for each of the desired months of
coverage.
(3) Payments of coverage
islands will be allocated in the order specified in paragraph (c) of this
§ 70.02.
Section
71.00 Enrollment of Qualified Individuals in QHPS [112]
(01/15/2017, GCR 16-100)
Section 71.01 In general
(01/15/2017, GCR 16-100)
(a) General requirements [113]
AHS will accept a QHP selection from an individual who is
determined eligible for enrollment in a QHP in accordance with § 11.00,
and will:
(1) Notify the issuer of the
individual's selected QHP; and
(2)
Transmit information necessary to enable the QHP issuer to enroll the
individual.
(b) Timing
of data exchange [114]
AHS will:
(1) Send
eligibility and enrollment information to QHP issuers and HHS promptly and
without undue delay;
(2) Establish
a process by which a QHP issuer acknowledges the receipt of such information;
and
(3) Send updated eligibility
and enrollment information to HHS promptly and without undue delay, in a manner
and timeframe specified by HHS.
(c) Records [115]
Records of all enrollments in QHPs will be maintained.
(d) Reconcile files [116]
AHS will reconcile enrollment information with QHP issuers
and HHS no less than on a monthly basis.
(e) Notice of employee's receipt of APTCs and
CSRs to an employer [117]
AHS will notify an employer that an employee has been
determined eligibility for advance payments of the premium tax credit and cost-
sharing reductions and has enrolled in a qualified health plan through VHC
within a reasonable timeframe following a determination that the employee is
eligible for advance payments of the premium tax credit and cost-sharing
reductions and enrollment by the employee in a qualified health plan through
VHC. Such notice must:
(1) Identify
the employee;
(2) Indicate that the
employee has been determined eligible for advance payments of the premium tax
credit and cost-sharing reductions and has enrolled in a qualified health plan
through VHC;
(3) Indicate that, if
the employer has 50 or more full-time employees, the employer may be liable for
the payment assessed under § 4980H of the Code; and
(4) Notify the employer of the right to
appeal the determination and where to file the appeal as described in §
45.00(b).
Section
71.02 Annual open enrollment periods [118]
(01/15/2017, GCR 16-100)
(a) General requirements [119]
(1) Annual open enrollment periods (AOEPs)
will be provided consistent with this subsection, during which qualified
individuals may enroll in a QHP and enrollees may change QHPs.
(2) A qualified individual may only be
permitted to enroll in a QHP or an enrollee to change QHPs during the AOEP
specified in paragraph (e) of this subsection, or a special enrollment period
(SEP) described in § 71.03 for which the qualified individual has been
determined eligible.
(b)
[Reserved]
(c) [Reserved]
(d) Notice of AOEP [120]
AHS will provide a written AOEP notification to each enrollee
no earlier than the first day of the month before the open enrollment period
begins and no later than the first day of the open enrollment period.
(e) AOEP [121]
The AOEP will be in accordance with federal law.
(f) Coverage effective dates
during the AOEP [122]
(1) Coverage will be
effective January 1, for a QHP selection received on or before December
15.
(2) To the extent the AOEP
extends beyond December 15, for a QHP selection received:
(i) Between the first and the fifteenth day
of a month during the AOEP, coverage will be effective on the first day of the
following month.
(ii) Between the
sixteenth and the last day of a month during the AOEP, coverage will be
effective on the first day of second following month.
(iii) For example, coverage will be effective
February 1 for a QHP selection received from December 16 through January
15.
Section
71.03 Special enrollment periods (SEP) [123]
(01/15/2017, GCR 16-100)
(a) General requirements [124]
(1) AHS will provide SEP consistent with this
subsection, during which qualified individuals may enroll in QHPs and enrollees
may change QHPs.
(2) For the
purpose of this subsection, "dependent" has the same meaning as it does in
26
CFR §
54.9801-2, referring to any
individual who is or who may become eligible for coverage under the terms of a
QHP because of a relationship to a qualified individual or enrollee.
(b) Effective dates [125]
(1) Regular effective dates
Except as specified in paragraphs (b)(2) and (3) of this
subsection, for a QHP selection received by AHS from a qualified
individual:
(i) Between the first and
the fifteenth day of any month, the coverage effective date will be the first
day of the following month; and
(ii) Between the sixteenth and the last day
of any month, the coverage effective date will be the first day of the second
following month.
(2)
Special effective dates
(i) In the case of
birth, adoption, placement for adoption, or placement in foster care, coverage
is effective for a qualified individual or enrollee on the date of birth,
adoption, placement for adoption, or placement in foster care or, if elected by
the qualified individual or enrollee, in accordance with paragraph (b)(1) of
this subsection.
(ii) In the case
of marriage, as described in paragraph (d)(2) of this subsection, coverage is
effective for a qualified individual or enrollee on the first day of the month
following plan selection.
(iii) In
the case of a qualified individual or enrollee eligible for a special
enrollment period as described in paragraphs (d)(4), (d)(5), or (d)(9) of this
subsection, coverage is effective on an appropriate date based on the
circumstances of the special enrollment period.
(iv) In a case where an individual loses
coverage as described in paragraph (d)(1) or (d)(6)(iii) of this subsection, if
the plan selection is made before or on the day of the loss of coverage, the
coverage effective date is on the first day of the month following the loss of
coverage. If the plan selection is made after the loss of coverage, the
coverage is effective on the first day of the following month.
(v) In the case of a court order as described
in paragraph (d)(2)(i) of this subsection, coverage is effective for a
qualified individual or enrollee on the date the court order is
effective.
(vi) In a case where an
enrollee or their dependent dies as described in paragraph (d)(2)(ii) of this
subsection, coverage is effective on the first day of the month following the
plan selection.
(vii) In a case
where an individual gains access to a new QHP as described in paragraph (d)(7)
of this subsection or becomes newly eligible for enrollment in a QHP through
VHC in accordance with § 19.01 as described in paragraph (d)(3) of this
subsection, if the plan selection is made on or before the date of the
triggering event, coverage is effective on the first day of the month following
the date of the triggering event. If the plan selection is made after the date
of the triggering event, coverage is effective in accordance with paragraph
(b)(1) of this subsection.
(3) Option for earlier effective dates
Subject to demonstrating to HHS that all of the participating
QHP issuers agree to effectuate coverage in a timeframe shorter than discussed
in paragraph (b)(1) or (b)(2)(ii) of this subsection, one or both of the
following may be done for all applicable individuals:
(i) For a QHP selection received from a
qualified individual in accordance with the dates specified in paragraph (b)(1)
or (b)(2)(ii) of this section, a coverage effective date for a qualified
individual may be provided earlier than specified in such paragraphs.
(ii) For a QHP selection received from a
qualified individual on a date set by the state after the fifteenth of the
month, a coverage effective date of the first of the following month may be
provided.
(4) APTC and
CSR
Notwithstanding the standards of this subsection, APTC,
Vermont Premium Reduction and federal and state CSR will adhere to the
effective dates specified in § 73.06.
(c) Availability and length of SEP [126]
(1) General rule. Unless specifically stated
otherwise herein, a qualified individual or enrollee has 60 days from the date
of a triggering event to select a QHP.
(2) Advanced availability.
A qualified individual or their dependent who is described in
one of the following paragraphs of this subsection has 60 days before and after
the date of the triggering event to select a QHP:
(i)
(d)
(3) if
they become newly eligible for enrollment in a QHP through VHC because they
newly satisfy the requirements under § 19.01;
(iii)
(d)
(7) .
(3) Special rule. In the case of a qualified
individual or enrollee who is eligible for an SEP as described in paragraphs
(d)(4), (d)(5), or (d)(9) of this subsection, AHS may define the length of the
SEP as appropriate based on the circumstances of the SEP, but in no event will
the length of the SEP exceed 60 days.
(d) SEPs [127]
AHS will allow a qualified individual or enrollee, and, when
specified below, their dependent, to enroll in or change from one QHP to
another if one of the following triggering events occur:
(1) The qualified individual or their
dependent either:
(i) Loses MEC. The date of
the loss of coverage is the last day the individual would have coverage under
their previous plan or coverage;
(ii) Is enrolled in any non-calendar year
group health plan or individual health insurance coverage, even if the
qualified individual or their dependent has the option to renew such coverage.
The date of the loss of coverage is the last day of the plan or policy year;
or
(iii) Loses medically needy
coverage only once per calendar year. The date of the loss of coverage is the
last day the individual would have medically needy coverage.
(2) Gain or loss of dependent
(i) The qualified individual gains a
dependent or becomes a dependent through marriage, birth, adoption, placement
for adoption, or placement in foster care, or through a child support order or
other court order.128
(ii) The
enrollee loses a dependent or is no longer considered a dependent through
divorce or legal separation as defined by state law in the state in which the
divorce or legal separation occurs, or if the enrollee or their dependent
dies.
(3) The qualified
individual, or their dependent, becomes newly eligible for enrollment in a QHP
through VHC because they newly satisfy the requirements under § 17.02
(citizenship, status as a national, lawful presence) or § 19.01
(incarceration);
(4) The qualified
individual's or their dependent's enrollment or non-enrollment in a QHP is
unintentional, inadvertent, or erroneous and is the result of the error,
misrepresentation, misconduct or inaction of an officer, employee, or agent of
AHS or HHS, its instrumentalities, or an individual or entity authorized by AHS
to provide enrollment assistance or conduct enrollment activities, as evaluated
and determined by AHS. For purposes of this provision, misconduct includes, but
is not limited to, the failure to comply with applicable standards under this
rule or other applicable federal or state laws, as determined by AHS. In such
cases, AHS may take such action as may be necessary to correct or eliminate the
effects of such error, misrepresentation, misconduct or inaction. See §
76.00(e)(3) regarding correction of an erroneous termination or cancellation of
coverage;
(5) The enrollee or their
dependent adequately demonstrates to AHS that the QHP in which they are
enrolled substantially violated a material provision of its contract in
relation to the enrollee;
(6) Newly
eligible or ineligible for APTC, or change in eligibility for CSR.
(i) The enrollee is determined newly eligible
or newly ineligible for APTC or has a change in eligibility for CSR;
(ii) The enrollee's dependent enrolled in the
same QHP is determined newly eligible or newly ineligible for APTC or has a
change in eligibility for CSR; or
(iii) A qualified individual or their
dependent who is enrolled in an eligible employer-sponsored plan is determined
newly eligible for APTC based in part on a finding that such individual is
ineligible for qualifying coverage in an eligible- employer sponsored plan,
including as a result of their employer discontinuing or changing available
coverage within the next 60 days, provided that such individual is allowed to
terminate existing coverage.
(7) The qualified individual or enrollee, or
their dependent, gains access to new QHPs as a result of a permanent move and
(i) Had minimum essential coverage as
described in § 23.00 for one or more days during the 60 days preceding the
date of the permanent move; or
(ii)
Was living outside of the United State or in a United States territory at the
time of the permanent move; or
(iii) Meets other criteria established under
federal law. [129]
(8)
The qualified individual who is an Indian, as defined by §
4 of
the Indian Health Care Improvement Act, may enroll in a QHP or change from one
QHP to another one time per month;
(9) The qualified individual or enrollee, or
their dependent, demonstrates to AHS, in accordance with guidelines issued by
HHS, that the individual meets other exceptional circumstances, including:
(i) An individual missed their initial open
enrollment period while waiting for their employer to be determined eligible.
Under this scenario, an individual's employer is ultimately denied, or fails to
pay premiums in order to effectuate coverage on behalf of their
employees.
(ii) An individual with
a certificate of exemption is notified by HHS that they are no longer eligible
for an exemption, if the individual is otherwise eligible for enrollment in a
QHP.
(iii) An individual becomes
eligible for enrollment in a QHP that is a catastrophic plan by receiving a
certificate of exemption as described in § 23.06. The individual may only
use this special enrollment period to enroll in a catastrophic plan.
(iv) An individual whose enrollment in a QHP
has been terminated based on a citizenship or immigration status inconsistency
submits sufficient documentation of citizenship or immigration status.
[130]
(v) An eligible individual is
a victim of domestic abuse or spousal abandonment as described in §
12.03(b). This special enrollment period is available to any member of a
household who is a victim of domestic abuse, including unmarried and dependent
victims within the household, as well as victims of spousal abandonment,
including their dependents.
(e) Loss of coverage [131]
(1) Loss of coverage described in paragraph
(d)(1) of this subsection includes those circumstances described in paragraphs
(d)(1)(ii) and (iii) of this subsection and in paragraphs (3)(i) through (iii)
below. Loss of coverage does not include voluntary termination of coverage or
other loss due to:
(i) Failure to pay premiums
on a timely basis, including COBRA premiums prior to expiration of COBRA
coverage; or
(ii) Termination of an
individual's coverage for cause (which could include, but not be limited to,
termination because of an action by the individual that constituted fraud or
because the individual made an intentional misrepresentative of a material
fact). [132]
(2)
Eligibility for COBRA when the qualified individual or their dependent loses
coverage does not disqualify the individual or their dependent from a special
enrollment period under this subsection.
(3) The following conditions also qualify an
employee for a special enrollment period under (d)(1) of this subsection: [133]
(i) Loss of eligibility for coverage. In the
case of an employee or dependent who has coverage that is not COBRA
continuation coverage, the conditions are satisfied at the time the coverage is
terminated as a result of loss of eligibility. Loss of eligibility under this
paragraph does not include a loss due to the failure of the employee or
dependent to pay premiums on a timely basis or termination of coverage for
cause (such as making a fraudulent claim or an intentional misrepresentation of
a material fact in connection with the plan). Loss of eligibility for coverage
under this paragraph includes (but is not limited to):
(A) Loss of eligibility for coverage as a
result of legal separation, divorce, cessation of dependent status (such as
attaining the maximum age to be eligible as a dependent child under the plan),
death of an employee, termination of employment, reduction in the number of
hours of employment, and any loss of eligibility for coverage after a period
that is measured by reference to any of the foregoing;
(B) In the case of coverage offered through
an HMO, or other arrangement, in the individual market that does not provide
benefits to individuals who no longer reside, live or work in a service area,
loss of coverage because an individual no longer resides, lives, or works in
the service area (whether or not within the choice of the
individual);
(C) In the case of
coverage offered through an HMO, or other arrangement, in the group market that
does not provide benefits to individuals who no longer reside, live or work in
a service area, loss of coverage because an individual no longer resides, lives
or works in the service area (whether or not within the choice of the
individual), and no other benefit package is available to the individual;
and
(D) A situation in which a plan
no longer offers any benefits to the class of similarly situated individuals
[134] that includes the individual.
(ii) Termination of employer contributions.
In the case of an employee or dependent who has coverage that is not COBRA
continuation coverage, the conditions are satisfied at the time employer
contributions towards the employee's or dependent's coverage terminate.
Employer contributions include contributions by any current or former employer
that was contributing to coverage for the employee or dependent.
(iii) Exhaustion of COBRA continuation
coverage. [135] In the case of an employee or dependent who has coverage that
is COBRA continuation coverage, the conditions are satisfied at the time the
COBRA continuation coverage is exhausted. An individual who satisfies the
conditions of paragraph (e)(3)(i) of this subsection, does not enroll, and
instead elects and exhausts COBRA continuation coverage satisfies the
conditions of this paragraph.
Section 72.00 Duration of QHP Eligibility
Determinations without Enrollment. [136]
(01/15/2017, GCR 16-100)
To the extent that an individual who is determined eligible
for enrollment in a QHP does not select a QHP within their enrollment period,
or is not eligible for an enrollment period, in accordance with § 71.00,
and seeks a new enrollment period prior to the date on which their eligibility
is redetermined in accordance with § 75.00 (annual redetermination), AHS
will require the individual to attest as to whether information affecting their
eligibility has changed since their most recent eligibility determination
before determining their eligibility for a special enrollment period, and will
process any changes reported in accordance with the procedures specified in
§ 73.00 (mid-year redetermination).
Section 73.00 Eligibility Redetermination
during a Benefit Year [137]
(01/15/2017, GCR 16- 100)
Section 73.01 General requirement
(01/15/2017, GCR 16-100)
AHS must redetermine the eligibility of an individual in a
health-benefits program or for enrollment in a QHP during the benefit year if
it receives and verifies new information reported by the individual or
identifies updated information through the data matching described in §
73.04, and such new information may affect eligibility.
Section 73.02 Verification of reported
changes
(01/15/2017, GCR 16-100)
In general [138]
AHS will:
(a) Verify
any information reported by an individual in accordance with the processes
specified in §§ 53.00 through 56.00 prior to using such information
in an eligibility redetermination; and
(b) Provide periodic electronic notifications
regarding the requirements for reporting changes and an individual's
opportunity to report any changes as described in § 4.03(b), to an
individual who has elected to receive electronic notifications, unless the
individual has declined to receive notifications under this paragraph
(b).
Section 73.03
Reestablishment of annual renewal date for Medicaid enrollees [139]
(01/15/2017, GCR 16-100)
(a) If a redetermination is made during a
benefit year for a Medicaid enrollee because of a change in the individual's
circumstances and, subject to the limitation under (b) of this subsection,
there is enough information available to renew eligibility with respect to all
eligibility criteria, a new 12-month renewal period may begin.
(b) Limitation on AHS's ability to request
additional information. For renewal of a Medicaid enrollee whose financial
eligibility is determined using MAGI-based income, any requests by AHS for
additional information from the individual will be limited to information
relating to such change in circumstance.
Section 73.04 Periodic examination of data
sources [140]
(01/15/2017, GCR 16-100)
AHS will periodically examine the available data sources
described in § 56.01.
For QHP enrollees:
(a) This periodic examination will be to
identify the following changes:
(1) Death;
and
(2) For an individual on whose
behalf APTC or CSR is being provided, eligibility for Medicare or
Medicaid.
(b) AHS may
make additional efforts to identify and act on other changes that may affect an
individual's eligibility for enrollment in a health-benefits program or in a
QHP, provided that such efforts:
(1) Would
reduce the administrative costs and burdens on individuals while maintaining
accuracy and minimizing delay, and that applicable requirements with respect to
the confidentiality, disclosure, maintenance, or use of such information will
be met; and
(2) Comply with the
standards specified in § 73.05(b). [141]
Section 73.05 Redetermination and
notification of eligibility [142]
(01/15/2017, GCR 16- 100)
(a) Enrollee-reported data [143]
If AHS verifies updated information reported by an
individual, AHS will:
(1) Promptly
redetermine the individual's eligibility in accordance with eligibility
standards;
(2) Notify the
individual regarding the redetermination in accordance with the requirements
specified in § 68.00; and
(3)
Notify the individual's employer, as applicable, in accordance with §
71.01(e).
(b) Data
matching [144]
(1) For QHP enrollees:
(i) If AHS identifies updated information
regarding death, in accordance with § 73.04(a)(1), or regarding any factor
of eligibility not regarding income, family size, or family composition, AHS
will:
(A) Notify the individual regarding the
updated information, as well as the individual's projected eligibility
determination after considering such information;
(B) Allow the individual 30 days from the
date of the notice to notify AHS that such information is inaccurate;
and
(C) If the individual responds
contesting the updated information, proceed in accordance with § 57.00
(inconsistencies).
(D) If the
individual does not respond within the 30-day period, proceed in accordance
with paragraphs (a)(1) and (2) of this subsection.
(ii) If AHS identifies updated information
regarding income, family size or family composition, with the exception of
information regarding death, AHS will:
(A)
Follow procedures described in paragraphs (b)(1)(i)(A) and (B) of this
subsection; and
(B) If the
individual responds confirming the updated information, proceed in accordance
with paragraphs (a)(1) and (2) of this subsection.
(C) If the individual does not respond within
the 30-day period, maintain the individual's existing eligibility determination
without considering the updated information.
(D) If the individual provides more
up-to-date information, proceed in accordance with § 73.02.
(2) For Medicaid
enrollees, if AHS identifies updated information regarding any factor of
eligibility, AHS will proceed in accordance with the provisions of §
57.00(c).
Section
73.06 Effective dates for QHP eligibility redeterminations [145]
(01/15/2017, GCR 16-100)
(a) Except as specified in paragraphs (b)
through (e) of this subsection, AHS will implement changes for QHP eligibility
redeterminations as follows:
(1) Resulting
from a redetermination under this section, on the first day of the month
following the date of the notice described in § 73.05(a)(2); or
(2) Resulting from an appeal decision, on the
date specified in the appeal decision; or
(3) Affecting enrollment or premiums only, on
the first day of the month following the date on which AHS is notified of the
change;
(b) Except as
specified in paragraphs (c) through (e) of this subsection, AHS may determine a
reasonable point in a month after which a change described in paragraph (a) of
this subsection will not be effective until the first day of the month after
the month specified in paragraph (a). Such reasonable point in a month must be
no earlier than the 15th of the month.
(c) Except as specified in paragraphs (d) and
(e) of this subsection, AHS will implement a change described in paragraph (a)
of this subsection that results in a decreased amount of APTC or a change in
the level of CSR and for which the date of the notices described in paragraphs
(a) (1) and (2) of this subsection, or the date on which AHS is notified in
accordance with paragraph (a)(3) of this subsection is after the 15th of the
month, on the first day of the month after the month specified in (a) of this
subsection.
(d) AHS will implement
a change associated with the events described in § 71.03(b)(2)(i) and (ii)
on the coverage effective dates described in § 71.03(b)(2)(i) and (ii),
respectively.
(e) Notwithstanding
paragraphs (a) through (d) of this subsection, AHS will provide the effective
date of a change associated with the events described in § 71.03(d)(4),
(d)(5) and (d)(9) based on the specific circumstances of each
situation.
Section 73.07
Recalculation of APTC/CSR
(01/15/2017, GCR 16-100)
(a) When an eligibility redetermination in
accordance with this section results in a change in the amount of APTC for the
benefit year, AHS will recalculate the amount of APTC in such a manner as to:
(1) Account for any APTC made on behalf of
the tax filer for the benefit year for which information is available to AHS,
such that the recalculated APTC is projected to result in total advance
payments for the benefit year that correspond to the tax filer's total
projected premium tax credit for the benefit year, calculated in accordance
with § 60.00, and
(2) Ensure
that the APTC provided on the tax filer's behalf is greater than or equal to
zero and is calculated in accordance with § 60.03.
(b) When an eligibility redetermination in
accordance with this section results in a change in CSR, AHS will determine an
individual eligible for the category of CSR that corresponds to their expected
annual household income for the benefit year (subject to the special rule for
family policies under § 13.03).
Section 74.00 Reserved
(01/15/2017, GCR 16-100)
Section 75.00 Eligibility Renewal. [146]
(01/15/2017, GCR 16-100)
Section 75.01 In general
(01/15/2017, GCR 16-100)
(a) Renewal occurs annually
Except as specified in §§ 75.02(k) and 75.02(l),
eligibility of an individual in a health-benefits program or for enrollment in
a QHP will be renewed on an annual basis.
(b) Updated income and family size
information
In the case of an individual who requested an eligibility
determination for a health-benefits program (i.e., health benefits other than
enrollment in a QHP without APTC or CSR), AHS will request updated tax return
information, if the individual has authorized the request of such tax return
information, data regarding Social Security benefits, and data regarding income
(as described in § 56.01) for use in the individual's eligibility
renewal.
(c) Authorization
of the release of tax data to support annual redetermination [147]
(1) AHS must have authorization from an
individual in order to obtain updated tax return information described in
paragraph (b) of this subsection for purposes of conducting an annual
redetermination.
(2) AHS is
authorized to obtain the updated tax return information described in paragraph
(b) of this subsection for a period of no more than five years based on a
single authorization, provided that:
(i) An
individual may decline to authorize AHS to obtain updated tax return
information; or
(ii) An individual
may authorize AHS to obtain updated tax return information for fewer than five
years; and
(iii) AHS must allow an
individual to discontinue, change, or renew his or her authorization at any
time.
Section
75.02 Renewal procedures for QHP enrollment
(01/15/2017, GCR 16-100)
(a) Alternative procedures for annual
renewals
AHS will conduct annual renewals of QHPs using one of the
following:
(1) The procedures
described in this section;
(2)
Alternative procedures specified by HHS for the applicable benefit year;
or
(3) Alternative procedures
approved by HHS based on a showing by AHS that the alternative procedures would
facilitate continued enrollment in coverage for which the individual remains
eligible, provide clear information about the process to the individual
(including regarding any action by the individual necessary to obtain the most
accurate redetermination of eligibility), and provide adequate program
integrity protections.
(b) Continuation of coverage
An individual who is enrolled in a QHP and whose QHP remains
available will not be required to reapply or take other actions to renew
coverage for the following year.
(c) Notice to enrollee [148]
For renewal of an individual's eligibility for enrollment in
a QHP, AHS will provide an annual renewal notice to an individual, including
the following:
(1)
[Reserved]
(2) [Reserved]
(3) The individual's projected eligibility
determination for the following year, after considering any updated information
described in § 75.01(b), including, if applicable, the amount of any APTC
and the level of any CSR or eligibility for Medicaid.
(d) Timing [149]
(1) For renewals under this section for
coverage effective January 1, 2015, the notice provisions of paragraph (c) of
this subsection and § 71.02(d) will be satisfied through a single,
coordinated notice.
(2) For
renewals under this section for coverage effective on or after January 1, 2017,
the notice specified in paragraph (c) of this subsection may be sent separately
from the notice of annual open enrollment specified in § 71.02(d),
provided that:
(i) The notice specified in
paragraph (c) of this subsection is sent no earlier than the date of the notice
of annual open enrollment specified in § 71.02(d); and
(ii) The timing of the notice specified in
paragraph (c) of this subsection allows a reasonable amount of time for the
individual to review the notice, provide a timely response, and for any changes
in coverage elected during the AOEP to be implemented.
(e) Changes reported by enrollees
[150]
(1) An individual must report any
changes for the information listed in the notice described in paragraph (c) of
this subsection within 30 days from the date of the notice.
(2) An individual, or an application filer,
on behalf of the individual, may report changes via the channels available for
the submission of an application, as described in § 52.02(b).
(f) Verification of reported
changes [151]
Any information reported by an individual under paragraph (e)
of this subsection will be verified by AHS using the processes specified in
§§ 53.00 through 56.00, including the relevant provisi
