AGENCY OF HUMAN SERVICES
DEPARTMENT FOR CHILDREN AND FAMILIES
(DCF)
MEDICAID (M100-M970)
Section M430 Patient Share Payment for Long-Term Care,
Including Waiver and
Hospice
Services.
Section M431 Determining Residence Period for Long-Term
Care.
Section
M432 Deductions from Patient
Share.
Section M433 Determining which Provider Receives
Patient Share Payment.
Sections M434 - M439
[Reserved].
Section M440 Transfer of Income or Resources by
Individuals Requesting
Long-Term
Care
Coverage.
Section M441 - M499
[Reserved].
Section M500 Hospital
Services.
Section M501 Methods and Standards for
Reimbursement.
Section M505 Disproportionate Share
Programs.
Section M510 Inpatient
Services.
Section M511 Excluded
Services.
Section M512 Dental
Procedures.
Section M513 Psychiatric
Care.
Section M514 Care of Newborn
Child.
Section M520
Section M600 Physicians and Other Licensed
Practitioners.
Section M610 Physician
Services.
Section M611 Psychiatric
Services.
Section M612 Intestinal By-Pass Surgery for Obesity;
Gastric Stapling.
Section M613 Covered Organ and Tissue
Transplants.
Section M614 Physician
Visits.
Section M616 Sterilizations and Related Procedures.
Section
M617 Abortion.
Section
M618 Acupuncture.
Section M619 Medical and Surgical Services of a
Dentist.
Section M620 Dental Services for Beneficiaries Under
Age
21.
Section M621 Dental Services for Beneficiaries Age 21
and
Older.
Section M622 Orthodontic
Treatment.
Section M630 Podiatry
Services.
Section M640 Chiropractic
Services.
Section M650 Audiology Services/Hearing
Aids.
Section M660 Psychologists Practicing
Independently.
Section M670 Eyeglasses and Vision Care
Services.
Section M680 Nurse
Practitioners.
Section M710 Home Health Agency
Services.
Section M711 Payment
Conditions.
Section M715 Hospice
Services.
Section M720 Clinic
Services.
Section M721 Mental Health
Clinics.
Section M722 Indian Health Service
Facilities.
Section M723 Rural Health
Clinics.
Section
M730 Laboratory and Radiology
Services.
Section M740 Personal Care
Services.
Section M750 Ambulance
Services.
Section
M751 Reimbursement.
Section
M755 Transportation.
Section M760 Planned Parenthood of
Section M770 Early and Periodic Screening, Diagnosis
and Treatment (EPDST)
Services.
Section
M771 Informing.
Section M772 Screening and
Outreach.
Section M773 Corrective
Treatment.
Section M774 Rates of
Payment.
Section M781 Private Non-Medical
Institutions.
Section M800 Drugs and
Pharmaceutical Items, Medical Supplies and Equipment.
Section M801 Beneficiaries Eligible for Medicaid and
Medicare.
Section M810 Prescribed
Drugs.
Section M811 Smoking Cessation
Products.
Section M812 Family Planning
Items.
Section M813 Payment Conditions.
Section M820 Whole
Blood.
Section M830 Medical
Supplies.
Section M840 Durable
Medical Equipment
(DME).
Section M841 Wheelchairs, Mobility Devices and Seating
Systems.
Section M842 Augmentative Communication
Devices/Systems.
Section M843 Prosthetics
Devices.
Section M900 Long-Term Care
Institutions.
Section
M901 Definitions.
Section M902 Medical Review Systems.
Section M910 Per Diem Rates and Payment
Conditions.
Section M920 Daily Care Services - All Long-Term Care
Facilities.
Section M930 Duration of Coverage (All Long-Term Care
Facilities).
Section M940 Patient
Classifications.
Section M950 Reconsideration, Appeal of Fair Hearing -
Client Requests.
Section M960 Denial or Termination of Provider
Agreement.
Section M970 Level I and Level II Care in Vermont
General Hospitals.
Section M100 General Description - Medicaid Program.
Medicaid is a federal-state program of financial help with the
cost of medical care.
Medicaid covers most, but not all, medically necessary medical
care and services provided to eligible individuals (see sections M500-M999 for
covered services). In order to receive federal financial participation in
program expenditures, the state must provide coverage to certain mandated
categories of beneficiaries [42 U.S.C. § 1396a(a)(10)(A)] and offer
specified categories of medical services [42 U.S.C. § 1396a(a)(10)]. At state
option, additional categories of beneficiaries may be covered or services can
be offered, for which federal financial participation is also available.
Services are provided through fee-for-service and managed health care delivery
systems as described in section M103. The
In order to obtain federal financial participation in the Vermont
program, a state plan must be filed with and approved by Health Care Financing
Administration (HCFA) (42 U.S.C. § 1396a). Among other things, the plan
describes the amount, duration and score of services included in the
The scope of coverage for
children under the Early Periodic Screening, Diagnosis and Treatment (EPSDT)
provisions or 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,
...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. 42 U.S.C. § 1396d(r) (5).
A further definition of the scope of
EPSDT services is found in 42 C.F.R. § 1396d(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.
Medicaid is provided to pregnant women, individuals age 20 or
younger, parents or caretaker relatives of a dependent child, and aged, blind
or disabled individuals, as long as the individual meets general and financial
eligibility criteria and has, if required of him/her:
• assigned rights to any medical support and other payments for
medical care;
• cooperated with the department in establishing paternity;
• enrolled in a group health plan if the department has determined
this would be cost-effective; and
• declared, under penalty of perjury, that he/she is a citizen or
national of the United States or a non-citizen qualified to participate in the
Medicaid program (see sections on Citizenship).
Most individuals who are eligible for and receiving Supplemental
Security Income (SSI/AABD) benefits or who meet the
Irrevocable trusts are not counted in the SSI program or under the
Individuals receiving essential person grants and the essential
persons for whom the state-funded AABD-EP benefits are paid are not
automatically eligible and must meet all eligibility criteria before being
granted Medicaid.
Section M101 Purpose - Medicaid Program.
Medicaid was established as a result of amendments in 1965 that
added Title XIX to the Social Security Act. It is a program administered within
a federal - state regulatory framework. The first statutory section of Title
XIX. 42 U.S.C. § 1396. "Appropriation." states:
For the purpose of enabling each State, as far as practicable,
under the conditions in such State, to furnish (1) medical assistance on behalf
of families with dependent children and of aged, blind, or disabled
individuals, whose income and resources are
insufficient to meet the costs of necessary medical services, and (2)
rehabilitation and other services to help such families and beneficiaries
attain or retain the capability for independence and self-care, there is hereby
authorized to be appropriated for each fiscal year a sum sufficient to carry
out the purposes of this subchapter. The sums made available under this section
shall be used for making payments to States which have submitted, and had approved
by the Secretary. State plans for medical assistance.
M101.1 Purpose -
The Vermont Health Access Plan (VHAP) operates as a Research and
Demonstration Project authorized under Section 1115(a) of the Social Security
Act. This program permits federal financial participation in health benefit
coverage to low-income, previously uninsured
The department may, by rule, impose additional limitations on
coverage of services or items for expansion populations included in the waiver
for the effective and efficient administration of the program, consistent with
state and federal law and waiver terms and conditions.
Section M102 Eligibility and Enrollment Process.
The eligibility and enrollment process includes the steps an
individual requesting health care assistance and the department must take to
determine an individual's eligibility for and enrollment in health care assistance
programs.
Eligible means the department has decided the individual meets all
the eligibility criteria specific to the coverage group such as age, residency,
and income level.
Enrolled means the department has
received full payment of required premiums for the individual who has been
determined to meet all eligibility criteria specific to the coverage group.
Enrolled individuals are health care assistance beneficiaries. Coverage begins
the first day of the month after receipt of any required premiums, unless
retroactive coverage provisions apply as in rule M113.
The person (or group) must:
• apply for health care assistance,
• give necessary facts about their (or their family's) situation
for the eligibility tests, and
• pay any required premium by the due date.
The department must:
• accept all health care assistance applications and premium
payments,
• compare the facts of the
individual's situation to the health care assistance eligibility rules,
• make decisions on initial and continuing eligibility for health
care assistance,
• notify the individual of its decisions, and
• keep records of decisions and the facts used to make them.
Rules and time limits for these steps are given in M110-M149.
M102.1 Premiums.
Certain health care assistance groups are required to pay a
monthly premium as a condition of initial and continuing coverage. The amount
of the premium depends on the net income of the assistance group on the most
recent approved version of eligibility on the case record at the time the bill
is generated, and for some coverage groups, the existence of other insurance
that includes both hospital and physician coverage.
Failure to pay the full premium
by the last day of the month shall result in disenrollment.
The premium payment system is described in M150 through M150.2.
Section M103 Benefit Delivery Systems.
Eligible beneficiaries receive covered services through either the
fee-for-service or a managed health care delivery system. Most beneficiaries
are required to receive covered services through a managed health care delivery
system. The following beneficiaries are exempt from managed health care
enrollment and will receive covered services through the fee-for-service
delivery system:
a) home and community-based
waiver beneficiaries;
b) beneficiaries living in
long-term care facilities, including ICF/MRs;
c) beneficiaries who are
receiving hospice care when they are found eligible for Medicaid;
d) children under age 21 enrolled in the high-tech home care
program;
e) beneficiaries who have private
health insurance that includes both hospital and physician services or
beneficiaries who have Medicare (Parts A and/or B);
f) beneficiaries who meet a
spend-down who are not enrolled in a VHAP managed health care plan; and
g) beneficiaries whose
requirement to enroll in a managed health care delivery system is anticipated
to last for three or fewer months based on known changes, such as imminent
Medicare eligibility.
If the beneficiary is not exempt under subsections a-g above, he
or she will be required to receive covered services through a managed health
care delivery system.
Choice Options for Beneficiaries Subject to the Managed Health
Care Delivery System Requirement
Options 1 through 4 below apply to beneficiaries who belong to a
category of beneficiaries to whom one or more commercial managed care plans
have a contractual obligation to offer plan
enrollment
Option 1 - When the beneficiary belongs to a category of
beneficiaries for whom two or more commercial managed care plans have a
contractual obligation to offer plan enrollment and the beneficiary resides in
a geographic area in which two or more commercial managed care plans have the
capacity to accept new plan enrollees, the beneficiary's choice is enrollment
in one of the two or more commercial managed care plans available.
NOTE: The standards the department uses to determine the
geographic area that a managed health care plan serves are defined in the
Welfare Procedures Manual at P-2443; these standards are in accordance with
federal standards for access to care and the Department of Banking, Insurance,
Securities and Health Care Administration's Rule 10.
Option 2 - When the beneficiary belongs to a category of
beneficiaries for whom one or more commercial managed care plans have a
contractual obligation to offer plan enrollment, the beneficiary resides in a
geographic area in which only one commercial managed care plan has the capacity
to accept new plan enrollees, and the beneficiary's city or town of residence
is served by two or more PCCM providers who are available, accessible, and
appropriate, the beneficiary's choice is between enrollment in the one
commercial managed care plan available or enrollment
in the PCCM program. This option is subject to approval by the Health Care
Financing Administration.
Option 3 - When the beneficiary belongs to a category of
beneficiaries for whom one or more commercial managed care plans have a
contractual obligation to offer plan enrollment and all commercial managed care
plans lack the capacity to accept new plan enrollees, and the beneficiary's
city or town of residence is served by two or more PCCM providers who are
available, accessible, and appropriate, the beneficiary's choice is to enroll
in the PCCM program. This option is subject to approval by the Health Care
Financing Administration.
Option 4 - When the beneficiary belongs to a category of beneficiaries
for whom one or more commercial managed care plans have a contractual
obligation to offer plan enrollment and all commercial managed care plans lack
the capacity to accept new plan enrollees, and the beneficiary's city or town
of residence is served by only one PCCM provider who is available, accessible,
and appropriate, the beneficiary's choice is to select the PCCM program or
choose to receive services through the fee-for-service system. This option is
subject to approval by the Health Care Financing Administession.
Options 5 and 6 below apply to beneficiaries who belong to a
category of beneficiaries for whom
enrollment in a commercial managed care plan is not available due to absence of
a plan that has a contractual obligation to offer plan enrollment to this
category of beneficiaries
Option 5 - When the beneficiary's city or town of residence is
served by two or more PCCM providers who are available, accessible, and
appropriate, the beneficiary's choice is to enroll in the PCCM program. This
option is subject to approval by the Health Care Financing Administration.
Option 6 - When the beneficiary's city or town of residence is
served by only one PCCM provider who is available, accessible, and appropriate,
the beneficiary's choice is to enroll in the PCCM program or choose to receive
services through the fee-for-service system. This option is subject to approval
by the Health Care Financing Administration.
When none of the above options applies, the beneficiary receives
Medicaid-covered services through the fee for service system.
A benefit counselor will assist
beneficiaries in making an informed choice among available managed health care
delivery system options. When enrollment in a managed care delivery system is
not mandatory, a benefits counselor will assist
beneficiaries in making an informed choice between enrolling in a managed
health care delivery system or remaining in the fee-for-service system.
M103.1 Fee-For-Service System.
Payment is made using a fee-for-service reimbursement system for:
• services furnished to beneficiaries not required to enroll in
managed health care plans who are ineligible for voluntary enrollment,
• services furnished to beneficiaries who are eligible for
voluntary enrollment and have chosen not to enroll,
• certain wrap-around and other services not included in the
contracts with managed health care plans, and
• services furnished to beneficiaries during retroactive periods
of eligibility or prior to enrollment in managed health care plans.
This process includes the following steps the department, the
eligible Medicaid beneficiary and the medical care provider must take for the
provider to receive payment for services
given to the beneficiary.
The department must:
• give each Medicaid eligible person an identification document
showing that the person has been found eligible for Medicaid,
• accept and process all provider claims itself or through its
administrative agent, and
• notify providers of decisions on claims and pay approved claims.
The beneficiary must:
• tell the provider he or she wants the provider's services
charged to Medicaid,
• advise the provider if he or she has private health insurance
coverage in addition to Medicaid,
• accept liability for any applicable co-payment (see Obligation
of Receipts), and
• show the provider his or her identification document if it has
been issued.
The provider must:
• verify that the individual is still eligible for Medicaid on the
date the service is provided,
• bill any other liable third parties prior to billing Medicaid,
• accept the Medicaid payment rate as payment in full and bill the
beneficiary only for any applicable co-payments once Medicaid has been accepted
as a source of payment,
• give a Medicaid covered service (see sections M500-M999), and
• file a claim with the department or its agent, including all
necessary information about the service and the identifying information from
the beneficiary's identification document.
Rules and time limits for these
steps are given in sections M150-M159 and M500- M599.
M103.2 Managed Health Care Plan System.
Under a managed health care plan, a per-person payment for a
defined array of services is made to the plan each month for each enrolled
member.
Upon enrollment, managed health care plans shall provide their
members with handbooks that include information such as the following:
• what services are covered and how to access those services;
• the procedures for changing primary care providers;
• the procedures for obtaining specialty referrals;
• services that do not require a primary care provider referral;
• services that are covered as wrap-around benefits;
• appointment procedures and
information on what to do in a medical emergency;
• information about member rights and responsibilities;
• information on how to register a complaint or file a formal
grievance with the plan.
A. Managed Health Care Plan
Services
Medicaid beneficiaries enrolled in managed health care plans are
eligible for the same range of medically necessary services as those
beneficiaries in the fee-for-service system.
1. Services
Requiring Plan Referral
The following services as defined in the State Plan and by
regulation are included in the monthly payments made to the managed health care
plans subject to negotiated contract provisions and must be accessed through
the beneficiary's primary care provider (Medicaid regulatory citations are
indicated where applicable):
• outpatient services in a general hospital or ambulatory surgical
center (M520);
• physician services (M600-M618);
• medical and surgical services of a dentist (M619);
• covered organ and tissue transplants, including expenses related
to providing the organ or doing a donor search (M613);
• home health care (M710);
• hospice services by a Medicare-certified hospice provider
(M715);
• outpatient therapy services (home infusion therapies and
occupational, physical, speech and nutrition therapy) (M520, M710);
• prenatal and maternity care (M510, M600);
• medical
equipment and supplies (M830, M840);
• skilled nursing facility services for up to 30 days length of
stay per episode (M900);
• mental health and chemical dependency services (M721);
NOTE: If a participating managed health care plan has a contract
with an institution for mental diseases, services are limited to 30 days per
episode and 60 days per calendar year.
• podiatry services (M630);
The following services are also included in the monthly payments
made to the health plans, but may be accessed by health plan enrollees from the
plan's network providers without a referral from their primary care provider:
• unlimited visits per calendar year to a network gynecological
health care provider for reproductive or gynecological care, as well as visits
related to follow-up care for problems identified during such visits;
• one mental
health and chemical dependency visit (plans may determine the number of visits
beyond the initial visit that can be provided before authorization is required
from the plan's mental health and substance abuse intake coordinator, or
primary care physician); and
• one routine eye examination every 24 months (M670).
Medicaid beneficiaries enrolled in managed health care plans are
eligible to receive additional services as defined in the State Plan and by
regulation that are not included in the managed health care plan package. Some
of these services do not require a referral from the beneficiary's primary care
provider and are reimbursed on a fee-for-service basis. Examples of these
services are:
• transportation services (M755);
• dental care for children under age 21 (M620) and limited dental
services for adults up to the annual benefit maximum (M621);
• eyeglasses for children under
age 21 furnished through the department's sole source contractor (M670);
• chiropractic services for children under age 21 (M640);
• family planning services (defined as those services that either
prevent or delay pregnancy);
• personal care services (M740); and
• prescription drugs and over-the-counter drugs prescribed by a
physician for a specific disease or medical condition (M810-M812).
ANFC-related Medicaid beneficiaries age 21 and older and
SSI-related Medicaid beneficiaries age 18 and older enrolled in a managed
health care plan are subject to the following co-payment requirements, unless
exempt under M150.1(B):
• $ 75.00 for the first day of an inpatient hospital stay in a
general hospital.
• $ 3.00 per day per hospital for hospital outpatient services
unless the individual is also covered by Medicare. An individual covered by
Medicare has no co-payment requirement for outpatient services.
Medicaid beneficiaries age 21 and older enrolled in a managed
health care plan are subject to the following co-payment requirements, unless
exempt under M150.1(B):
• $ 3.00 for each dental visit.
• Prescriptions:
• $ 1.00 for each prescription, original or refill, having a usual
and customary charge of $ 29.99 or less;
• $ 2.00 for each prescription, original or refill, having a usual
and customary charge of more than $ 30.00 but less than $ 50.00;
• $ 3.00 for each prescription, original or refill, having a usual
and customary charge of $ 50.00 or more.
D. Enrollment
1. Choice of
Managed Health Care Delivery System
a. When
beneficiaries are required to enroll in a managed health care plan (M103 Option 1), a benefit counselor will
assist beneficiaries in making an informed choice among available managed
health care plan options. The benefits counselor will initiate a follow-up
contact with an individual who has failed to notify the benefits counselor of
his or her decision of a plan and will provide additional information if
requested to do so. If no choice has been made within 30 days of being
contacted, the benefits counselor will assign the individual to a managed care
plan using a state-approved algorithm.
1. All eligible
members of a Medicaid group are expected to select the same managed health care
plan, except when it creates a hardship or a different plan is indicated for
medical reasons. The department reserves the right to determine, in these
specific cases, when enrollment in a different managed health care plan is
indicated.
2. Beneficiaries enrolled in managed health care plans will be
required to select a primary care provider (PCP) from among the plan's network
of providers. The benefits counselor will provide beneficiaries with
information about each plan's provider network so that they may select a PCP at
the time of enrollment or when contacted by the plan. A beneficiary who fails
to select a PCP will have one assigned by the plan. Once assigned, individuals
may make subsequent changes in their PCP every 30 days with fifteen days notice
to the managed health care plan. An individual's stated preference is
contingent upon the availability of the chosen PCP.
b. When
beneficiaries are required to enroll in a managed health care plan or the PCCM
program (M103 Options 2 and 3), a benefit counselor will assist beneficiaries
in making an informed choice among available managed health care plans and the
PCCM program. The benefits counselor will initiate a follow-up contact with an
individual who has failed to notify the benefits counselor of his or her
decision to enroll in a plan or the PCCM program and will provide additional
information if requested to do so. If no choice has been made within 30 days of
being contacted, the benefits counselor will assign the individual to a managed
care plan or the PCCM program and a PCCM provider using a state-approved
algorithm.
2. Change of Managed Health Care Plan
Enrollees may change their choice of managed health care plan for
any reason within 30 days of the effective date of coverage under a plan.
Members may change plans once per year thereafter, and at other times for good
cause. Good cause is limited to the following circumstances:
• The individual notifies the department of a change in his or her
place of residence and, as a result, is outside the service area of the plan.
• The department has found that there is a rational and
justifiable reason for determining that good cause exists, or, upon appeal, the
Human Services Board finds good cause exists.
Managed health care plan changes will become effective on the
first day of the following month, if all required actions have been completed
on or before the 15th day of the prior month. Otherwise, the change shall
become effective the first of the second month after all required actions are
completed.
At least 30 days prior to the anniversary date, enrollees will
receive a notice of their opportunity to renew their enrollment with their
current managed health care plan or to
choose another plan. Information about the plan options and assistance
available in making a selection will be included in the notice.
In rare instances it may become necessary to pursue disenrollment
of individuals who are intentionally unresponsive to basic managed care
expectations. The following may be disenrolled:
• Individuals who pose a threat to plan employees or other
members.
• Individuals who regularly fail to arrive for scheduled
appointments without canceling, despite documented aggressive outreach efforts
by the managed health care plan.
• Individuals who do not cooperate with treatment and have not
made an affirmative decision to refuse treatment, despite documented aggressive
outreach efforts by the plan.
Grounds for disenrollment does not include individuals who have
cooperated with the plan in its effort to inform them fully of the treatment
options and the consequences of their
decisions regarding treatment and who have subsequently made an informed
decision to refuse treatment.
Plan disenrollment requests must conform to criteria for
disenrollment established by the department. Managed health care plans must
notify the affected member, or his or her designated representative, in
writing, of a plan-initiated request for disenrollment. Only the department may
disenroll a member from a managed health care plan.
Individuals remain in the managed health care plan until the
department decides to disenroll the individual. Individuals are notified of
this decision in writing and of their right to request a fair hearing before
the Human Services Board. Medicaid beneficiaries who are disenrolled, unless
enrolled in another managed health care plan or the PCCM program immediately
thereafter, will receive services through the traditional fee-for-service system.
An individual not enrolled in a Medicaid managed health care plan
who joins a Medicaid group will be enrolled in the head of household's managed
health care plan. An individual already enrolled in a managed health care plan
who joins another Medicaid group will remain
in his or her current health plan until the next review. Subsequent changes in
managed health care plan enrollment may be made in accordance with provisions
under Change of Managed Health Care Plan.
E. Appeals of Managed Health Care Plan Decisions
Beneficiaries enrolled in managed health care plans have the right
to appeal medical care decisions made by the managed health care plans based on
medical/clinical necessity determinations. Although the medical director of the
managed health care plan will make medical/clinical determinations, the
department retains the authority to review and affirm or deny such
determinations made by the managed care plans.
Beneficiaries first must seek remedy of a medical care decision
through the managed health care plan's formal grievance process. The managed
health care plan may take up to 15 days to seek resolution of a complaint
related to medical care and must address issues in fewer than 15 days if
warranted by the patient's condition. Plans may take up to 30 days to seek
resolution of a complaint not related to medical care. The decision of the
managed health care plan shall be in writing and shall be sent to the
beneficiary and to the department.
If a beneficiary disagrees with
the decision resulting from the managed health care plan's grievance process,
he or she may request a fair hearing.
A managed health
care plan must provide a service if it is determined medically/clinically
necessary by the department.
M103.3 Primary Care Case Management Program.
The primary care case management (PCCM) program is a managed
health care service delivery system that requires a beneficiary to choose a
primary care provider (PCP) and to access specified medical care through this
provider. The primary care provider (PCP) will provide and coordinate medical
care for the beneficiary through direct service delivery or by making
appropriate referrals to other providers for necessary services.
Payments are made to providers using the fee-for-service
reimbursement method.
For beneficiaries enrolled in the PCCM program specialty services
require referral, unless the service is designated as a self-referral service.
See M103.3(D).
1. "Adverse
determination" means a determination by the department that an admission,
availability of care, continued stay or other health care service has been
reviewed and, based upon the information provided, does not meet the
department's requirements for medical necessity, appropriateness, health care
setting, level of care or effectiveness, and the requested service is therefore
denied, reduced or terminated.
2. "Ambulatory review"
means utilization review of health care services performed or provided in an
outpatient setting.
3. "Case management"
means a coordinated set of activities conducted for individual patient
management of serious, complicated, protracted or other health conditions.
4. "Certification"
means a determination by the department or its designated utilization review
organization that an admission, availability of care, continued stay or other
health care service has been reviewed and, based on the information provided,
satisfies the department's requirements for medical necessity, appropriateness, health care
setting, level and intensity of care and effectiveness.
5. "Clinical peer"
means a health care provider who holds a non-restricted license in a state of
the
6. "Clinical review
criteria" means the written screening procedures, decision abstracts,
clinical protocols, practice guidelines and utilization management and review
guidelines used by the department to determine the necessity and appropriateness
of health care services.
7. "Commissioner" means
the Commissioner of the Vermont Department of Social Welfare.
8. "Concurrent review"
means utilization review conducted during a beneficiary's hospital stay or
course of treatment.
9. "Confidentiality
code" means the confidentiality requirements applicable to the department
under state and federal law.
10. "Credentialing verification" means the process of
obtaining and verifying information about a health care provider sufficient to
determine if the provider can be enrolled as a participating provider in the
Medicaid program.
11. "Department" means
the Department of Social Welfare.
12. "Discharge
planning" means the formal process for determining, before discharge from
a health care facility, the coordination and management of the care that a
beneficiary will receive following the discharge.
13. "Emergency medical
condition" means the sudden and, at the time, unexpected onset of an
illness or medical condition that manifests itself by symptoms of sufficient
severity, including severe pain, that the absence of immediate medical attention
could reasonably be expected by the prudent layperson, who possess an average
knowledge of health and medicine, to result in:
a. placing the
member's physical or mental health in serious jeopardy; or
b. serious
impairment to bodily functions; or
c. serious dysfunction of any bodily organ or part.
14. "Emergency
services" means health care items and services furnished or required to
evaluate and treat an emergency medical condition.
15. "Grievance" means a
written or oral complaint submitted by or on behalf of a beneficiary regarding
the:
a. availability,
delivery or quality of health care services; or
b. claims
payment, handling or reimbursement for health care services.
16. "Gynecological health
care services" means preventive and routine reproductive health and
gynecological care, including annual screening, counseling, and treatment of
gynecological disorders and diseases in accordance with the most current
published recommendations of the
17. "Gynecological health
care provider" means a health care provider or health care facility that
is primarily engaged in providing gynecological health care services.
18. "Health care provider" or "provider" means
a person, partnership or corporation, other than a facility or institution,
licensed or certified or authorized by law to provide professional health care
service to an individual during that individual's medical care, treatment or
confinement.
19. "Health care
facility" means all facilities and institutions, whether public or
private, proprietary or nonprofit, that offer diagnosis, treatment, inpatient
or ambulatory care to two or more unrelated persons. The term shall not apply
to any facility operated by religious groups relying solely on spiritual means
through prayer or healing, but includes all facilities and institutions
included in 18 V.S.A. § 9432(10).
20. "Health care
services" or "services" means services for the diagnosis, prevention,
treatment, cure or relief of a health condition, illness, injury or disease.
21. "Medical director"
means a health care provider who is board-certified or board-eligible in his or
her field of specialty and who is charged by the department with responsibility
for overseeing all clinical activities of the PCCM program, or his or her
designee.
22. "Medically-necessary care" is defined at M107.
23. "Network" means all
providers participating in Medicaid who have also agreed to act as the primary
care provider (PCP) for one or more beneficiary.
24. "Peer review
committee" means a committee as defined in 26 V.S.A. § 1441, and for
purposes of this rule includes any committee established by the department pursuant
to 18 V.S.A. § 9414(c)(1) and 10.202(G)(1) of this rule.
25. "Person" means a
natural person, partnership, unincorporated association, corporation, limited
liability company, municipality, the state of
26. "Primary care provider"
is defined at M103.3 (B).
27. "Primary care
services" include services provided by providers specifically trained for
and skilled in first-contact and continuing care for persons with undiagnosed
signs, symptoms or health concerns, not limited by problem origin (biological,
behavioral or social), organ system or diagnosis. Primary care services include health promotion, disease
prevention, health maintenance, counseling, patient education, case management,
and the diagnosis and treatment of acute and chronic illnesses in a variety of
health care settings.
28. "Prospective
review" or "prior authorization" means utilization review conducted
before an admission or a course of treatment. (See also M106.)
29. "Quality assurance
program" means a set of procedures and activities designed to safeguard or
improve the quality of medical care by assessing the quality of care or
service, usually against a set of established standards, and taking action to
improve it.
30. "Quality
improvement" means the effort to improve the level of performance of and
outcomes of treatment delivered to beneficiaries. Opportunities to improve care
and service are found primarily by continual examination of, and continual
feedback and education about how services are provided.
31. "Quality of care"
means the degree to which health care services for individuals and populations
increase the likelihood of desired health outcomes, decrease the probability of
undesired health outcomes, and are consistent with current professional
knowledge.
32. "Referral" means that a PCP has authorized that a
beneficiary should have one or more appointments with a health care provider
for consultation, diagnosis, or treatment of a medical condition, to be covered
as a benefit.
33. "Retrospective
review" means utilization review of medical necessity that is conducted
after services have been provided to a beneficiary, but does not include the
review of a claim that is limited to an evaluation of reimbursement levels, veracity
of documentation, accuracy of coding or adjudication for payment.
34. "Second opinion"
means an opportunity or requirement to obtain a clinical evaluation by a
provider other than the one originally making a recommendation for a proposed
health care service to assess the clinical necessity and appropriateness of the
proposed service.
35. "Secondary
verification" means verification of a health professional's credentials
based on evidence obtained by means other than direct contact with the issuing
source of the credential (e.g., copies of certificates provided by the applying
health professional).
36. "Stabilized" means, with respect to an emergency
medical condition, that no material deterioration of the condition is likely,
within reasonable medical probability, to result or occur before a beneficiary
can be transferred.
37. "Urgently-needed
care" or "urgent care" means those health care services that are
necessary to treat a condition or illness of an individual that if not treated
within twenty-four (24) hours presents a serious risk of harm.
38. "Utilization
management" means the set of organizational functions and related
policies, procedures, criteria, standards, protocols and measures used by the department
to ensure that it is appropriately managing access to and the quality and cost
of health care services provided to its beneficiaries.
39. "Utilization
review" means a set of formal techniques designed to monitor the use of,
or evaluate the clinical necessity, appropriateness, efficacy, or efficiency
of, health care services, procedures, or settings. Techniques may include
ambulatory review, prior authorization, second opinion, certification,
concurrent review, case management, discharge planning or retrospective review.
40. "Utilization review
guidelines" mean the normative standards for resource utilization for
various clinical conditions and medical services that are used by the department in deciding whether to
approve or deny health care services.
41. "Utilization review
organization" means an entity that conducts utilization review, other than
the department performing a review for its own beneficiaries.
B. Primary Care
Provider (PCP)
Under this system a payment is made to the primary care provider
(PCP) each month for case management services provided to each beneficiary
enrolled with the PCP. Family practitioners, general internists, pediatricians,
or doctors of general medicine, that are enrolled with Vermont Medicaid may
become a PCP in the PCCM program. Specialists may become a PCP only under the
conditions described below. The PCP selected by a beneficiary shall coordinate
needed medical services. PCPs will be responsible for providing beneficiaries
with referrals to specialists when in their judgment it is considered medically
necessary; for coordinating all ancillary, outpatient and inpatient services;
and for preventing the duplication of services.
If a beneficiary has either a life-threatening condition or
disease, or a degenerative or disabling condition or disease, that requires
specialized medical care over a prolonged
period of time, a specialist with expertise in treating the condition or
disease may act as the beneficiary's PCP. If a specialist agrees to act as the
PCP, the specialist shall provide and coordinate medical care for the
beneficiary through direct service delivery or by making appropriate referrals
to other providers for necessary services. The OVHA medical director must
review and approve of such arrangements before a specialist may become the PCP.
If the request is denied by OVHA, the beneficiary has the right to appeal
OVHA's decision and to request a fair hearing.
C. Services
Requiring a PCP's Referral
The following services must be accessed through the beneficiary's
PCP and are subject to the department's prior authorization requirements.
Services requiring prior authorization are found in the Provider Manual.
(Medicaid regulatory citations are indicated where applicable):
• inpatient services (M510);
• outpatient services in a general hospital or ambulatory surgical
center (M520);
• physician
services (M600-M618);
• specialty medical and surgical services of a dentist (M619);
• covered organ and tissue transplants, including expenses related
to providing the organ or doing a donor search (M613);
• home health care (M710);
• hospice services by a Medicare-certified hospice provider
(M715);
• outpatient therapy services (home infusion therapies and
occupational, physical, speech and nutrition therapy) (M520, M710);
• medical equipment and supplies (M830, M840);
• skilled nursing facility services (M900);
• podiatry services (M630);
The following services may be accessed by beneficiaries without a
referral from their primary care provider (PCP):
• unlimited visits per calendar year to a PCCM gynecological
health care provider for reproductive or gynecological care, as well as visits
related to follow-up care for problems identified during such visits;
• mental health and chemical dependency visits up to benefits of $
500 per year. Thereafter, providers must request prior authorization from the
department for additional services;
• mental health and chemical dependency services provided by a
community mental health center;
• Community Rehabilitation and Treatment Services (CRT);
• one routine eye examination every 24 months (M670) and
eyeglasses for children under age 21 furnished through the department's sole
source contractor (M670);
• transportation
services (M755);
• emergency services(M106.4);
• dental care for children under age 21 (M620) and limited dental
services for adults up to an annual benefit maximum (M621);
• chiropractic services for children under age 21 (M640);
• maternity/prenatal (M510, M600);
• family planning services (defined as those services that either
prevent or delay pregnancy); and
• personal care services (M740).
ANFC-related Medicaid beneficiaries age 21 and older and
SSI-related Medicaid beneficiaries age 18 and older enrolled in a PCCM are
subject to the following copayment
requirements, unless exempt under M150.1(B):
• $ 75.00 for the first day of an inpatient hospital stay in a
general hospital.
• $ 3.00 per day per hospital for hospital outpatient services
unless the individual is also covered by Medicare. An individual covered by
Medicare has no copayment requirement for outpatient services.
Medicaid beneficiaries age 21 and older enrolled in a PCCM are
subject to the following copayment requirements, unless exempt under M150.1(B):
• $ 3.00 for each dental visit.
• Prescriptions:
• $ 1.00 for each prescription, original or refill, having a usual
and customary charge of $ 29.99 or less;
• $ 2.00 for each prescription, original or refill, having a usual
and customary charge of more than $ 30.00 but less than $ 50.00;
• $ 3.00 for
each prescription, original or refill, having a usual and customary charge of $
50.00 or more.
F. Enrollment
1. Choice of Primary Care
Provider (PCP)
A benefits
counselor will assist beneficiaries in making an informed decision among the
choices described in M103, Options 5 and 6.
The benefits counselor will initiate a follow-up contact with an
individual who has failed to notify the benefits counselor of his or her
decision and will provide additional information if requested to do so. If two
or more PCCM PCPs are available and no choice has been made within 30 days of
being contacted, the benefits counselor will assign the individual to a PCP
using a state-approved algorithm.
2. Change of Primary Care
Provider (PCP)
Enrollees may change their primary care provider (PCP) for any
reason every 30 days. Primary care provider
changes will become effective on the first day of the following month, if all
required actions have been completed by the fifteenth of the prior month.
Otherwise, the change shall become effective the first of the second month
after all required actions are completed.
If a beneficiary has to change PCP as a result of his or her PCP
restricting or terminating participation in the PCCM program, the department
will assist the beneficiary in selecting another PCP in order to assure
continuity of care.
The department has sole authority for disenrolling beneficiaries
from the PCCM program. The department may disenroll beneficiaries from the PCCM
program for any of the following reasons:
• The beneficiary loses Medicaid eligibility;
• The beneficiary fails to pay required premiums;
• The beneficiary is placed in a nursing facility or ICF-MR for
more than thirty (30) days, enrolls in any other state waiver program, enrolls
in the department's "High Tech Home
Care" program, or enrolls in Medicare or other comprehensive health
insurance plan;
• The beneficiary's change of residence places him or her outside
the area where choice of PCCM provider is available, and the beneficiary
chooses not to continue enrollment in the PCCM program;
• The department has found that there is a rational and
justifiable reason for determining that good cause exists, or upon appeal, the
Human Services Board finds good cause exists, as the result of a formal request
for disenrollment filed by the beneficiary;
• The department has found that there is a rational and
justifiable reason for determining that good cause for disenrollment or
transfer to another PCCM provider exists, as the result of a formal request for
disenrollment filed with the department by the beneficiary's PCP;
• The department has found that there is a rational and
justifiable reason for determining that good cause exists, or, upon appeal, the
Human Services Board finds good cause exists; or
• The beneficiary poses a threat
to PCCM providers, staff or other beneficiaries.
• The beneficiary regularly fails to arrive for scheduled
appointments without canceling, despite documented aggressive outreach efforts
by his or her PCP; and
• The beneficiary does not cooperate with treatment and has not
made an affirmative decision to refuse treatment, despite documented aggressive
outreach efforts by their PCP.
Grounds for disenrollment do not include beneficiaries who have
cooperated with their PCP in his/her effort to inform them fully of the
treatment options and the consequences of their decisions regarding treatment
and who have subsequently made an informed decision to refuse treatment.
The beneficiary will remain enrolled in the PCCM program until the
department decides to disenroll or continue the enrollment of the beneficiary.
Each beneficiary will be notified of the department's decision in writing and
of his/her right to request a fair hearing before the Human Services Board.
Beneficiary disenrollments will become effective on an end-of-month basis, but not fewer than five (5) days after the
department has made a determination that the beneficiary will be disenrolled.
Individuals who are disenrolled, unless enrolled in a managed
health care plan immediately thereafter, will receive services through the
fee-for-service system.
4. Conversion of Managed Care
Plan Enrollees to the PCCM program
If a beneficiary's delivery system is changed from a commercial
managed care plan to the PCCM program, the beneficiary will be assigned to his
or her existing PCP. Thereafter, the beneficiary may change his or her PCP
according to the provisions of M103.3 F.2.
If the managed care plan member's PCP does not participate as a
PCP in the PCCM program, the beneficiary will receive covered benefits in the
fee-for-service system. The beneficiary's subsequent enrollment in the PCCM
program will be deferred for at least six months beyond the date of disenrollment
from the managed care plan. The department will make every effort to enroll the
beneficiary's provider in the PCCM program prior to the expiration of the
enrollment deferral period.
G. Quality Assurance and Utilization
Review
1. The department shall ensure
that health care services provided to its beneficiaries are consistent with
prevailing professionally-recognized standards of medical practice. To that
end, the department shall establish and implement procedures ensuring the
availability of, accessibility to and continuity of care for each beneficiary
consistent with the beneficiary's clinical condition, including procedures for
the identification, evaluation, resolution and follow-up of potential and actual
problems in their administration and delivery of health care services.
2. The department shall develop
and maintain an internal quality assurance program that monitors and evaluates
the full range of its health care services across all institutional and
noninstitutional settings. The quality assurance program shall be fully
described in writing and provided to all administrative and clinical staff of
the department, and made available to all providers upon request. A summary of
the program shall be provided to anyone upon request.
3. The department's quality
assurance and utilization management program shall ensure that in making
decisions to approve or deny care, it uses not only utilization review standards and guidelines but
also clinical case data, information and practice guidelines so as to balance
the clinical decision-making process with its cost-containment measures.
4. The department shall have in
place the administrative structures, policies, and procedures necessary to
support operations that meet the requirements and criteria contained in these
rules.
5. The department shall clearly
define the organizational relationships and responsibilities for quality
assurance functions and assign them to appropriately qualified individuals.
6. The department shall establish
effective procedures to develop, compile, and evaluate the statistical and
other information necessary to support an effective quality assurance and
utilization management program.
7. The department's quality
assurance program shall include, but not be limited to, the following
components:
a) A designated
committee that is responsible for the department's quality assurance
activities. The committee shall include, but not be limited to, at least one beneficiary in the PCCM program and
participating providers.
b)
Accountability of the designated committee to the commissioner of the department
through the medical director.
c) Participation
in the quality assurance program by the appropriate providers, support staff
and beneficiaries. At a minimum, this shall include all PCPs, unless good cause
is shown why they should not participate. The department shall establish
programs to periodically train such providers, support staff and members to
participate meaningfully in the quality assurance program.
d) Supervision
of the quality assurance program by the medical director of the department, who
shall be a physician licensed in
e)
Regularly-scheduled meetings of the designated committee.
f) Minutes or
records of the meetings of the designated committee that describe, in detail,
the committee's actions, including the problems discussed, recommendations made
and any other pertinent information.
H. Quality Management and Improvement
1. The department shall establish an internal system capable of
identifying opportunities to improve care. This system shall be structured to
identify practices that result in improved health care outcomes, identify
problematic utilization patterns, identify those providers that may be
responsible for either exemplary or problematic patterns, and foster an
environment of continuous quality improvement.
2. The medical director shall
have primary responsibility for the quality assessment and quality improvement
activities required of, and carried out by or on behalf of, the department. The
medical director shall approve the written quality assessment and quality
improvement programs and shall periodically review and revise the program
documents and act to ensure their ongoing appropriateness.
3. The department shall use the
findings generated by the system to work, on a continuing basis, with network
providers and other staff to improve the health care delivered to its
beneficiaries.
4. The department shall develop
and maintain an organizational program for designing, measuring, assessing and
improving the processes and outcomes of health
care as identified in its quality improvement program, which shall be under the
direction of its medical director. The organizational program shall include:
(a) A written
statement of the objectives, lines of authority and accountability, evaluation
tools, including data collection responsibilities, performance improvement
activities and an annual effectiveness review of the quality improvement
program.
(b) An annual
written quality improvement plan that describes how the department intends to:
(i) analyze both
processes and outcomes of care, including focused review of individual cases as
appropriate, to discern the causes of variation;
(ii) identify
the targeted diagnoses and treatments to be reviewed by the quality improvement
program each year. In determining which diagnoses and treatments to target for
review, the department shall consider practices and diagnoses that affect a
substantial number of its beneficiaries or that could place beneficiaries at
serious risk. This section shall not be construed to require the department to
review every disease, illness and condition that may affect a beneficiary;
(iii) use a
range of appropriate methods to analyze quality, including:
i) collecting
and analyzing information on over-utilization and under-utilization of
services, high-volume and high-risk services, and the continuity and
coordination of care for acute and chronically-ill populations;
ii) evaluating
courses of treatment and outcomes of health care, including health status
measures, consistent with reference data bases such as current medical
research, knowledge, standards and practice guidelines; and
iii) collecting
and analyzing information specific to a beneficiary or provider or providers,
gathered from multiple sources such as utilization management, claims
processing, and documentation of both the satisfaction and grievances of
beneficiaries;
(iv) compare
program findings with past performance, as appropriate, and with internal goals
and external standards, where available, adopted by the department;
(v) measure the performance of network providers and conduct peer
review activities, such as:
i) identifying
practices that do not meet the department's standards:
ii) taking
appropriate action to correct deficiencies;
iii) monitoring
providers to determine where they have implemented corrective action; and
iv) taking
appropriate action when a provider has not implemented corrective action;
(vi) use treatment protocols and practice parameters developed
with the appropriate clinical input and using the evaluations described in
paragraphs (i) and (ii) of this subsection (b), or use acquired treatment
protocols developed with appropriate clinical input, and give its providers
sufficient information about the protocols to enable them to meet the standards
established in the protocols;
(vii) evaluate access to care for beneficiaries according to
standards established in M103.3, including
the travel and waiting time standards;
(viii) describe the department's strategy for integrating public
health and Agency of Human Services goals with the health services offered to
beneficiaries, including a description of the department's good faith efforts
to initiate or maintain communication with other AHS departments to develop
coordinated services for designated populations;
(ix) use preventive health services, such as:
i) adopting
practice guidelines specific to preventive health services that are based on
reasonable medical evidence;
v) establishing effective procedures for informing beneficiaries
on a continual basis about health promotion and preventive health services
available to them; and
vi) assessing its performance in the use of preventive health
services;
(x) implement improvement strategies related to program findings;
(xi) evaluate
periodically, but not less than annually, the effectiveness of the strategies
implemented in paragraph (x) of this subsection (b);
(xii) ensure that the PCCM providers and beneficiaries have the
opportunity to participate in developing, implementing and evaluating the
quality improvement system; and
(xiii)provide beneficiaries the opportunity to comment on the
quality improvement process.
I. Utilization
Review and Management
1. The department shall be
responsible for monitoring all utilization review activities carried out by it
or on its behalf and for ensuring that all requirements of this rule and other
applicable laws and rules are met.
2. The department will meet the
standards established by 18 V.S.A. 9414.
3. The department shall implement
a written utilization review program that describes all review activities, both
delegated and non-delegated, for services provided to its beneficiaries. The
program document shall describe the following:
a) procedures to
evaluate whether the requested service is a covered service. In the case of new
technology or new application of existing technology, the department has a
mechanism to evaluate its inclusion among covered services based on reviews of
information from appropriate bodies, using professionals in the process;
b) procedures to
evaluate the clinical necessity, appropriateness, efficacy or efficiency of
health services;
c) the practice
guidelines, data sources and utilization review guidelines used in utilization
review decision-making;
d) the process
by which individual clinical case data, assessments and information are
prospectively, concurrently and retrospectively used together with clinical
review criteria and utilization review guidelines in making decisions to
approve or deny requested health care services;
e) the criteria
used to reach utilization review decisions when individual clinical assessments
and utilization review guidelines conflict;
f) the process for conducting reviews of adverse determinations;
g) mechanisms to
ensure the consistent application of review criteria decisions that, within the
scope of coverage limits, are compatible with the unique needs of each
individual patient and each presenting situation;
h) the data
collection processes and analytical methods used in assessing the utilization
of health care services by its beneficiaries;
i) provisions
for ensuring the confidentiality of clinical and proprietary information;
j) the organizational structure (for example, utilization review
committee, quality assurance committee, or other committee) that periodically
assesses utilization review activities and reports to the OVHA Director; and
k) the staff position functionally responsible for the day-to-day
management of the utilization review function.
4. The department's utilization
review program shall use documented clinical review
criteria that are based on sound clinical evidence and are evaluated
periodically to ensure their ongoing efficacy. The department may develop its
own clinical review criteria, or it may purchase clinical review criteria from
qualified vendors. These criteria shall be periodically reviewed and updated by
the department with the involvement of practicing physicians and other health
care providers within the PCCM network. The department shall give relevant
clinical review criteria to its network providers, and shall make them
available to members upon request.
5. The department shall have a
registered nurse or physician immediately available by telephone to render
utilization review determinations to its providers outside of normal business
hours, when such decisions are required to be rendered outside of normal
business hours. If urgent care is required outside of normal business hours,
the request for authorization must be made on the next business day.
6. With regard to utilization
review determinations, the department shall ensure that:
a) individual
clinical case assessments, data and practice guidelines for the relevant
clinical conditions are given equal or greater weight than utilization review guidelines in making decisions to
approve or deny care, with the former taking precedence over the latter when
there is a conflict between the two;
b) all
determinations to deny or limit an admission, service, procedure or extension
of stay are rendered by the commissioner with the advice of the medical
director. Such determinations shall be made in accordance with clinical and
medical necessity criteria established in M106 and M107 and relevant clinical
practice guidelines;
c) it does not
retroactively deny reimbursement for a covered service provided to a
beneficiary by a provider who relied upon the written or oral authorization of
the department or its agents prior to providing the service to the beneficiary,
or for a covered service provided to a beneficiary by his or her primary care
provider or a specialist who relied upon the written or oral referral of the primary
care provider, except in cases where there was material misrepresentation or
fraud; and
d) all
authorizations are confirmed in writing within twenty-four hours of being given
in a manner that specifies the services authorized, and are included as part of
the beneficiary's records.
7. The department shall issue utilization review decisions in a
timely manner pursuant to the requirements of M106.
a) The
department shall obtain all information required to make a utilization review
decision, including pertinent clinical information.
b) The
department shall have a process to ensure that utilization reviewers apply
clinical review criteria consistently.
8. The department shall routinely
assess the effectiveness and efficiency of its utilization review program.
9. The department shall have a
data system sufficient to support utilization review program activities and to
generate management reports to enable it to effectively monitor and manage
health care services provided to its beneficiaries.
10. If the department delegates
any utilization review activities to a utilization review organization, the
department shall maintain effective oversight of those activities, which shall
include:
a) a written description of the utilization review organization's
activities and responsibilities, including reporting requirements;
b) evidence of
formal approval of the utilization review organization program by the
department; and
c) a process by
which the department evaluates the performance of the utilization review
organization.
11. department shall coordinate
the utilization review program with its other medical management activities,
including quality improvement, data reporting, grievance procedures, and
processes for assessing beneficiary satisfaction.
12. The department shall provide
beneficiaries and providers with access to its review staff by a toll-free
number or collect-call telephone line.
13. When conducting utilization
review, the department shall collect only the information necessary to perform
the function.
14. Compensation to persons
providing utilization review services for the department shall not contain
incentives, direct or indirect, for those persons to limit access to medically-necessary care.
Compensation to such persons may not be based, directly or indirectly, on the
quantity or type of adverse determinations rendered.
J. Procedures for Utilization Review Decisions
1. The department shall maintain
written procedures for making utilization review decisions and for notifying
beneficiaries, representatives of beneficiaries, and providers acting on behalf
of beneficiaries of its decisions.
2. For initial and concurrent
review determinations, the department shall, within three (3) working days of
obtaining all necessary information regarding the admission, procedure or
service requiring a review determination, make the determination and notify the
treating provider of the determination by telephone. Written confirmation of
the determination will be sent to the provider within twenty-four (24) hours of
the telephone notification.
a) In the case
of an adverse concurrent review determination, the beneficiary shall not be
liable for any services provided before notification to the beneficiary of the
adverse determination. Benefits will continue if a fair hearing is requested.
b) The
department shall establish procedures to expedite initial and concurrent review
determinations in cases involving urgently-needed care. In no event shall the
department take more than twenty-four (24) hours from the time the service is
first requested to make an initial or concurrent review determination for such
services.
3. The department shall conduct
retrospective review determinations consistent with federal requirements.
4. A written notification of an
adverse determination shall include the principal reason or reasons for the
determination and instructions on how to appeal the determination and how to
request additional information. Within 90 days of PCCM program implementation,
the department will add to the written notification, the clinical rationale for
the determination including an explanation of the clinical review criteria used
to make the determination. The department shall make the actual clinical review
criteria available to the beneficiary upon request.
5. The department shall act
promptly and in good faith to obtain the information
necessary to make utilization review decisions. For purposes of this section,
"necessary information" includes the results of any face-to-face
clinical evaluation or second opinion that may be required.
6. The department shall have
written procedures to address the failure or inability of a provider or a
beneficiary to provide all necessary information for utilization review, which
shall include a description of the information required for the review. Copies
of the procedures are available to all network providers. In cases where the
provider or beneficiary will not release the necessary information, the
department may deny certification. In no event shall the department penalize a
provider for failing to provide a beneficiary's medical records to the
department when the beneficiary has not authorized release of the records and
the provider is not otherwise obligated by law or regulation to disclose the
records.
K. Fair Hearings, Appeals and Grievances
1. Fair Hearings Beneficiaries
may appeal a denial, reduction or termination of benefits by requesting a fair
hearing orally or in writing as specified in M144. Beneficiaries must request a
hearing within 90 days of the adverse action. The department shall act on a
fair hearing within the timeframes specified
in the Human Services Board rules found at P2127.
2. Expedited Appeal Beneficiaries
may request an expedited appeal orally or in writing of a denial, reduction or
termination of urgent care or emergency services. The department shall respond
as expeditiously as the beneficiary's medical condition requires, but in no
event more than three (3) days after receipt of the information necessary to
resolve the appeal. This shall include any appeal related to whether or not the
service in question constitutes emergency services or urgent care.
Beneficiaries who are dissatisfied with the resolution of an expedited appeal
may continue with the fair hearing process.
3. Grievance Beneficiaries may
file a grievance orally or in writing related to complaints about availability,
delivery or quality of health care or about claims payment, handling or
reimbursement for health care services. The Department shall respond to
grievances within thirty (30) days after receipt of the information necessary
to resolve the grievance. Grievances that relate to a denial, reduction or
termination of benefits may be appealed to the Human Services Board.
4. Guidelines for Fair Hearings,
Expedited Appeals and Grievances Fair hearings shall be conducted pursuant to
Human Services Board rules. Expedited appeals and
grievances shall be conducted pursuant to the following guidelines:
a) The person or
persons reviewing the expedited appeal or grievance on behalf of the department
shall not have been involved with the adverse determination or other issue that
is the subject of the hearing, appeal or grievance.
b) The
department shall act promptly and in good faith to obtain the information
necessary to resolve the appeal or grievance. For purposes of this section,
"necessary information" includes the results of any face-to-face
clinical evaluation or second opinion that may be required.
c) The
department shall document its resolution in writing. The resolution shall
contain:
• The names and titles of the person or persons reviewing the
appeal or grievance on behalf of the department;
• A statement of the reviewers' understanding of the beneficiary's
appeal or grievance;
• The reviewers' decision in clear terms, including the basis or
other rationale for the decision in
sufficient detail for the beneficiary to understand the decision;
• A reference to the evidence or documentation used by the
reviewers in making the decision, including clinical review criteria used to
make a determination relating to medical
• In the case of expedited appeals a notification that the
beneficiary may continue with the fair hearing process, if he or she is
dissatisfied with the resolution of the expedited appeal.
• The number of the State Health Care Ombudsman.
d) The
department shall provide the beneficiary with all the information in its
possession or control relevant to the appeal or grievance process and the subject
of the appeal or grievance, including applicable policies or procedures and (to
the extent applicable) copies of all necessary and relevant medical records.
The department will not charge the beneficiary for copies of any records or
other documents necessary to resolve the appeal or grievance.
e) For fair
hearings and expedited appeals related to medical care, the department shall provide any covered service
that had been denied or restricted for which a reversal has been made by its
reviewers or by the Human Services Board.
f) If fair
hearing or expedited appeal relates to a concurrent review determination for
emergency services or urgent care, the service shall be continued without liability
to the beneficiary until the department has notified the beneficiary of its
final resolution, consistent with fair hearing rules.
5. Appeals Register The
department shall maintain written records documenting all fair hearings,
expedited appeals and grievances received during a calendar year (the appeals
register). The department shall retain the register compiled for a calendar
year for three years. Each register shall contain, at a minimum, the following
information:
• The identity of the beneficiary who filed the fair hearing,
expedited appeal or grievance, using a unique identification number assigned
consistently to that beneficiary;
• A general description of the reason for the fair hearing,
expedited appeal or grievance;
• The date the request was received by the department;
• The date of each review and hearing (if any);
• In the case of an expedited appeal, whether the appeal was
resolved or went to fair hearing;
• The number of days it took to gather the information necessary
to resolve issue and the resolution of the fair hearing, expedited appeal or
grievance.
6. Information The department
shall share the information collected by it in its fair hearing, expedited
appeal and grievance processes with the persons responsible for its quality
assurance, quality improvement and utilization review and management programs.
7. Procedures The department will
maintain procedures by which persons who are unable to file written appeals may
notify the department of a grievance or an appeal. The department shall be
responsible for documenting such grievances and providing copies to the
beneficiaries for their use, or the use of their representatives.
L. Emergency Services
1. Beneficiaries have access to
emergency services twenty-four (24) hours per day, seven (7) days per week,
while the beneficiary is within the
2. The department shall cover
emergency services necessary to screen and stabilize a beneficiary and does not
require prior authorization of such services.
3. The department will cover
urgently-needed care whether the beneficiary is inside or outside of
4. Any provider providing
services under this section shall furnish to the beneficiary's primary care
provider all relevant and necessary medical information for the beneficiary's
ongoing care.
M. Medical Records
1. Medical Records Practices. The department shall work with its
PCCM providers to establish, maintain and use a patient record system that will
facilitate the documentation and retrieval of statistically-meaningful clinical
information, as follows:
a) Clinical
records should be maintained in a manner that is current, detailed and
organized and that permits effective beneficiary care and quality review.
Records may be written or electronic.
2. Maintenance of Health Care
Information: Confidentiality Procedures. The department shall comply with the
confidentiality procedures in 33 V.S.A. 111, AHS rule 96.1 and applicable
federal law.
N. Provider Agreement
1. The department will not
include any provision in the PCCM addendum to the provider agreement that
prohibits the health care provider from disclosing to beneficiaries or
potential beneficiaries information about the agreement or the beneficiaries'
benefit plan that may affect their health or any decision regarding their
health.
2. The department shall not prohibit a PCCM PCP from, or penalize
a PCCM PCP for, discussing treatment options with beneficiaries regardless of
the department's position on the treatment options, or advocating on behalf of
beneficiaries within the utilization review or appeals processes established by
the department, nor shall it penalize a provider because the provider in good
faith reports to state or federal authorities any act or practice by the
department that jeopardizes patient health or welfare.
3. The PCCM agreement shall
contain provisions clearly stating the requirements and responsibilities of the
PCCM program and participating providers with respect to administrative
policies and programs, including but not limited to payment terms, utilization
review, quality assessment and improvement programs, grievance procedures, data
reporting requirements, confidentiality requirements, and any applicable federal
or state requirements. The agreement must allow the provider to participate in
the department's quality assurance program, dispute resolution process, and
utilization management program.
5. No PCCM agreement shall
contain a provision offering an inducement to a provider to forego providing
medically-necessary services to a beneficiary.
6. Each PCCM agreement shall contain provisions to ensure the
availability and confidentiality of the health records necessary to monitor and
evaluate the quality of care, and to conduct medical and other health care
evaluations and audits to determine, on a concurrent or retrospective basis,
the medical necessity and appropriateness of care provided to beneficiaries.
Each provider agreement shall include provisions requiring the provider to make
health records available as required by law to appropriate state and federal
authorities involved in assessing the quality of care or investigating the
grievances or complaints of beneficiaries, and to comply with the applicable
state and federal laws related to the confidentiality of medical or health
records.
7. The PCCM provider agreement
shall describe a mechanism for informing each provider participating in its
PCCM program on an ongoing and current basis of the specific covered health
services for which the provider will be responsible, including any limitations
or conditions on the services.
O. Network Adequacy
1. The department will not
require any beneficiary to be assigned to the PCCM program unless covered
health care services, including referrals to participating
specialty physicians, are accessible to members on a timely basis, as follows.
The department will make a good faith effort to attract sufficient numbers and
types of providers to ensure that all covered health care services will be
provided without unreasonable delay.
a) Travel time
standards. Travel times for PCCM beneficiaries, under normal conditions from
their residence or place of business, generally should not exceed the
following:
• thirty (30) minutes to a network primary care provider;
• thirty (30) minutes to an outpatient facility for mental health
or chemical dependency services;
• sixty (60) minutes for laboratory, x-ray, pharmacy, general
optometry, inpatient psychiatric, MRI and inpatient medical rehabilitation
services;
• ninety (90) minutes for cardiac catheterization laboratory,
kidney transplantation, major trauma treatment, neonatal intensive care, and
open-heart surgery services; and
• reasonable
accessibility for other specialty hospital services, including major burn care,
organ transplantation (other than kidneys), and specialty pediatric care.
b) Waiting time
standards. Waiting times for appointments should generally not exceed the
following:
• immediate access to emergency care;
• twenty-four (24) hours for urgent care;
• two (2) weeks for the initial treatment of non-emergency or
non-urgent care, with prompt follow-up care as necessary, including referrals
for specialty services;
• ninety (90) days for preventive care (including routine physical
examinations); and
• thirty (30) days for routine laboratory, x-ray, general
optometry, and all other routine services.
c) The department shall develop and implement written standards or
guidelines that address the assessment of provider capacity to provide timely
access to health care services.
2. The department will not
require any beneficiary to be assigned to the department shall, either directly
or through contracts or other arrangements, provide the services of primary
care providers sufficient to respond to initial and basic care needs of
members. The department shall inform its primary care providers of their
responsibility to provide referrals and any specific procedures that must be followed
in providing referrals.
3. The department shall permit
its beneficiaries to make at least two visits per calendar year to a network
gynecological health care provider for reproductive or gynecological care, as
well as visits relating to follow-up care for problems identified during such
visits, without a referral from the beneficiary's primary care providers. All
such visits shall be subject to the utilization review procedures used by the
department. A gynecological health care provider providing services under this
section shall furnish to the beneficiary's primary care provider all relevant
and necessary medical information for ongoing care.
4. The PCPs shall ensure the coordination and continuity of care
for their patients. For purposes of this section, "coordination and
continuity of care" mean that a beneficiary's health care services are
managed by the PCP in a manner that facilitates the treatment of a condition,
illness or other medical condition, including all primary care services and any
necessary referrals. The department shall establish guidelines for referrals to
both participating and non-participating physicians and other providers.
5. The department shall permit
certain new members to continue to use their previous providers, so long as
those providers agree to abide by the department's payment rates, quality-of-care
standards and protocols, and to provide the necessary clinical information to
the plan, as follows:
• new beneficiaries with life-threatening, disabling or
degenerative conditions shall be allowed to continue to see their providers for
sixty (60) days from the date of enrollment or until accepted by a new provider
within the PCCM program, whichever is shorter; and
• women in their second or third trimester of pregnancy shall be
allowed to continue to obtain care from their previous provider until the
completion of postpartum care.
6. The department shall establish policies and procedures to
ensure the orderly transfer of those beneficiaries whose providers' agreement has
expired or been terminated, whether with or without cause, to other health care
providers in the PCCM network.
7. The department shall establish
policies and procedures through which a beneficiary with a condition that
requires ongoing care from a specialist may obtain a standing referral to a
participating specialist, subject to the utilization review procedures. For
purposes of this provision, "standing referral" means a referral for
ongoing care to be provided by a participating specialist that authorizes a series
of visits with the specialist for either a specific time period or a limited
number of visits, and which is provided according to a treatment plan developed
by the beneficiary's primary care provider, the specialist, the beneficiary and
the department.
8. The department shall ensure
that beneficiaries may obtain a referral to a health care provider outside of
P. Confidential Information
The department shall take the appropriate steps necessary to
ensure that information gathered by it in its quality assurance activities
shall be confidential and privileged.
Q. Disclosure of Information
The department shall supply to each beneficiary upon enrollment
and upon major revision thereafter the following information. The information
shall be in handbook form and in twelve-point type, and shall be in plain
language. This requirement may be satisfied by giving a copy of the handbook to
each household, rather than to each individual beneficiary. The department
shall make available to any beneficiary, upon request, a listing by specialty
of the name, telephone number and address of all health care providers and
health care facilities enrolled in PCCM and Medicaid (including, in the case of
physicians, information as to board certification). This list shall be updated
(by addendum or otherwise) at least once every six months, and shall indicate
which primary care providers are accepting new
patients. In addition, the handbook shall include:
1. Coverage provisions, including
covered health care services and items, benefit maximums, benefit limitations,
exclusions from coverage (including procedures deemed experimental or
investigational by the department), restrictions on referral or treatment
options, requirements for prior authorization or utilization review, the use of
formularies, and any other limitations on the services covered.
2. A description of the M108
procedure for coverage of prescription drugs from manufacturers that do not
participate in the federal rebate program. In addition to the criteria
contained in M108, the department shall also consider the following criteria in
making M108 determinations for prescription drugs. The currently covered drug:
• has not been effective in treating the patient's medical
condition; or
• causes or is reasonably expected to cause adverse or harmful
reactions in the beneficiary.
3. If prior authorization or utilization review is required before
obtaining treatment or services, the process a beneficiary must use to obtain
that authorization or review, including any time lines that apply.
4. The financial inducements
offered to any Medicaid provider or health care facility for the reduction or
limitation of health care services. Nothing in this paragraph shall be construed
to require disclosure of individual contracts or the specific details of any
financial arrangement between the department and a health care provider.
5. The beneficiary's
responsibility for payment of premiums, coinsurance, co-payments, deductibles
and any other charges, annual limits on a beneficiary's financial
responsibility, caps on payments for covered services, and the beneficiary's
financial responsibility for non-covered procedures, treatments or services.
6. The beneficiary's financial
responsibility for payment when services are provided by a health care provider
who is not part of the PCCM network or by any provider after an adverse
determination by the department.
7. The criteria used by the
department for selecting and credentialing the health
care providers it enrolls.
8. The grievance and appeals
procedures used to resolve disputes between a beneficiary and the department.
9. A summary of its quality
assessment and quality improvement programs.
10. The utilization review
procedures of the organization, including the credentials and training of
utilization review personnel.
11. The procedure for obtaining
emergency services, including any requirements for prior authorization and
payment for services rendered outside of
12. All necessary mailing
addresses and telephone numbers to be used by beneficiaries seeking information
or authorization.
13. The process for selecting
primary care providers and for obtaining access to other providers in the PCCM
network, including any restrictions on the use of network specialists.
14. The procedure for changing
primary and specialty care providers within PCCM,
including any restrictions on changing providers.
15. How beneficiaries can obtain
standing referrals to Medicaid participating specialists, or use specialists or
specialized facilities to provide and coordinate their primary and specialty
care.
16. The waiting time and travel
time standards established in this rule.
17. Whether the health care
providers are prohibited from participating in other managed care plans or from
performing services for persons who are not members of the PCCM program.
18. Opportunities for beneficiary
participation in the development of departmental policies and in the
department's quality assurance and quality improvement activities.
19. The consumer information and
services, including the toll-free number for the OVHA Ombudsman.
20. A list of all information
available to the beneficiary upon request.
Section M104 Authorized
Representative.
The parent, guardian or other caretaker responsible for a minor
child acts as the child's representative in the eligibility process.
When a person cannot act for himself, because of his physical or
mental condition, one of the following people may act as his authorized
representative in the eligibility process.
A court
appointed legal guardian or legal representative; or
A relative,
friend or other person who knows about or handles his affairs; or
A person he
names in a letter to the department to take his place when he cannot come for a
necessary interview because of an unexpected emergency.
When a person dies before he can apply for retroactive Medicaid
coverage, the administrator or executor of his estate, a surviving relative or
other responsible person may act as his authorized representative.
Section M105 Case Records.
The Department
keeps a permanent written record of facts and actions concerning a person's (or
group's) Medicaid eligibility for administrative and accountability purposes.
Information about each person or group is kept in an individual case file in
the district office responsible for the town where the person or group lives.
Information necessary to assure prompt and correct payments of Medicaid
benefits is also stored in computer files.
Information which identifies a person or group as a Medicaid
applicant or recipient is only given out when it is necessary to furnish or pay
for Medicaid services. A recipient may permit the Department to give
information to another agency to help him get services from that agency.
Information about many applicants or recipients, which does not
identify persons or groups by name or other individual characteristics, may be
combined in the form of statistics or general descriptions for planning,
research and program administration.
Section M106 Prior Authorization.
M106.1 Background.
Prior
authorization is a process used by the department to assure the appropriate use
of health care services. The goal of prior authorization is to assure that the
proposed health service [n1] is medically needed; that all appropriate,
less-expensive alternatives have been given consideration; and that the
proposed service conforms to generally accepted practice parameters recognized
by health care providers in the same or similar general specialty who typically
treat or manage the diagnosis or condition. It involves a request for approval
of each health service that is designated as requiring prior approval before
the service is rendered. The department shall notify each patient and provider
of its decision, which is arrived at by applying the criteria set forth in
M106.3.
[n1 "Health services" as used in these rules include
services, items or procedures.]
M106.2 Criteria for Services Requiring Prior Authorization.
The department may require prior authorization of payment for a
service when one or more of the following criteria are met.
1. The health service is of questionable medical necessity as
determined by the department.
2. The department determines that
use of the health service needs monitoring to manage the expenditure of program
funds.
3. Less expensive appropriate
alternatives to the health service are generally available.
4. The health service is
investigational.
5. The health service is newly
developed or modified.
6. The department determines that
monitoring a health service of a continuing nature is necessary to prevent the
continuation of the service when it ceases to be beneficial.
The complete and current list of all services and items including
procedure codes that require prior authorization is set out in the Provider
Manual. The list is updated periodically. Additions and deletions to the list
are also published in advance in the provider advisory newsletter and other communications to providers.
M106.3 Prior Authorization Determination.
A request for
prior authorization of a covered health service will be approved if the health
service:
1. is medically necessary (see
M107);
2. is appropriate and effective
to the medical needs of the beneficiary;
3. is timely, considering the
nature and present state of the beneficiary's medical condition;
4. is the least expensive,
appropriate health service available;
5. is FDA approved, if it is FDA
regulated;
6. is subject to a manufacturer's
rebate agreement, if a drug;
7. is not a preliminary procedure
or treatment leading to a service that is not covered;
8. is not the repair of an item
uncovered by Medicaid;
9. is not experimental or
investigational;
10. is furnished by a provider
with appropriate credentials.
The department is responsible for determining questions of
coverage and medical necessity under the Vermont Medicaid program. The
department may contract with external organizations to help make these
determinations; however, the final decision rests with the department.
Supporting information for a prior authorization request must
include a completed claim and a completed medical necessity form. Additional
information that may be required includes:
• the patient's complete medical record;
• the patient's plan of care;
• a statement of
long-term and short-term treatment goals;
• a response to clinical questions posed by the department;
• a second opinion or an evaluation by another practitioner, at
Medicaid expense;
• the practitioner's detailed and reasoned opinion in support of
medical necessity;
• a statement of the alternatives considered and the provider's
reasons for rejecting them; and,
• a statement of the practitioner's evaluation of alternatives
suggested by the department and the providers reasons for rejecting them.
If any of this additional information is required, the department
will notify the provider promptly. Once the necessary information has been
received, the beneficiary will be sent a notice of decision that may be
appealed. See M142.
M106.4 Waiver of Prior Authorization.
The department
shall waive the requirement that a covered service receive prior authorization
if, in the department's judgment, the service provided without prior
authorization meets one or both of the following circumstances.
• The service was required to treat an emergency medical
condition.
• The service was provided prior to the determination of Medicaid
eligibility and within the retroactive coverage period.
M106.5 Prior Authorization Process.
Prior authorization commences with the receipt of a written prior
authorization request. The department will issue a notice of decision within
three working days of receiving all necessary information. The department will
act in good faith to obtain the necessary information promptly so that it can
determine, within 30 days, whether the request may be approved. The department
will issue a notice of decision within 30 days of receiving the initial prior
authorization request, even if all necessary information has not been received.
Section M107 Medical Necessity.
"Medically
necessary" means health care services, including diagnostic testing,
preventive services, and aftercare, that are appropriate, in terms of type,
amount, frequency, level, setting, and duration to the beneficiary's diagnosis
or condition. Medically necessary care must be consistent with generally
accepted practice parameters as recognized by health care providers in the same
or similar general specialty as typically treat or manage the diagnosis or
condition, and
1. help restore or maintain the
beneficiary's health; or
2. prevent deterioration or
palliate the beneficiary's condition; or
3. prevent the reasonably likely
onset of a health problem or detect an incipient problem.
Additionally, for EPSDT-eligible beneficiaries, medically
necessary includes a determination that a service is needed to achieve proper
growth and development or prevent the onset or worsening of a health condition.
Section M108 Procedure for Requesting Coverage of a Service or
Item.
Any beneficiary
may request that the department cover a service or item that is not already
included on a list of covered services and items. The request should be sent to
the Director of the Office of Vermont Health Access (OVHA). The director will
review the request and supporting documentation and make a good faith effort to
obtain any additional information quickly to allow the commissioner to make a
decision within thirty days. In no case will a request for a service or item be
approved for coverage unless it is medically necessary.
Each decision shall result in one of four outcomes. The four
possible outcomes are: (1) the commissioner approves coverage of the service or
item for the individual and adds it to a list of pre-approved services or
items; (2) the commissioner approves coverage of the service or item for the
individual and does not add it to a list of pre-approved services or items; (3)
the commissioner does not approve coverage of the service or item for the
individual and adds it to a list of pre-approved services or items; or (4) the
commissioner does not approve coverage of the service or item for the
individual and does not add it to a list of pre-approved services or items.
If the commissioner's decision is to add the service or item to a
pre-approved list of covered services, a
PP&D memorandum will be issued delineating the addition. All such PP&D
memoranda will be incorporated into the rule as soon as practical. An adverse
decision from the commissioner may be appealed through the fair hearing process.
An adverse decision may not be renewed by the same beneficiary until twelve
months have elapsed since the previous final decision or until new
documentation of the individual's condition, a change in the individual's
condition, new medical evidence, or a change in technology has been
demonstrated.
The Office of Vermont Health Access shall, semiannually, issue a
PP&D memorandum updating the listing of all affirmative coverage decisions
made under this procedure that do not result in the service or item that is
authorized being added to a list of pre-approved services or items. This list
shall include the commissioner's coverage decisions, plus negotiated
settlements and Human Services Board and Vermont Supreme Court decisions.
Because this list shall be available for public inspection, it shall be
composed in a manner that protects beneficiaries' right to confidentiality. The
department will ensure that all Medicaid beneficiaries who are similarly
situated to the individual who has obtained coverage will be treated similarly
with respect to coverage of the same service or item.
If, under this
section, an individual requests that a service or item be covered, the
following criteria will be considered, in combination, in determining whether
to cover the service or item for the individual and/or to add it to a list of
pre-approved services or items, with the following exception. If the service or
item is subject to FDA approval and has not been approved (criterion #9 below),
the request for coverage of the service or item will be denied.
1. Are there extenuating
circumstances that are unique to the beneficiary such that there would be
serious detrimental health consequences if the service or item were not
provided?
2. Does the service or item fit
within a category or subcategory of services offered by the Vermont Medicaid
program for adults?
3. Has the service or item been
identified in rule as not covered, and has new evidence about efficacy been
presented or discovered?
4. Is the service or item
consistent with the objectives of Title XIX?
5. Is there a rational basis for
excluding coverage of the service or item? The purpose
of this criterion is to ensure that the department does not arbitrarily deny
coverage for a service or item. The department may not deny an individual coverage
for a service or item solely based on its cost.
6. Is the service or item
experimental or investigational?
7. Have the medical
appropriateness and efficacy of the service or item been demonstrated in the
literature or by experts in the field?
8. Are less expensive, medically
appropriate alternatives not covered or not generally available?
9. Is FDA approval required, and
if so, has the service or item been approved?
10. Is the service or item
primarily and customarily used to serve a medical purpose, and is it generally
not useful to an individual in the absence of an illness, injury, or
disability?
Section M110 Application.
Section M111 Application Requirement.
Any individual
who wants Medicaid must file a Medicaid application with the department except:
An individual who has applied at a Social Security Office for supplemental
security income.
If an individual granted SSI/AABD also wants retroactive Medicaid
coverage before the start of the cash assistance grant, he/she must file a
separate application for retroactive Medicaid coverage and be found eligible
based on criteria other than receiving cash assistance.
Filing an application means taking or mailing a signed Medicaid
application form to a department office, preferably the district office
responsible for the town where the applicant lives. Department offices give
Medicaid application forms to any individual who asks for one. Medicaid
providers, referring agencies and other locations serving the public may also
keep supplies of application forms.
An application form must be signed by individuals applying for
Medicaid or by their authorized representative.
Section M112 Reapplication and Reenrollment.
Any individual
who has applied before for Medicaid and is not now eligible for coverage may
reapply at any time.
To reapply, the individual (or group) must file a new up-to-date
signed application form with the department. An authorized representative may
act for the individual or group when needed.
When an individual has been disenrolled from coverage solely for
non-payment of a premium, if the department receives and processes the payment
on the next business day following the last day of the month the premium was
due, the coverage group will be automatically reenrolled without a new
application and without a break in benefits.
If the department receives and processes the payment after the
first business day after the month the premium was due, but within the first
month after closure, the coverage group will be automatically reenrolled for
the next month with a one month break in coverage. Beneficiaries must submit a
new application, however, if any change in a coverage group's circumstances
affects its eligibility or a review of the case is scheduled for the current
month or the following month.
Section M113
Retroactive Application.
Medicaid may be granted retroactively for up to three calendar
months before the month of application provided all eligibility criteria were
met during the retroactive period and any premiums required for those months
have been received by the department. A woman is not eligible for the 60-day
post-pregnancy period (i.e., when no other categorical criterion is met) if she
was granted retroactively after her pregnancy has ended.
An authorized representative may apply for retroactive coverage on
behalf of an individual who dies before he or she can apply for Medicaid.
Payments for Medicare cost sharing for individuals who are
Qualified Medicare Beneficiaries (QMBs) and not otherwise eligible for Medicaid
are first made in the month following the month QMB eligibility is determined.
There is no retroactive QMB coverage.
Payments for Medicare cost sharing for the other Medicare
cost-sharing groups can be paid for allowed Medicare costs incurred prior to
the month of application provided all eligibility criteria were met during the
three month retroactive period.
Section M114 Date of Application.
The date of application is the day on which a signed Medicaid
application form is received in a Department office, or the day on which an
application for Supplemental Security Income/Aid to the Aged, Blind or Disabled
(SSI/AABD) is filed with a Social Security office.
The application date sets the time limits for making a decision on
the application and the earliest date retroactive coverage may begin.
Section M115 Choice of Category.
In order to be found eligible for Medicaid, an individual must
meet one of the following requirements:
(1) be found
eligible for Medicaid as determined by the Department of Social Welfare's
application of SSI/AABD-related Medicaid rules (M200 Section); or
(2) be found
eligible for Medicaid as determined by the Department of Social Welfare's application of ANFC-related Medicaid
rules (M300 Section).
Any individual seeking Medicaid coverage has the right to select
which of the two sets of rules listed above, he or she wishes to have applied
to his or her eligibility determination. In order to assist applicants in
making this decision, the Department of Social Welfare is responsible for
providing the following information:
(1) the
requirements specific to SSI/AABD-related Medicaid eligibility. In order to be
SSI/AABD-related, an applicant must be either:
- 65 years of age or older, or
- blind, or
- disabled
(2) the
requirements specific to ANFC-related Medicaid eligibility. In order to be
ANFC-related, an applicant must be:
- 20 years of age or younger, or
- a parent or caretaker relative of a child who meets the ANFC age
criteria for a child and is deprived of parental care and support in accordance
with the rules of the ANFC-related Medicaid program.
In some instances an applicant may meet the non-financial
requirements applicable to both ANFC-and SSI/AABD-related Medicaid eligibility.
In these cases, the Department of Social Welfare is responsible for providing
the following information regarding the financial requirements of both
programs.
(1) The SSI/AABD
rules usually allow more extensive exclusions of income and resources. In
addition, a larger portion of earned income may be disregarded than is allowed
by the ANFC-related rules. If the applicant who meets the non-financial
requirements of both programs is the only member of the family in need of
Medicaid enrollment, it may be more advantageous for him or her to apply under
the SSI/AABD-related rules than under the ANFC-related rules.
(2) When an
individual(s) who has a choice of category and other members of his/her family
apply for Medicaid at the same time, the individual(s) having a choice of category may choose to apply on the
basis of the rules of the program for which the rest of the family is not
eligible. In this situation, the individual(s) with the choice must be included
in the other family members' Medicaid group when determining their financial
eligibility for Medicaid provided that the inclusion of the individual(s)
having the choice of category is required by the rules of the program under
which the other family members are applying and his/her inclusion does not
result in prohibited deeming.
If one or more members of the family are already enrolled in Medicaid,
the worker must determine if any change in the family's circumstances has
occurred since the most recent eligibility determination which would require a
redetermination of his/her (their) Medicaid eligibility. If circumstances
relevant to his/her (their) Medicaid eligibility have changed the Medicaid
eligibility of the members of the family who are already enrolled in Medicaid
must be redetermined prior to completing the determination of Medicaid
eligibility for those family members who are not currently enrolled in
Medicaid. If circumstances relevant to Medicaid eligibility have not changed,
no redetermination of Medicaid eligibility should be completed at this time.
When one or more family members are already enrolled in and remain
eligible for Medicaid, the determination of the other family members' financial
eligibility for Medicaid will exclude from
consideration:
All of their (i.e. the Medicaid recipients' or recipient's)
benefits which are based on financial need; and
Those portions of their (i.e. the Medicaid recipients' or
recipient's) income used to determine their benefits with the following
exception. The exclusion of income does not apply to individuals found eligible
due to total countable income which does not exceed one of the special income
tests but does exceed the applicable Protected Income Level; and
Resources owned solely or jointly by the Medicaid recipient(s)
with the following exception. A resource cannot be excluded if it was an
excluded resource for the family member(s) already enrolled in Medicaid solely
because the joint-owner member(s) of the subsequent applicant group refused to
make the resource accessible to the family member(s) already enrolled in
Medicaid.
Section M116 VHAP Program.
Individuals found no longer eligible for Medicaid shall have their
financial eligibility under the rules of the Vermont Health Access Plan (VHAP) determined -before Medicaid is closed. An
individual who meets the financial eligibility criteria for VHAP shall be
accepted in that program, subject to program enrollment caps and shall have 30
days in which to pay any required premium.
In areas where managed care is available, the individual shall be
contacted by the benefits counselor and enrolled in a managed health care plan.
A delay in
paying a required premium or in choosing a plan could result in a gap between
the date when Medicaid coverage ends and the date when VHAP coverage begins.
Section M120 Initial Eligibility.
Section M121 Application Decisions.
A decision must
be made to grant or deny any Medicaid application filed with a Department
Office.
Medicaid is granted when a person's situation passes all necessary
eligibility tests. When a family group applies together, some members may pass
the tests and be granted Medicaid while
other members do not and must be denied. A Medicaid grant begins on the first
day that all eligibility tests are passed. This may be the first of a month
during which all the tests are passed at anytime during that month, except when
an income spend-down test is necessary (see Section M423).
Medicaid is denied when a persons situation does not pass any one
or more of the eligibility tests. A Medicaid denial takes effect on the day the
decision is made.
An application decision may grant Medicaid for a part of the
period applied for and deny it for another part (such as the retroactive
period) because the person did not pass all the tests for the full time.
When an applicant fails to do his part, an application may be
denied if a decision cannot be made within the time limit, for example:
An applicant fails to give necessary information or proofs asked
for or takes longer than expected without explaining the delay; or
An applicant fails to have necessary medical examinations asked
for.
When an
applicant has done everything he was asked to do, the application will not be
denied even though a decision cannot be made before the time limit.
Section M122 Decision Time Limits.
A decision on a
Medicaid application must be made as soon as possible, but no later than:
90 days after the application
date, if the application is based on a person's disability; or
30 days after the application
date for any other Medicaid application.
The decision is not completed until a written notice of the
decision has been given or mailed to the applicant.
Decisions may take longer in unusual situations, such as:
An examining physician delays sending a necessary report; or
An unexpected
emergency or administrative problem beyond Department control delays action on
applications.
Section M123 Application Forms.
An applicant's signed application form(s) is the main source of
information used to make a decision on the applicant's application.
The application form(s) provides the applicant's written record of
the facts about his/her situation as related to Medicaid eligibility tests. A
relative, friend or other interested person may help the applicant to fill out
the statement. If the applicant has no one to help, he/she may ask for help at
a Department Office.
The applicant, or his/her authorized representative (see
Authorized Representative), who signs the form(s) is held responsible for the
truth of the information on the form. When no interview is necessary, the
Department will make the application decision from the information on the
form(s) and any necessary proofs. It may be necessary to write or telephone the
applicant for more information or explanation of entries on the form(s).
An interview is a face-to-face meeting between the applicant, or
his/her authorized representative (see Authorized Representative), and a
Department employee to review the applicant's application form(s) and resolve
any problems or questions about the applicant's situation in relation to the
Medicaid eligibility tests.
An interview must be held when:
The Medicaid application includes a patient living in a long-term
care living arrangement unless it is clear that no additional information will
be gained from an interview (see below); or
The application form(s) does not give enough clear and consistent
information about the applicant's situation to make a decision on his/her
application.
An interview may be desirable, but not necessary, to work out
complex eligibility test problems, or to help an applicant who has trouble
understanding eligibility rules or in giving written information.
Interviews are
private. One representative chosen by the applicant may be present to help
explain the applicant's situation. Interviews are held at the District Office
or at the long-term care facility where the applicant is living. An interview
at home, or some other location convenient for both, may be arranged if unusual
health or transportation problems make an office visit impossible for the
applicant or his/her representative.
A face-to-face
interview is not required if no additional information will be gained. If the
client is unable to respond to questions, consider a telephone interview with
the individual(s) acting on behalf of the client to obtain additional
information.
Section M125 Social Security Numbers.
The Department will notify applicants or recipients that Social
Security numbers will be used in the administration of the Medicaid program.
Refusal to furnish a Social Security number, refusal to verify a
Social Security number, or refusal to apply for a Social Security number for
any applicant or recipient shall make that individual ineligible for
assistance. However, refusal to furnish a Social Security number shall not
affect eligibility if the individual is a
member of a religious organization that objects to this practice.
The Department will advise applicants how to apply for Social
Security numbers and will not delay, deny or discontinue assistance during the
issuance and verification of such numbers.
Section M126 Verification (Proof).
Verification means proof of an applicant's statements by written
records or documents shown to the Department's employee or agent, or by
statements of another person who adds to or supports the applicant's
statements.
Proof of the following is required:
All applicants' and recipients' Social Security numbers.
Verification of application for such numbers is an acceptable substitute until
such time as the Social Security numbers are received and verified; and
A medical decision,
based on professional examination and judgment, on blindness, disability or
incapacity; and
All resources, when the total is within $ 200 of the resource
maximum; and
Proof of citizenship or alienage status and identity (M170).
Proof may also be necessary when the statement form and interview,
if one is held, do not give enough clear and consistent information to make a
decision on any other eligibility test.
Proof documents are returned to the applicant as soon as necessary
information is recorded. Proof documents may be brought to the interview if one
is held. Added proofs asked for after review of the applicant's statement may
be sent or brought to the office.
When an applicant refuses to give necessary proofs, the
application may be denied.
Section M127 Collateral Sources.
Contact with
sources other than the applicant may be made concerning his eligibility for aid
or benefits. These contacts are limited to interviews, telephone calls, or
correspondence necessary to obtain information required to make a decision on
eligibility. Information requested from collateral sources is limited to the
specific eligibility factors in question.
Common collateral sources are relatives, landlords, employers,
town officials, Town Service Officers, public records, doctors, medical
facilities, etc. Other agencies which have worked with the client are generally
the best source of collateral information.
When information given by the client is either insufficient or
questionable, contact with a collateral source may be made without the client's
consent. Information requested from collateral sources is limited to
eligibility requirements.
Section M128 Requirement to Apply for Annuities, Pensions, Etc.
As a condition of eligibility, the Department of Social Welfare
requires an applicant or recipient to take all necessary steps to obtain any
annuities, pensions, retirement, or disability benefits to which he or she may
be entitled, unless he or she can show good
cause for not doing so. Annuities, pensions, retirement and disability benefits
include, but are not limited to, veterans' compensation and pensions, Old-Age,
Survivors, and Disability Insurance (OASDI) benefits, railroad retirement
benefits, and unemployment compensation. Application for these benefits, when
appropriate, must be verified prior to granting or continuing Medicaid.
Individuals are not required to apply for cash assistance programs
such as SSI/AABD or ANFC as a condition of eligibility for Medicaid.
Section M129 Pursuit of Medical Support, Third-Party Medical
Payments and Private Health Insurance.
As a condition of initial and continuing eligibility, all Medicaid
applicants and beneficiaries 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 detailed in M129.1-M129.3
below.
M129.1 Assignment of Rights to Support and Payments.
Medicaid applicants and beneficiaries with the legal authority to
do so must assign their rights to medical
support and third-party payments for medical care to the department, with the
exceptions noted below. If they have the legal authority to do so, they must
also assign the rights of any other Medicaid applicants and beneficiaries to
such support and payments to the department.
No assignment is required for Medicare payments or cash payments
from the Department of Veterans Affairs for aid and attendance.
M129.2 Cooperation in Obtaining Support and Payments.
Medicaid applicants and beneficiaries must cooperate with the department
in obtaining medical support and third-party payments for medical care unless
the department has granted them a good cause waiver for not cooperating
(M129.21). To meet this requirement, the department may require an individual
to:
provide information or evidence relevant and essential to obtain
such support or payments; appear as a witness in court or at another
proceeding;
provide information or attest to lack of information under penalty
of perjury; or
take any other
reasonable steps necessary for establishing parentage or securing medical
support or third-party payments.
The department shall exempt an unmarried pregnant woman with
income under 200 percent of the federal poverty level 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.
M129.21 Good Cause for Noncooperation.
Medicaid applicants and beneficiaries may request a waiver of the
cooperation requirement from the department. Those to whom the department has
granted a good cause waiver for noncooperation are eligible for Medicaid,
provided that all other program requirements are met. The department shall
grant such waivers when either of the following circumstances has been
substantiated to the department'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.
2. Compliance with the
cooperation requirement would entail pursuit of medical support for a child:
• conceived as a result of incest or rape from the father of that
child;
• for whom adoption proceedings are pending; or
• for whom adoptive placement is under active consideration.
Individuals requesting waivers of the cooperation requirement bear
the primary responsibility for providing the documentation the department deems
necessary to substantiate their claims of good cause. The department shall
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.
M129.3
Enrollment in a Health Insurance Plan.
The department may require a Medicaid applicant or beneficiary to
enroll or remain enrolled in a group health insurance plan for which the department
pays the premiums. Payment of group health insurance premiums shall be made
only under the conditions specified in this section and in M158.1 and remain
entirely at the department's discretion. Such payment of premiums shall not be
considered an entitlement for any individual.
As a condition of continuing eligibility, the department may
require beneficiaries to remain enrolled in individual health insurance plans,
provided that they are enrolled in plans for which the department has been
paying the premiums on a continuous basis since July 2000.
For the purposes of this section and M158.1, 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 M130 Continuing Eligibility.
Section M131
Eligibility Review Requirement.
Once granted, Medicaid coverage continues until a decision is made
to end it because the person (or group) no longer passes all the eligibility
tests or the recipient chooses not to continue Medicaid coverage although still
eligible. Eligibility must be reviewed to take into account any changes in the
facts of the recipient's situation from the facts on which the grant decision
was based.
Each Medicaid recipient is responsible for reporting to the
Department any change in his situation that is related to the Medicaid
eligibility tests (such as changes in income, resources, disability, living
arrangement, Medicaid group membership, etc.). He must report any change within
ten days after he learns of it.
Every recipient's Medicaid eligibility must be reviewed in full
every so often, whether or not his situation changes. The frequency of full
reviews depends on how likely the recipient's situation is to change.
Eligibility reviews are carried out under the same rules as
initial eligibility investigations (see Sections M123-M126). New up-to-date
forms must be filed and proofs given. Interviews are not, however, required,
but may be used to clear up incomplete or
inconsistent information. Collateral sources may also be used, as needed.
The Department reminds recipients when eligibility must be
reviewed by sending necessary forms and directions far enough ahead to complete
the review within the time limit. If the recipient fails to do his part,
Medicaid coverage may be ended.
Section M132 Review Frequency.
Individuals receiving cash assistance through Supplemental
Security Income/Aid to the Aged, Blind or Disabled (SSI/AABD) or state Aid to
the Aged, Blind or Disabled (AABD) do not need a separate Medicaid eligibility
review by the department. Their Medicaid eligibility is reviewed by the Social
Security Administration at the same time as their cash assistance eligibility.
When a recipient's situation is known to change frequently,
schedule more frequent reviews. If the Medicaid group meets more than one of
the following criteria, schedule a review at the earliest required time.
A full
eligibility review must be completed within 12 months after the initial eligibility date, or the date of last full
eligibility review, for:
• individuals whose Medicaid group has stable countable income
under one of the following levels applicable to their Medicaid eligibility
determination: the ANFC payment level in effect as of
• individuals living in long-term care whose gross income does not
exceed the Institutional Income Standard or whose monthly cost of long-term
care exceeds their monthly spend-down requirement;
• children whose Medicaid group has stable countable income under
one of the special income levels and who will not become ineligible for the
special income level due to age in the 12-month period;
• children living in Vermont for whom an adoption assistance
agreement is in effect or foster care maintenance payments are being made under
title IV-E of the Social Security Act;
• children committed by a
• women
determined eligible for the breast and cervical cancer treatment group.
A full eligibility
review must be completed within six months after the initial eligibility date,
or the date of last full eligibility review, for:
• individuals voluntarily placed in the care of Social and
Rehabilitation Services, and
• individuals living in long-term care who have gross income over
the Institutional Income Standard, have excess income over the cost of
long-term care, and must spend-down this excess income on other medical
expenses. A review of income eligibility must be completed every month.
• persons determined eligible as working disabled.
A full
eligibility review must be completed by the end of the six-month accounting
period for:
• individuals living in the community who were not eligible for
Medicaid until their Medicaid group incurred medical expenses equal to their
spend-down amount (i.e., the group met
their six-month spend-down requirement).
A full
eligibility review must be completed (at the stated time) for:
• an individual granted Medicaid because he/she meets the ANFC age
criteria whose eligibility based on age is ending (review month is the month
prior to the month of the child's birthday),
• a woman granted Medicaid because she was pregnant whose Medicaid
eligibility under that provision is ending (review month is the month in which
the 60th day, beginning with the last day of the pregnancy, falls),
• a child who has been granted Medicaid based on the special
income level whose eligibility for the special income level is ending (review
month is the month prior to the month of the child's birthday),
• a family found eligible for the 12-month (or 36-month)
transitional Medicaid extension whose eligibility under this coverage provision
is ending must be redetermined (before Medicaid is terminated), and
• individuals who lose SSI/AABD for a reason other than a final
determination by the Social Security
Administration that the individual is no longer blind or disabled. Medicaid is
reviewed when cash benefits under SSI/AABD are ended and before Medicaid is
terminated.
Section M134 Quality Control Review.
The main reason for quality control review is to be sure that
Medicaid rules are clear and consistently applied and that Medicaid applicants
and recipients can understand and give correct information for the eligibility
tests.
A random sample
of active Medicaid recipients is chosen each month for a full field review of
their Medicaid eligibility. Each eligibility factor must be verified with the
recipient and collateral sources. If the recipient refuses to cooperate in
completing a quality control review, his or her Medicaid benefits must be
closed.
A similar sample
of negative actions (denials, closures, benefit decreases) is also chosen each
month. These reviews do not usually require a contact with the applicant or
recipient, although the reviewer may sometimes need to check facts with him or
her.
When the quality
control review shows different facts about the individual's situation, the
department must schedule an eligibility review and take action to correct
errors or review the effect of the changes.
Section M135 Recipient Fraud Investigation.
An individual who deliberately hides or omits information or gives
false information to get, or help another person to get, benefits he or she
would not otherwise be eligible for may be prosecuted under
When the department learns that fraud may have been committed, it
will investigate the case with respect for confidentiality and the legal rights
of the recipient. If appropriate, the case will be referred to the State's
Attorney, Attorney General, or United States Attorney for a decision on whether
to prosecute.
Section M140 Notice and Appeal.
Section M141
Notice of Decision.
Each Medicaid applicant/recipient must be given written notice of
the decision on his or her application or review of eligibility. A group notice
must include notice of the decisions about each member of the group.
All notice letters must contain:
A statement of
what action the Department intends to take;
When it intends to take the action;
The reasons for the intended action;
The policy citation(s) that supports the action;
An explanation of the individual's right to appeal the decision
and the circumstances under which a hearing will be granted; and
Note: The Department need not grant a hearing if the sole issue is
a Federal or State law requiring a mandated change adversely affecting some or
all recipients.
An explanation of the circumstances under which Medicaid is
continued if a hearing is requested.
When an eligibility review decision will end or reduce the amount
of Medicaid coverage an individual has been receiving, the notice of decision
must be mailed at least ten (10) days before the closure or change will take
effect, except when:
The Department has facts confirming the death of a Medicaid
recipient;
The Department has facts confirming that the recipient has been
granted Medicaid in another State;
The recipient has been admitted or committed to an institution
where he or she is ineligible for further services;
The Department receives a clear written statement signed by a
recipient that:
1. He or she no longer wishes
services; or
2. Gives information that requires termination or reduction of
services and indicates that he or she understands that this must be the result
of supplying that information;
The recipient's whereabouts are unknown and the post office
returns agency mail directed to him or her indicating no forwarding address; or
A change in the
level of medical care is prescribed by the recipient's physician.
The Department receives a clear written statement signed by a
recipient that:
1. He or she no longer wishes
services; or
2. Gives information that
requires termination or reduction of services and indicates that he or she
understands that this must be the result of supplying that information;